Transitioning from conventional to cover crop systems with minimum tillage does not alter nutrient loading.

Nutrient loading from conventional row-crop production systems impairs surface waterbodies in the mid-southern United States. This study was conducted to determine whether minimum tillage and winter cover crops can decrease nutrient loading in surface runoff from conventionally tilled row-crop fields. The effects of winter cover crops and minimum tillage on N and P loading from a corn (Zea mays L.)-soybean [Glycine max (L.) Merr.] rotation system were investigated on production fields in northwestern Mississippi using a split-field approach. As measured at the edge of the field, minimum tillage with cover crops had no effect on surface runoff from production fields regarding N or P loading (p > .10 for all nutrient loads), discharge (p > .10), or loss of suspended solids (p > .10). Minimum tillage and cover crops decreased sediment and nutrient concentrations in runoff for total N (p = .05) and total P (p = .09) but had no effect on other nutrients of interest. Although these practices decreased total N concentration by 36% in surface runoff to receiving waters, this reduction was only seen when aboveground cover crop biomass was present (p = .07). Regardless of the time of year, minimum tillage with cover crops decreased total P concentration in surface runoff by 27% (p = .09). These data indicate that it is unlikely that minimum tillage and cover crops will affect N and P loading while transitioning to a conservation production system in the mid-southern United States.

Graft survival of fourth-time renal transplant recipients is similar to third-time recipients: A SRTR database analysis.

BACKGROUND: Candidates for repeat kidney transplant (KT) have increased. While graft and patient survival are inferior to primary KT, second and third KTs improve patient survival over dialysis. Little is known about the outcomes after fourth KTs. METHODS: We retrospectively compared characteristics of third and fourth KTs in the SRTR. Factors associated with graft survival in third vs fourth KT and patient survival of fourth KT vs patients waitlisted for a 4th KT were assessed by Cox regression and multivariable linear regression analysis. RESULTS: There were 3055 third- and fourth-time KTs performed in the United States. Fourth-time graft survival was not significantly different from third-time transplants (HR 1.06, P = .653). Patients who received a fourth KT have a significant survival advantage compared with patients who remained on the waitlist for a fourth KT (HR = 0.53, P = .006). CONCLUSIONS: Graft and patient survival of fourth KTs are comparable to third KTs, but inferior to first and second KTs in terms of graft and patient survival. Recipients of fourth KT have had an increased life expectancy compared with patients waitlisted for a fourth KT.

A clinical tool to risk stratify potential kidney transplant recipients and predict severe adverse events.

Preoperative risk assessment of potential kidney transplant recipients often fails to adequately balance risk related to underlying comorbidities with the beneficial impact of kidney transplantation. We sought to develop a simple scoring system based on factors known at the time of patient assessment for placement on the waitlist to predict likelihood of severe adverse events 1 year post-transplant. The tool includes four components: age, cardiopulmonary factors, functional status, and metabolic factors. Pre-transplant factors strongly associated with severe adverse events include diabetic (OR: 3.76, P<.001), coronary artery disease (OR: 3.45, P<.001), history of CABG/PCI (OR 3.1, P=.001), and peripheral vascular disease (OR 2.74, P=.008).The score was evaluated by calculation of concordance index. The C statistic of 0.74 for the risk stratification group was considered good discrimination in the validation cohort (N=127) compared to the development cohort (N=368). The pre-transplant risk group was highly predictive of severe adverse events (OR 2.36, P<.001). Patients stratified into the above average-risk group were four times more likely to experience severe adverse events compared to average-risk patients, while patients in the high-risk group were nearly 11 times more likely to experience severe adverse events. The pre-transplant risk stratification tool is a simple scoring scheme using easily obtained preoperative characteristics that can meaningfully stratify patients in terms of post-transplant risk and may ultimately guide patient selection and inform the counseling of potential kidney transplant recipients.

Tumor histopathology predicts outcomes after resection of colorectal cancer liver metastases treated with and without pre-operative chemotherapy.

BACKGROUND AND OBJECTIVES: Study objectives, included determination of: (i) associations between radiologic and pathologic responses of colorectal cancer liver metastases (CRCLM) to chemotherapy; and (ii) whether CRCLM histopathology is associated with recurrence free survival (RFS) after resection among patients not treated with pre-operative chemotherapy (untreated). METHODS: Demographics, clinicopathologic characteristics, and outcomes among patients who underwent CRCLM resection from 2007 to 2014 were reviewed. Tumor regression grade (TRG) of 1-2 and 4-5 depict low and high proportions of viable tumor relative to fibrosis, respectively. RESULTS: Of 138 patients, 84 (60.9%) were treated with pre-operative chemotherapy. In these patients, there was no difference in proportions with TRG 1-2 among those with verses without radiologic response (26.9% vs. 18.8%, P = 0.393). TRG 1-2 was associated with superior RFS on univariable (median 15 vs. 6 months, P < 0.001) and multivariable (P = 0.005) analyses. Radiologic response was not associated with RFS. Among untreated patients (n = 54), TRG 4-5 was associated with poor RFS on univariable (median 44 vs. 15 months, P = 0.011) and multivariable (P = 0.012) analyses. CONCLUSIONS: High proportions of CRCLM fibrosis occur in 20% of patients without radiologic response to chemotherapy. Among untreated patients, high proportion of viable tumor relative to fibrosis is associated with poor RFS after resection. J. Surg. Oncol. 2016;113:456-462. © 2016 Wiley Periodicals, Inc.

