Background & Aims:The surge in unhealthy alcohol use during the COVID-19 pandemic may have detrimental effects on the rising burden of alcohol-associated liver disease (ALD) on liver transplantation (LT) in the US. We evaluated the impact of the pandemic on temporal trends for LT including ALD. Approach & Results: Utilizing data from United Network for Organ Sharing, we analyzed waitlist outcomes in the US through March 1, 2021. In a short-period analysis, patients listed or transplanted between June 1, 2019 and February 29, 2020 were defined as the "pre-COVID" era and after April 1, 2020 were defined as the "COVID" era. Interrupted time-series analyses utilizing monthly count data from 2016-2020 were constructed to evaluate rate change for listing and LT prior to and during the COVID-19 pandemic. Rates for listings (P=0.19) and LT (P=0.14) were unchanged during the pandemic despite a significant reduction in the monthly listing rates for HCV (-21.69%, P <0.001) and NASH (-13.18%; P <0.001). There was a significant increase in ALD listing (+7.26%; P <0.001) and LT (10.67%; P <0.001) during the pandemic. In the COVID era, ALD (40.1%) accounted for more listings than those due to HCV (12.4%) and NASH (23.4%) combined. The greatest increase in ALD occurred in young adults (+33%) and patients with severe alcoholic hepatitis (+50%). ALD patients presented with a higher acuity of illness, with 30.8% of listings and 44.8% of LT having a MELD-Na > 30. Conclusions: Since the start of COVID-19 pandemic, ALD has become the most common indication for listing and the fastest increasing cause for LT. Collective efforts are urgently needed to stem the rising tide of ALD on healthcare resources.

Background. To reduce the disparity in access to liver transplant (LT), United Network for Organ Sharing implemented an exception policy in May 2019, which capped hepatocellular carcinoma (HCC) exception score to the median Model for End-Stage Liver Disease (MELD) at transplant within the donor service area minus 3 points (MMaT-3) after the 6-mo wait period. We aimed to evaluate how this policy affected HCC waitlist outcomes. Methods. Using United Network for Organ Sharing data, we analyzed waitlist outcomes in HCC patients at the time they received exception points from in the pre-MMaT era (August 15, 2017, to November 15, 2018) and MMaT era (June 1, 2019, to August 30, 2020). Comparisons were made within the HCC group and HCC versus non-HCC (at time of listing) groups in the pre-MMaT and MMaT eras and regions were grouped as low, medium, and high MELD based on MMaT. Results. HCC group: LT probability within HCC patients decreased by 20% (subhazard ratio [sHR], 0.78; 95% confidence interval [CI], 0.74-0.85) between the eras and decreased by 41% in low MELD regions (sHR, 0.59; 95% CI, 0.52-0.66). Waitlist dropout was unchanged. Matched HCC versus non-HCC groups: HCC patients had 80% higher LT probability (sHR, 1.84; 95% CI, 1.71-1.99) than non-HCC patients in the pre-MMaT era; which decreased to a 14% higher LT probability in MMaT era. In low and medium regions, HCC patients had over twofold higher LT probability in the pre-MMaT era, which decreased to a ~20% higher probability (sHR, 1.14; 95% CI, 1.06-1.23) in the MMaT era. After implementation of the acuity circle policy, HCC patients had lower LT probability (sHR, 0.84; 95% CI, 0.74-0.94) than non-HCC patients. Conclusions. The geographic disparity between HCC and non-HCC patients has improved with the MMaT-3 policy. Despite lower LT probability for HCC patients, waitlist dropout was not adversely impacted.

The future of long-duration spaceflight missions will place our vehicles and crew outside of the comfort of low-Earth orbit. Luxuries of quick resupply and frequent crew changes will not be available. Future missions will have to be adapted to low resource environments and be suited to use resources at their destinations to complete the latter parts of the mission. This includes the production of food, oxygen, and return fuel for human flight. In this chapter, we performed a review of the current literature, and offer a vision for the implementation of cyanobacteria-based bio-regenerative life support systems and in situ resource utilization during long duration expeditions, using the Moon and Mars for examples. Much work has been done to understand the nutritional benefits of cyanobacteria and their ability to survive in extreme environments like what is expected on other celestial objects. Fuel production is still in its infancy, but cyanobacterial production of methane is a promising front. In this chapter, we put forth a vision of a three-stage reactor system for regolith processing, nutritional and atmospheric production, and biofuel production as well as diving into what that system will look like during flight and a discussion on containment considerations.

There have been conflicting data regarding liver transplantation (LT) outcomes for hereditary hemochromatosis (HH), with no recent data on LT outcomes in patients with HH in the past decade. Using the United Network for Organ Sharing registry, we evaluated waitlist and post‐LT survival in all adult patients listed for HH without concomitant liver disease from 2003 to 2019. Post‐LT survival for HH was compared with a propensity‐matched (recipient and donor factors) cohort of recipients with chronic liver disease (CLD). From 2003 to 2019, 862 patients with HH were listed for LT, of which 55.6% (n = 479) patients underwent LT. The 1‐ and 5‐year post‐LT survival rates in patients with HH were 88.7% (95% confidence interval [CI], 85.4%–91.4%) and 77.5% (95% CI, 72.8%–81.4%), respectively, and were comparable with those in the propensity‐matched CLD cohort (p value = 0.96). Post‐LT survival for HH was lower than for Wilson's disease, another hereditary metabolic liver disease with similar LT volume (n = 365). Predictors for long‐term (5‐year) post‐LT mortality included presence of portal vein thrombosis (hazard ratio [HR], 1.96; 95% CI, 1.07–3.58), obesity measurements greater than Class II (HR, 1.98; 95% CI, 1.16–3.39), and Karnofsky performance status (HR, 0.98; 95% CI, 0.97–0.99) at the time of LT. The leading cause of post‐LT death (n = 145) was malignancy (25.5%), whereas cardiac disease was the cause in less than 10% of recipients. In conclusion, short‐ and long‐term survival rates for HH are excellent and comparable with those of other LT recipients. Improving extrahepatic metabolic factors and functional status in patients with HH prior to LT may improve outcomes.

Exploring austere environments required a reimagining of resource acquisition and utilization. Cyanobacterial in situ resources utilization (ISRU) and biological life support system (BLSS) bioreactors have been proposed to allow crewed space missions to extend beyond the temporal boundaries that current vehicle mass capacities allow. Many cyanobacteria and other microscopic organisms evolved during a period of Earth’s history that was marked by very harsh conditions, requiring robust biochemical systems to ensure survival. Some species work wonderfully in a bioweathering capacity (siderophilic), and others are widely used for their nutritional power (non-siderophilic). Playing to each of their strengths and having them grow and feed off of each other is the basis for the proposed idea for a series of three bioreactors, starting from regolith processing and proceeding to nutritional products, gaseous liberation, and biofuel production. In this paper, we discuss what that three reactor system will look like, with the main emphasis on the nutritional stage.