The use of high-risk donor livers, which is reflective of the gross national shortage of organs available for transplantation, has gained momentum. Despite the demand, many marginal livers are discarded annually. We evaluated the impact of center volume on survival outcomes associated with liver transplantation using high-donor risk index (DRI) allografts. We queried the Scientific Registry of Transplant Recipients database for deceased donor liver transplants (n ¼ 31,576) performed between 2002 and 2008 for patients who were 18 years old or older, and we excluded partial and multiple liver transplants. A high-DRI cohort (n ¼ 15,668), which was composed of patients receiving grafts with DRIs > 1.90, was analyzed separately. Transplant centers (n ¼ 102) were categorized into tertiles by their annual procedure volumes: high-volume centers (HVCs; 78-215 cases per year), medium-volume centers (MVCs; 49-77 cases per year), and low-volume centers (LVCs; 5-48 cases per year). The endpoints were allograft survival and recipient survival. In comparison with their lower volume counterparts, HVCs used donors with higher mean DRIs (2.07 for HVCs, 2.01 for MVCs, and 1.91 for LVCs), more donors who were 60 years old or older (18.02% for HVCs, 16.85% for MVCs, and 12.39% for LVCs), more donors who died after a stroke (46.52% for HVCs, 43.71% for MVCs, and 43.36% for LVCs), and more donation after cardiac death organs (5.04% for HVCs, 4.45% for MVCs, and 3.51% for LVCs, all P values < 0.001). Multivariate risk-adjusted frailty models showed that increased procedure volume at a transplant center led to decreased risks of allograft failure [hazard ratio (HR) ¼ 0.93, 95% confidence interval (CI) ¼ 0.89-0.98, P ¼ 0.002] and recipient death (HR ¼ 0.90, 95% CI ¼ 0.83-0.97, P ¼ 0.004) for high-DRI liver transplants. In conclusion, HVCs more frequently used higher DRI livers and achieved better risk-adjusted allograft and recipient survival. A greater understanding of the outcomes of transplantation with high-DRI livers may improve their utilization, the postoperative outcomes, and future allocation practices.Liver

Thermal injuries have been a phenomenon intertwined with the human condition since the dawn of our species. Autologous skin translocation, also known as skin grafting, has played an important role in burn wound management and has a rich history of its own. In fact, some of the oldest known medical texts describe ancient methods of skin translocation. In this article, we examine how skin grafting has evolved from its origins of necessity in the ancient world to the well-calibrated tool utilized in modern medicine. The popularity of skin grafting has ebbed and flowed multiple times throughout history, often suppressed for cultural, religious, pseudo-scientific, or anecdotal reasons. It was not until the 1800s, that skin grafting was widely accepted as a safe and effective treatment for wound management, and shortly thereafter for burn injuries. In the nineteenth and twentieth centuries skin grafting advanced considerably, accelerated by exponential medical progress and the occurrence of man-made disasters and global warfare. The introduction of surgical instruments specifically designed for skin grafting gave surgeons more control over the depth and consistency of harvested tissues, vastly improving outcomes. The invention of powered surgical instruments, such as the electric dermatome, reduced technical barriers for many surgeons, allowing the practice of skin grafting to be extended ubiquitously from a small group of technically gifted reconstructive surgeons to nearly all interested sub-specialists. The subsequent development of biologic and synthetic skin substitutes have been spurred onward by the clinical challenges unique to burn care: recurrent graft failure, microbial wound colonization, and limited donor site availability. These improvements have laid the framework for more advanced forms of tissue engineering including micrografts, cultured skin grafts, aerosolized skin cell application, and stem-cell impregnated dermal matrices. In this article, we will explore the convoluted journey that modern skin grafting has taken and potential future directions the procedure may yet go.

While DRI remains an important aspect of allograft survival prediction models, liver transplantation at a HVC appears to result in improved allograft survival with high and very high risk DRI organs compared with LVC.

While the roots of burn care date back several millennia, recognition and treatment of psychiatric trauma has had a more contemporary journey. Our understanding of burn care has evolved largely separately from our understanding of psychiatry; however, proper care of the burn patient relies on the comprehension of both disciplines. Historically, high burn mortality rates have caused clinicians to focus on the physiological causes of burn mortality. As burn care improved in the 20th century, providers began to focus on the long-term health outcomes of burn patients, including mitigating mental health consequences of trauma. This shift coincided with advances in our understanding of psychological sequelae of trauma. Subsequently, an association between burn trauma and mental illness began to emerge. The current standard of care is the result of thousands of years of evolving practices and theories, yet our understanding of the pathophysiology of depression among survivors of severe burn injury is far from complete. By taking measure of the past, we aim to provide context and evidence for our current standards and emphasize areas for future lines of research.

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