Redo fundoplication in infants and children with recurrent gastroesophageal reflux

The Nissen fundoplication is well established as the surgical treatment for medically refractory gastroesophageal reflux (GER) in childhood. Recurrent GER following fundoplication is a challenging problem with a reported incidence ranging from 0% to 12%. From January 1974 to January 1989, 286 children have been treated for GER with Nissen fundoplication and gastrostomy tube placement at the University of Michigan C.S. Mott Children's Hospital; 242 of these children have been followed for an average of 30 months, the remaining 44 have been lost to follow-up. Twenty-nine children (12%) have developed recurrent reflux following fundoplication. Medical management with thickened upright feelings, gastrostomy feedings, or gastrojejunostomy tube feedings has been successful for 11 children with control of reflux symptoms. Five additional children who were treated nonoperatively died of coexistant medical problems within 2 months following documentation or recurrent reflux. The remaining 13 children have required redo fundoplication for wrap disruption or herniation, and an additional six children, initially treated at other institutions, have also undergone redo fundoplications. One other child treated at this hospital required redo fundoplication for a postoperative partial gastric volvulus causing gastric outlet obstruction. Of the 20 children who have undergone a second Nissen fundoplication, 16 (80%) are doing well without recurrent GER. Four children have developed recurrent GER with wrap disruption; 1 is doing well following a third fundoplication, 2 have been managed successfully with continuous feedings via gastrojejunostomy feeding tubes, and a fourth child died of complications related to a recurrent tracheoesophageal fistula. Conservative management with gastrojejunal tube feedings should be considered in the initial management of children with recurrent GER following fundoplication. If necessary, redo Nissen fundoplication, although technically difficult, is associated with a good outcome in the majority of children and is indicated for refractory recurrent GER following a failed antireflux procedure.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29266/1/0000324.pd

Two Plant Viral Suppressors of Silencing Require the Ethylene-Inducible Host Transcription Factor RAV2 to Block RNA Silencing

RNA silencing is a highly conserved pathway in the network of interconnected defense responses that are activated during viral infection. As a counter-defense, many plant viruses encode proteins that block silencing, often also interfering with endogenous small RNA pathways. However, the mechanism of action of viral suppressors is not well understood and the role of host factors in the process is just beginning to emerge. Here we report that the ethylene-inducible transcription factor RAV2 is required for suppression of RNA silencing by two unrelated plant viral proteins, potyvirus HC-Pro and carmovirus P38. Using a hairpin transgene silencing system, we find that both viral suppressors require RAV2 to block the activity of primary siRNAs, whereas suppression of transitive silencing is RAV2-independent. RAV2 is also required for many HC-Pro-mediated morphological anomalies in transgenic plants, but not for the associated defects in the microRNA pathway. Whole genome tiling microarray experiments demonstrate that expression of genes known to be required for silencing is unchanged in HC-Pro plants, whereas a striking number of genes involved in other biotic and abiotic stress responses are induced, many in a RAV2-dependent manner. Among the genes that require RAV2 for induction by HC-Pro are FRY1 and CML38, genes implicated as endogenous suppressors of silencing. These findings raise the intriguing possibility that HC-Pro-suppression of silencing is not caused by decreased expression of genes that are required for silencing, but instead, by induction of stress and defense responses, some components of which interfere with antiviral silencing. Furthermore, the observation that two unrelated viral suppressors require the activity of the same factor to block silencing suggests that RAV2 represents a control point that can be readily subverted by viruses to block antiviral silencing

Long-term radiographic follow-up of the Nissen fundoplication in children

This study examined 46 children 5–9 years (mean 6.7) after Nissen fundoplication surgery for gastroesophageal reflux (GER). Eleven were deceased and ten of the 35 families declined objective evaluation. The remaining 25 children (71%) had a barium swallow examination. In 16 of the 25 patients the fundoplication was intact. In 2 patients a small portion of the fundoplication was displaced above the diaphragm. In 5 patients there was residual esophageal disease. In 3 patients (one with esophageal disease), with a hiatus hernia prior to surgery, despite immediate postoperative reduction, the barium swallow examination done for this study revealed recurrent hiatus hernia but no GER. Long-term results of the Nissen fundoplication reveal success in eliminating clinically significant gastroesophageal reflux. Those patients with esophageal disease prior to the surgery need close interval follow-up to monitor continuing problems.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/46689/1/247_2006_Article_BF02389563.pd

A comparison of conventional and 137 Cs-based estimates of soil erosion rates on arable and grassland across lowland England and Wales

Soils deliver a range of ecosystem services and underpin conventional global food production which must increase to feed the projected growth in human population. Although soil erosion by water and subsequent sediment delivery to rivers are natural processes, anthropogenic pressures, including modern farming practices and management, have accelerated soil erosion rates on both arable and grassland. A range of approaches can be used to assess and document soil erosion rates and, in the case of the UK, these mainly comprise the 137Cs-based approach, conventional surveys using volumetric measurements, integration of information on suspended sediment flux, fine sediment source apportionment and landscape sediment retention and traditional bounded hydrological monitoring at edge-of-field using experimental platforms. We compare the erosion rates for arable and grassland in lowland England assessed by these different techniques. Rates assessed by volumetric measurements are similar to those generated by integrating information on suspended sediment flux, sources and landscape retention, but are much less than those estimated by the 137Cs-based approach; of the order of one magnitude less for arable land. The 137Cs approach assumes an initial distribution of 137Cs uniformly spread across the landscape and relates the sampled distribution to erosion, but other (transport) processes are also involved and their representation in the calibration procedures remains problematic. We suggest that the 137Cs technique needs to be validated more rigorously and conversion models re-calibrated. As things stand, rates of erosion based on the distribution of 137Cs may well overstate the severity of the problem in lowland Britain and, therefore, are not a reliable indicator of water erosion rates

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks