Leveraging technology in emergency management: An opportunity to improve compounding and cascading hazards linked to climate change

The Intergovernmental Panel on Climate (IPCC) Sixth Assessment report concluded that we will see an increase in frequency of extreme environmental events around the world including, hurricanes, droughts, and wildfires.1 The report further describes cascading hazards when one hazard triggers another in a series such as extreme heat triggering a collapse of the power grid. The IPCC also discusses compounding hazards as multiple disasters occur at the same time for example a hurricane occurring at the same time as COVID-19 and a mass casualty event prompting a Urban Search & Rescue (USAR) response such as the Surfside and the Florida condo collapse.2 Studies suggest that there are gaps relating to Hazard Mitigation Plans (HMP) in addressing cascading events.3,4

Mass Gathering Event Medical Preparedness and Response: A Review of Canadian Legislation and Guidelines

INTRODUCTION

The mass gathering event (MGE) industry is growing globally, including in countries such as Canada. MGEs have been associated with a greater prevalence of injury and illness when compared with daily life events, despite most participants having few comorbidities. As such, adequate health, safety, and emergency medical planning is required. However, there is no single entity regulating these concerns for MGEs, resulting in the responsibility for health planning lying with event organizers. This study aims to compare the legislative requirements for MGE medical response systems in the 13 provinces and territories of Canada.

METHODS

This study is a cross-sectional descriptive analysis of Canadian legislation. Lists of publicly available legislative requirements were obtained by means of the emergency medical services directors and Health Ministries. Descriptive statistics were performed to compare legislation.

RESULTS

Of the 13 provinces and territories, 10 responded. For the missing 3, a law library review confirmed the absence of specific legislation. Most (n = 6; 60%) provinces and territories referred to provisions in their Public Health laws. Four confirmed that MGE medical response was a municipal or local concern to be addressed by the event organizers.

CONCLUSIONS

No provinces could list specific legislation guiding safety, health, and medical response for an MGE.

AI and crisis leadership: Using the POP-DOC Loop to explore potential implications and opportunities for leaders

In the evolving landscape of crisis leadership and emergency management, artificial intelligence (AI) emerges as a potentially transformative force with far-reaching implications. Utilizing the POP-DOC Loop, a comprehensive framework for crisis leadership analysis and decision-making, this paper delves into the diverse roles that AI is poised to play in shaping the future of crisis planning and response. The POP-DOC Loop serves as a structured methodology, encompassing key elements such as information gathering, contextual analysis informed by social determinants, enhanced predictive modeling, guided decision-making, strategic action implementation, and appropriate communication. Rather than offer definitive predictions, this review aims to catalyze exploration and discussion, equipping researchers and practitioners to anticipate future contingencies. The paper concludes by examining the limitations and challenges posed by AI within this specialized context.

Syndromic Surveillance Implementation During Disaster Events

INTRODUCTION

Disease surveillance is an integral part of public health. These systems monitor disease trends and detect outbreaks, whereas they should be evaluated for efficacy. The United States Centres for Disease Control and Prevention publish Guidelines for Evaluating Surveillance Systems to encourage efficient and effective use of public health surveillance that are accepted worldwide.

OBJECTIVE

This study reviews syndromic surveillance during natural and man-made disasters internationally. It aims to (1) review the performance of syndromic surveillance via pre-specified attributes during disaster and to (2) understand its strengths and limitations.

METHODS

PubMed was systematically searched for the articles assessing syndromic surveillance during a disaster. A narrative review was carried out based on those articles. Updated Guidelines for Evaluating Public Health Surveillance Systems were used to review performance of systems.

RESULTS

5,059 studies from PubMed were evaluated, and 16 met inclusion criteria. The majority of these studies considered the implementation of syndromic surveillance useable during disaster events. Studies described systems giving relevant and timely information. Simplicity and timeliness were the most highlighted attributes.

CONCLUSION

Syndromic surveillance is simple, flexible, useful and usable during a disaster. Timely data can be obtained, but the quality of this type of data is sensitive to incomplete and erroneous reporting; because of this, a standardized approach is necessary to optimize these systems.

Reviewing the Health Care Impacts of Attacks on Critical Infrastructure

INTRODUCTION

Health care provision depends on reliable critical infrastructure (CI) to power equipment and to provide water for medication and sanitation. Attacks on CI limiting such functions can have a profound and prolonged influence on delivery of care.

METHODS

A retrospective analysis of the Global Terrorism Database (GTD) was performed of all attacks occurring from 1970-2020. Data were filtered using the internal database search function for all events where the primary target was "Utilities," "Food or Water Supply," and "Telecommunications." For the purposes of this study, the subtype "Food Supply" was excluded. Events were collated based on year, country, region, and numbers killed and wounded.

RESULTS

The GTD listed 7,813 attacks on CI, with 6,280 of those attacks targeting utilities, leading to 1,917 persons directly killed and 1,377 persons wounded. In total, there were 1,265 attacks targeting telecommunications causing 205 direct deaths and 510 wounded. Lastly, 268 attacks targeted the water supply with 318 directly killed and 261 wounded. Regionally, South America had the most attacks with 2,236, followed by Central America and the Caribbean with 1,390. Based on infrastructure type, the most attacks on utilities occurred in El Salvador (1,061), and the most attacks on telecommunications were in India (140). Peru (46) had the most attacks on its water supply.

