New insights regarding the incidence, presentation and treatment options of aorto-oesophageal fistulation after thoracic endovascular aortic repair: the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES To review the incidence, clinical presentation, definite management and 1-year outcome in patients with aorto-oesophageal fistulation (AOF) following thoracic endovascular aortic repair (TEVAR). METHODS International multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2011 with a total caseload of 2387 TEVAR procedures (17 centres). RESULTS Thirty-six patients with a median age of 69 years (IQR 56-75), 25% females and 9 patients (19%) following previous aortic surgery were identified. The incidence of AOF in the entire cohort after TEVAR in the study period was 1.5%. The primary underlying aortic pathology for TEVAR was atherosclerotic aneurysm formation in 53% of patients and the median time to development of AOF was 90 days (IQR 30-150). Leading clinical symptoms were fever of unknown origin in 29 (81%), haematemesis in 19 (53%) and shock in 8 (22%) patients. Diagnosis could be confirmed via computed tomography in 92% of the cases with the leading sign of a new mediastinal mass in 28 (78%) patients. A conservative approach resulted in a 100% 1-year mortality, and 1-year survival for an oesophageal stenting-only approach was 17%. Survival after isolated oesophagectomy was 43%. The highest 1-year survival rate (46%) could be achieved via an aggressive treatment including radical oesophagectomy and aortic replacement [relative risk increase 1.73 95% confidence interval (CI) 1.03-2.92]. The survival advantage of this aggressive treatment modality could be confirmed in bootstrap analysis (95% CI 1.11-3.33). CONCLUSIONS The development of AOF is a rare but lethal complication after TEVAR, being associated with the need for emergency TEVAR as well as mediastinal haematoma formation. The only durable and successful approach to cure the disease is radical oesophagectomy and extensive aortic reconstruction. These findings may serve as a decision-making tool for physicians treating these complex patients.

Deutsch, Polnisch oder Jiddisch? : Betrachtungen und Urkunden zur Ostjudenfrage

von Germano-Judäus

Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications

OBJECTIVES To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR). METHODS Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres). RESULTS Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively). CONCLUSIONS ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy.

The potential role of endometrial nerve fibers in the pathogenesis of pain during endometrial biopsy at office hysteroscopy

We aimed to evaluate whether nerve fibers are present in the endometrial layer of patients submitted to office hysteroscopy and their potential contribution to the pathogenesis of pain during that procedure. Through a prospective case-control study performed in tertiary centers for women's health, endometrium samples were collected during operative office hysteroscopy from 198 cycling women who previously underwent laparoscopy and/or magnetic resonance imaging investigation for infertility assessment. Samples were classified according to the degree of the pain patients experienced and scored from values ranging from 0 (absence of discomfort/pain) to 10 (intolerable pain) on a 10-cm visual analog scale (VAS). The presence of nerve fiber markers (S100, NSE, SP, VIP, NPY, NKA, NKB, NKR1, NKR2, and NKR3) in the endometrium was also evaluated by morphologic and immunohistochemical analyses. We found that S-100, NSE, NKR1, NK-A, NK-B, VIP, and NPY, were immunolocalized in samples of endometrium, in significantly (P < .01, for all) higher levels in samples collected from patients with VAS score > 5 (group A) than ≤ 5 (group B) and significantly (P < .0001 for all) positively correlated with VAS levels. A statistically significant (P = .018) higher prevalence of endometriosis and/or adenomyosis was depicted in patients of group A than group B. Data from the present study led us to conclude that nerve fibers are expressed at the level of the functional layer of the endometrium and may contribute to pain generation during office hysteroscopy, mainly in women affected by endometriosis and adenomyosis.

Policy Advice during a Crisis

Good policy making is an art. It involves a substantial element of personal judgement about risks and consequences of alternative courses of actions and decisions. It is also a science because it requires systematic gathering and analysis of evidence about a policy issue, and rational assessment of costs and benefits of various ways of addressing the issue. However, in a crisis, there is little time to gather evidence or to search for imaginative solutions to a problem. There is a tendency, in such a situation, to act under pressure rather than on the basis of evidence, analysis or informed judgement. Furthermore, a crisis often creates a situation in which policy makers receive all sorts of advice. This note discusses a set of concepts, originating mainly from economics, that can be used to assess soundness of policy and advice, particularly during a crisis. These are concepts of rationality, sustainability, inclusiveness, feasibility, practicality and tipping, which can be used in decision making in normal and crisis times to reduce risks of disastrous advice or policy.