Imaging Surveillance of Hypervascular Liver Lesions in Non-Cirrhotic Patients.

A consensus surveillance protocol is lacking for non-cirrhotic patients with hypervascular liver lesions presumed to represent hepatocellular adenomas. Patients with hypervascular liver lesions <5 cm not meeting criteria for focal nodular hyperplasia or hepatocellular carcinoma underwent surveillance with contrast-enhanced magnetic resonance imaging (MRI) 6, 12, and 24 months after baseline imaging. If lesions remained stable or decreased in size, then surveillance imaging was discontinued. Between 2011 and 2014, 116 patients with hypervascular liver lesions were evaluated. Seventy-nine patients were eligible for the surveillance protocol. Median follow-up was 24 months (range, 1-144 months). One patient (1 %) continued oral contraceptive pill (OCP) use and presented with hemorrhage requiring embolization 5 months after initial diagnosis. Ten patients (13 %) underwent elective embolization or surgical resection for size ≥5 cm. The remaining 68 patients (86 %) continued surveillance without hemorrhage or malignant transformation. Risk factors for requiring intervention during the surveillance period included younger age, larger lesion size, and estrogen use (all p < 0.05). Patients with hepatocellular adenomas <5 cm can safely be observed after discontinuing OCP with serial imaging 6, 12, and 24 months after diagnosis. If lesions remain stable or decrease in size, then longer-term surveillance is unlikely to identify patients at risk for complications.

Honoring patients' organ donation decisions when family conflict is present: Experience from a single organ procurement organization.

BACKGROUND: Donor designation refers to the laws and processes for documentation of an individual's wishes regarding organ donation should that person become eligible for donation at death. All 50 states have laws supporting donor designation. Donor-family conflict arises when a designated donor's family attempts to rescind the donor's authorization to donate. Little guidance exists in the current literature to address these situations. METHODS: Hospital public relations offices and organ procurement organization (OPO) records were queried to assess the incidence of legal action and adverse media coverage. Public legal records were searched for civil actions involving the hospitals at which these conflicts occurred. RESULTS: Fourteen cases of donor-family conflict were identified. Organ procurement proceeded in 9 (64%) of 14. A total of 38 organs were transplanted from these 9 donors. For those nine cases, median follow-up time was 57 months (interquartile range, 52-77 months; range, 38-114 months). The identified reasons for conflict include a belief by the family that they were given a choice in the decision about whether to proceed with donation; misunderstanding and lack of acceptance of the brain death diagnosis; disagreement among family members; concerns about timing/length of the donation process and desire to withdraw ventilator support; next-of-kin anger over cause of death when cause of death was suicide; and challenges to the validity of donor document and stated donor intent. No adverse news items were reported, and no lawsuits were filed in cases of donor-family conflict where organ donation proceeded. In addition, we found no mention of lawsuits brought against hospitals for failure to proceed with organ donation when donor was designated and eligible. CONCLUSION: The 2006 Anatomical Gift Act compels hospitals and OPOs to pursue donation regardless of family wishes in cases of brain death in designated donors. When a donor's family attempts to rescind the donor's authorization, the donor's wishes, not the families, should be honored. Fears of legal action and adverse media coverage are unfounded. Clinicians, OPO staff, and hospital administrators should strive to understand state donor designation law and create a plan for managing this conflict should it arise. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Graft weight/recipient weight ratio: how well does it predict outcome after partial liver transplants?

Partial graft liver recipients with graft weight/recipient weight (GW/RW) ratios < 0.8% are thought to have a higher incidence of postoperative complications, including small-for-size syndrome (SFSS). We analyzed a cohort of such recipients and compared those with GW/RW < 0.8% to those with GW/RW >or= 0.8%. Between 1999 and 2008, 107 adult patients underwent partial graft liver transplants: 76 from live donors [living donor liver transplantation (LDLT)] and 31 from deceased donors [split liver transplantation (SLT)]. Of these, 22 had GW/RW < 0.8% (12 with LDLT and 10 with SLT), and 85 had GW/RW >or= 0.8% (64 with LDLT and 21 with SLT). The baseline demographics and median length of follow-up were similar. SFSS developed in 3 recipients with GW/RW < 0.8% (13.6%) and in 8 recipients with GW/RW >or= 0.8% (9.4%; P = not significant). Other early complications were similar between the 2 groups. Inflow modification with splenic artery occlusion was performed in 13 recipients: 7 with GW/RW < 0.8% and 6 with GW/RW >or= 0.8%. Graft survival at 1 year post-transplant did not differ (91% versus 92%; P = not significant). In conclusion, GW/RW did not appear to be the only determinant of outcome after partial liver transplantation. Using techniques such as inflow modification may help to prevent some of the problems seen with smaller grafts.