Skill-Biased Technological Change and the Real Exchange Rate

We sketch a model that shows how skill-biased technological change may reverse the classic Balassa-Samuelson effect, leading to a negative relationship between the productivity in the tradable sector and the real exchange rate. In a small open economy, export goods are produced with capital, high-skilled and low-skilled labor, and traded for imported consumption goods. Non-tradable services are produced with low-skilled labor only. A rise in the productivity of capital has two effects: (1) It may reduce the demand for labor in the tradable sector if the substitutability of low-skilled labor and capital in the tradable sector is high; and (2) it increases the demand for non-tradables and its labor input. Overall demand for low-skilled labor declines if the labor force of the tradable sector is large relative to the labor force of the non-tradable sector. This leads to lower wages and thus to lower prices and a real exchange rate depreciation

Over-the-scope-clip closure of long lasting gastrocutaneous fistula after percutaneous endoscopic gastrostomy tube removal in immunocompromised patients: A single center case series

Over-the-scope-clips (OTSC(®)) have been shown to be an effective and safe endoscopic treatment option for the closure of gastrointestinal perforations, leakages and fistulae. Indications for endoscopic OTSC(®) treatment have grown in number and also include gastro cutaneous fistula (GCF) after percutaneous endoscopic gastrostomy (PEG) tube removal. Non-healing GCF is a rare complication after removal of PEG tubes and may especially develop in immunosuppressed patients with multiple comorbidities. There is growing evidence in the literature that OTSC(®) closure of GCF after PEG tube removal is emerging as an effective, simple and safe endoscopic treatment option. However current evidence is limited to the geriatric population and short standing GCF, while information on closure of long standing GCF after PEG tube removal in a younger population with significant comorbidities is lacking. In this retrospective single-center case-series we report on five patients undergoing OTSC(®) closure of chronic GCF after PEG tube removal. Four out of five patients were afflicted with long lasting, symptomatic fistulae. All five patients suffered from chronic disease associated with a catabolic metabolism (cystic fibrosis, chemotherapy for neoplasia, liver cirrhosis). The mean patient age was 43 years. The mean dwell time of PEG tubes in all five patients was 808 d. PEG tube dwell time was shortest in patient 5 (21 d). The mean duration from PEG tube removal to fistula closure in patients 1-4 was 360 d (range 144-850 d). The intervention was well tolerated by all patients and no adverse events occured. Successful immediate and long-term fistula closure was accomplished in all five patients. This single center case series is the first to show successful endoscopic OTSC(®) closure of long lasting GCF in five consecutive middle-aged patients with significant comorbidities. Endoscopic closure of chronic persistent GCF after PEG tube removal using an OTSC(®) was achieved in all patients with no immediate or long-term complications. OTSC(®) is a promising endoscopic treatment option for this condition with a potentially high immediate and long term success rate in patients with multiple comorbidities

Splenic duplication: a rare cause of acute upper gastrointestinal bleeding

Acute gastrointestinal bleeding represents a common medical emergency. We report the rare case of acute upper gastrointestinal bleeding caused by varices in the gastric fundus secondary to splenic duplication. Splenic duplication has been only rarely reported in the literature, and no case so far has described the associated complication of gastrointestinal bleeding, caused by venous drainage of the upper spleen via varices in the gastric fundus. We describe the imaging findings from endoscopy, endosonography, computed tomography (CT), flat-panel CT, and angiography in this rare condition and illustrate the effective role of intra-arterial embolizatio

Endoscopic vacuum therapy (EVT) for early infradiaphragmal leakage after bariatric surgery—outcomes of six consecutive cases in a single institution