Human Capital Externalities and Private Returns to Education in Kenya

We use micro data to analyse the effect of human capital externality on earnings and private returns to education. The earnings equations are estimated using the OLS method for a sample of full-time workers. The results show that human capital has a positive effect on earnings, indicating that an increase in education benefits all workers. However, men benefit more from women's education than the women do from men's. The effects of human capital externality on private returns to schooling are shown to vary substantially between rural and urban areas and across levels of the education system.

EDUCAÇÃO E DITADURA MILITAR: RELATOS DA HISTÓRIA OFICIAL E A MEMÓRIA DE PROFESSORES (1964-1985)

A presente pesquisa propõe analisar o contexto educacional ocorrido no período da ditadura militar, buscando extrair aspectos históricos e educacionais referentes ao período (1964- 1985). Trata-se de uma pesquisa realizada com professores do antigo segundo grau da rede pública de ensino do Município de Santo André (S.P). Optou-se por entrevistar seis professores que atuaram durante esse contexto histórico. Para investigar, foi utilizada a abordagem histórica-metodológica de cunho qualitativo, elegendo a memória como fonte principal de estudo. Para tanto, recorreu-se às contribuições de Bosi (Memória e sociedade: lembranças de velhos, 1984), Thompson (A voz do Passado, 1992), Romanelli (História da Educação no Brasil, 1978), Freitag (Escola Estado e Sociedade, 1980), Góes (O golpe na Educação, 1996), Cunha (Educação e Desenvolvimento Social no Brasil, 1977), Cardoso (Para uma crítica do presente, 2001), Vieira (Estado e miséria social no Brasil, 1995), Minguili (Direção de Escola de 2º grau no Estado de São Paulo, 1984), Arelaro (A extensão do ensino básico no Brasil, 1988), Teixeira (Política e administração de pessoal docente, 1988), Hilsdorf (História da educação brasileira, 2005), Gadotti (Educação e poder, 2001), Germano (Estado militar e educação no Brasil, 1990), Saviani (Escola e democracia, 1986), Santos (Professoras em tempos de mudanças, 2003). A hipótese trabalhada centra-se em interpretar a postura dos professores que atuaram no período em questão, relativa ao regime político que se instalou no País durante esta época, e de que forma isso repercutiu no seu trabalho docente. Na análise do contexto político/social e educacional, recorreu-se à revisão que forneceram subsídios para compreender e explicitar a voz do professor.

EDUCAÇÃO E DITADURA MILITAR: RELATOS DA HISTÓRIA OFICIAL E A MEMÓRIA DE PROFESSORES (1964-1985)

A presente pesquisa propõe analisar o contexto educacional ocorrido no período da ditadura militar, buscando extrair aspectos históricos e educacionais referentes ao período (1964- 1985). Trata-se de uma pesquisa realizada com professores do antigo segundo grau da rede pública de ensino do Município de Santo André (S.P). Optou-se por entrevistar seis professores que atuaram durante esse contexto histórico. Para investigar, foi utilizada a abordagem histórica-metodológica de cunho qualitativo, elegendo a memória como fonte principal de estudo. Para tanto, recorreu-se às contribuições de Bosi (Memória e sociedade: lembranças de velhos, 1984), Thompson (A voz do Passado, 1992), Romanelli (História da Educação no Brasil, 1978), Freitag (Escola Estado e Sociedade, 1980), Góes (O golpe na Educação, 1996), Cunha (Educação e Desenvolvimento Social no Brasil, 1977), Cardoso (Para uma crítica do presente, 2001), Vieira (Estado e miséria social no Brasil, 1995), Minguili (Direção de Escola de 2º grau no Estado de São Paulo, 1984), Arelaro (A extensão do ensino básico no Brasil, 1988), Teixeira (Política e administração de pessoal docente, 1988), Hilsdorf (História da educação brasileira, 2005), Gadotti (Educação e poder, 2001), Germano (Estado militar e educação no Brasil, 1990), Saviani (Escola e democracia, 1986), Santos (Professoras em tempos de mudanças, 2003). A hipótese trabalhada centra-se em interpretar a postura dos professores que atuaram no período em questão, relativa ao regime político que se instalou no País durante esta época, e de que forma isso repercutiu no seu trabalho docente. Na análise do contexto político/social e educacional, recorreu-se à revisão que forneceram subsídios para compreender e explicitar a voz do professor.