Purpose Anastomotic leakages or staple line defects after Roux-en-Y gastric bypass (RYGB) and primary laparoscopic sleeve gastrectomy (LSG), respectively, with consecutive bariatric revisional surgery are associated with relevant morbidity and mortality rates. Endoscopic vacuum therapy (EVT) with or without stent-over-sponge (SOS) has been shown to be a promising therapy in foregut wall defects of various etiologies and may therefore be applied in the treatment of postbariatric leaks. Methods We report the results of six consecutive patients treated with EVT (83% in combination with SOS) for early postoperative leakages in close proximity to the esophagogastric junction (EGJ) after LSG (n = 2) and RYGB (n = 4) from May 2016 to May2018. Results All patients (2/6 male, median age 51 years, median BMI 44.2 kg/m2) were treated successfully without further signs of persisting leakage at the last gastroscopy. The lesions’ size ranged from 0.5 cm2 to 9 cm2, and the leaks were connected to large (max. 225 cm2) abscess cavities in 80% of the cases. Median duration of treatment (= EVT in situ) was 23.5 days (range, 7–89). The number of endoscopic interventions ranged from 1 to 24 (median, n = 7), with a median duration between vacuum sponge replacements of 4 days. Conclusion EVT is an effective and safe treatment for staple line defects or anastomotic leakage after bariatric surgeries and can therefore be adopted for the treatment of midgut wall defects. Further studies with a greater number of patients comparing surgical drainage alone or in combination with EVT versus EVT alone are needed

A Systematic Review of the Perforated Duodenal Diverticula: Lessons Learned from the Last Decade

Background: The perforated duodenal diverticulum remains a rare clinical entity, the optimal management of which has not been well established. Historically, primary surgery has been the preferred treatment modality. This was called into question during the last decade, with the successful application of non-operative therapy in selected patients. The aim of this systematic review is to identify cases of perforated duodenal diverticula published over the past decade and to assess any subsequent evolution in treatment. Methods: A systematic review of English and non-English articles reporting on perforated duodenal diverticula using MEDLINE (2008-2020) was performed. Only cases of perforated duodenal diverticula in adults (> 18 years) that reported on diagnosis and treatment were included. Results: Some 328 studies were identified, of which 31 articles met the inclusion criteria. These studies included a total of 47 patients with perforated duodenal diverticula. This series suggests a trend towards conservative management with 34% (16/47) of patients managed non-operatively. In 31% (5/16) patients initially managed conservatively, a step-up approach to surgical intervention was required. Conclusion: Conservative treatment of perforated duodenal diverticula appears to be an acceptable and safe treatment strategy in stable patients without signs of peritonitis under careful observation. For patients who fail to respond to conservative treatment, a step-up approach to percutaneous drainage or surgery can be applied. If surgery is required, competence in techniques ranging from simple diverticulectomy to Roux-en-Y gastric diversion or even Whipple's procedure may be required depending on tissue friability and diverticular collar size. Keywords: Duodenal diverticulum; Duodenum; Management; Perforation

Diagnosis of Gastric Cancer in the Excluded Stomach After RYGB by Jejunogastrostomy Using a LAMS

For patients after bariatric surgery, diagnosis of gastric cancer is a challenge. We present a patient after Roux-en-Y gastric bypass with upper abdominal pain and abnormal computed tomography scan with diffuse wall thickening of the gastric antrum. Various biopsy techniques have been described, with surgical (laparoscopic) exploration being the most common. We were able to successfully diagnose gastric cancer in the excluded stomach by biopsy using a jejunogastrostomy, which proved to be safe and effective

The rainy season in the Southern Peruvian Andes: A climatological analysis based on the new Climandes index

The rainy season is of high importance for livelihoods in the Southern Peruvian Andes (SPA), especially for agriculture, which is mainly rain fed and one of the main income sources in the region. Therefore, knowledge and predictions of the rainy season such as its onset and ending are crucial for planning purposes. However, such information is currently not readily available for the local population. Moreover, an evaluation of existing rainy season indices shows that they are not optimally suited for the SPA and may not be directly applicable in a forecasting context. Therefore, we develop a new index, named Climandes index, which is tailored to the SPA and designed to be of use for operational monitoring and forecasting purposes. Using this index, we analyse the climatology and trends of the rainy season in the SPA. We find that the rainy season starts roughly between September and January with durations between 3 and 8 months. Both onset and duration show a pronounced northeast-southwest gradient, regions closer to the Amazon Basin have a considerably longer rainy season. The inter-annual variability of the onset is very high, that is, 2–5 months depending on the station, while the end of the rainy season shows a much lower variability (i.e., 1.5–3 months). The spatial patterns of total precipitation amount and dry spells within the rainy season are only weakly related to its timing. Trends in rainy season characteristics since 1965 are mostly weak and not significant, but generally indicate a tendency towards a shortening of the rainy season in the whole study area due to a later onset and an increase in precipitation sums during the rainy season in the northwestern study area

An investigation into the association of the physical fitness of equestrians and their riding performance : a cross-sectional study

Poor riding performance may be due to medical issues with the horse or a variety of other factors, such as inadequate equipment or deficiencies in training. The physical fitness of the equestrian is one of the most unexplained factors of current research. The aim of this study is to investigate the association between the physical fitness of the equestrian and riding performance. 115 equestrians were assessed for physical fitness and riding performance. Seven components of physical fitness (balance, endurance, flexibility, reaction, speed, strength, symmetry) were measured by a physiotherapist using equestrian-specific tests. Based on a video-recorded riding test, individual riding performance was rated by two equestrian judges. The riding test included the horse and rider performing a walk, sitting trot, rising trot and canter in both directions. A linear model for riding performance, including the domains of physical fitness and potential confounders (body-mass-index, riding experience, hours of riding per week, and test-motivation), was fitted to the data. Inter-rater reliability of the judges was investigated by calculating the intraclass correlation coefficient (ICC). Endurance, reaction and strength were positively associated with riding performance, whereas flexibility had a negative association. The final model could explain 16.7% of the variance in riding performance. The effects of endurance and strength were significant (P<0.05), but not that of reaction. No association with riding performance was found for the components of balance, speed and symmetry. The inter-rater reliability of judges was confirmed to be ‘good’ to ‘excellent’ (ICC=0.9, 95% confidence interval: 0.86-0.93). Findings suggest that physical fitness is positively associated with riding performance. Fitness-training for equestrians should be included in current training concepts. Future research should investigate whether similar associations exist for junior and elite athletes

Pre-Emptive Endoluminal Negative Pressure Therapy at the Anastomotic Site in Minimally Invasive Transthoracic Esophagectomy (the preSPONGE Trial): Study Protocol for a Multicenter Randomized Controlled Trial

Introduction: Anastomotic leakage (AL) accounts for a significant proportion of morbidity following oesophagectomy. Endoluminal negative pressure (ENP) therapy via a specifically designed polyurethane foam (EsoSponge®, B.Braun Medical, Melsungen, Germany) has become the standard of care for AL in many specialized centres. The prophylactic (pENP) application of this technique aims to reduce postoperative morbidity and is a novel approach which has not yet been investigated in a prospective study. The aim of this study is therefore to assess the effect of pENP at the anastomotic site in high-risk patients undergoing minimally invasive transthoracic Ivor Lewis oesophagectomy. Methods and analysis: The study design is a prospective, multi-centre, two-arm, parallel-group, randomised controlled trial and will be conducted in two phases. Phase one is a randomised feasibility and safety pilot trial involving 40 consecutive patients. After definitive sample size calculation, additional patients will be included accordingly during phase two. The primary outcome of the study will be the postoperative length of hospitalization until reaching previously defined “fit for discharge criteria”. Secondary outcomes will include postoperative morbidity, mortality and postoperative AL-rates based on 90-day follow-up. A confirmatory analysis based on intention-to-treat will be performed. Ethics and dissemination: The ethics committee of the University of Zurich approved this study (2019-00562), which has been registered with ClinicalTrials.gov on 14.11.2019 (NCT04162860) and the Swiss National Clinical Trials Portal (SNCTP000003524). The results of the study will be published and presented at appropriate conferences