CONCLUSION

The regions with the highest number of total attacks targeting CI have historically been in South America, with more attacks against power and utilities than other infrastructure. Although the numbers of persons directly killed and wounded in these attacks were lower than with other target types, the true impacts on lack of health care delivery are not accounted for in these numbers. By understanding the pattern and scope of these attacks, Counter-Terrorism Medicine (CTM) initiatives can be created to target-harden health care-related infrastructure.

Virtual Reality Training in Disaster Medicine: A Systematic Review of the Literature

SUMMARY STATEMENT

Disaster medicine (DM) training aims to recreate stressful, mass casualty scenarios faced by medical professionals in the field with high fidelity. Virtual (VR) and augmented reality (AR) are well suited to disaster training as it can provide a safe, socially distant simulation with a high degree of realism. The purpose of this literature review was to summarize the current use of VR or AR for simulation training of healthcare providers in DM education. A systematic review of peer-reviewed articles was performed from January 1, 2000, to November 21, 2020, on PubMed, Embase, and OVID. Exclusion criteria included non-English articles, computer-generated models without human participants, or articles not relating to DM, VR or AR. Thirty-two articles were included. Triage accuracy was evaluated in 17 studies. Participants reported improved confidence and positive satisfaction after the simulations. The studies suggest VR or AR can be considered for disaster training in addition to other, more traditional simulation methods. More research is needed to create a standardized educational model to incorporate VR and AR into DM training and to understand the relationship between disaster simulation and improved patient care.

Psychosocial interventions and strategies to support young people at mass gathering events: a scoping review

OBJECTIVES

To improve health and safety outcomes at mass gathering events (MGEs) for young attendees, it is essential to understand the psychosocial factors that may influence behaviour so that the implementation of support strategies before, during and after MGEs can be developed to enhance outcomes. This review identifies the psychosocial outcomes that may occur at MGEs, including social connection, substance use, risky behaviours and psychological distress and examines what interventions have been implemented to target these outcomes.

STUDY DESIGN

Scoping review.

METHODS

This study examined MGE psychosocial interventions with predominantly youth attendees was conducted using the Preferred Reporting Items of Systematic reviews and Meta-Analysis extension for Scoping Reviews guidelines. Papers were collected from the databases CINAHL, MEDLINE, Embase and PsycINFO. Titles and abstracts were scanned for relevance, followed by a full-text screening. Information relevant to the research question was extracted from papers meeting the inclusion criteria.

RESULTS

Twenty-six papers met the inclusion criteria. The psychosocial factors that were most studied included social influence, social interactions and psychological stressors, which lead to behaviours such as excessive alcohol consumption, drug taking, risky casual sex and risk taking amongst psychological factors of young attendees. Effective interventions implemented before or during MGEs, such as alcohol-free zones, antidrinking campaigns, psychoeducation and disapproval from parents with regard to drinking alcohol, showed promise in reducing harms.

CONCLUSION

Psychosocial interventions have the potential to reduce harms and enhance well-being for young people attending MGEs. This review has identified gaps and opportunities in the current literature with regard to psychosocial interventions and strategies to support young people at MGEs and makes recommendations to support the development and refinement of evidence-based interventions aimed at young MGE attendees.

Terrorist Attacks in Sub-Saharan Africa from 1970 through 2020: Analysis and Impact from a Counter-Terrorism Medicine Perspective

BACKGROUND

Sub-Saharan Africa (SSA) has become a hotspot for global terrorism, with nearly 50% of global terror-related deaths occurring in SSA in 2021. With a large population and complex geopolitical and social climate, terrorist activity further burdens an already strained medical system. This study provides a retrospective descriptive analysis of terrorist-related activity in SSA from 1970-2020.

METHODS

A retrospective analysis of the Global Terrorism Database (GTD) was performed for the region of SSA from 1970-2020. Data were filtered using the internal database search function for all events in the following countries: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Comoros, the Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, People's Republic of the Congo, Republic of the Congo, Rhodesia, Rwanda, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, South Sudan, Sudan, Swaziland, Tanzania, Togo, Uganda, Zaire, Zambia, and Zimbabwe. Number of attacks, deaths, and injuries, as well as primary weapons types, country where attacks occurred, and primary target types, were collated and analyzed.

RESULTS

A total 19,320 attacks were recorded, resulting in 77,565 deaths and 52,986 injuries. Firearms were the most frequent weapons used (8,745), followed by explosives (6,031), unknown (2,615), and incendiary (1,246), with all others making up the remainder (683.) Private citizens and property were the most frequently targeted entities (8,031), followed by general government facilities (2,582), police (1,854), business (1,446), military (805), diplomatic government facilities (741), and religious figures/institution (678), with all other targets making up the remainder (3,183).

CONCLUSION

The majority of deaths from terrorism in SSA are the result of firearm attacks and explosions. Nigeria, Somalia, South Africa, The Democratic Republic of the Congo, and Sudan have had the largest number of attacks since 1970, and Nigeria has the largest number of people killed and injured. The health implications of terrorist attacks are often compounded by violence and pose unique challenges to governments, populations, and aid organizations. By understanding the impact and scope of terrorist activity in SSA, Counter-Terrorism Medicine (CTM) initiatives can be employed to improve health care outcomes.

Why time matters when it comes to resilience: how the duration of crisis affects resilience of healthcare and public health leaders

The meaning of time, especially in crisis, where situations are likely to become even more complex, uncertain, and disruptive, is crucial. Incorporating previous research on organizational crises, organizational resilience, extreme context, and individual resilience, we know that leaders do play a crucial role when it comes to handle adversity in organizations but also that leaders might influence organizational resilience and employee resilience. Intensified by the COVID-19 pandemic, the leaders' ability to effectively deal with a critical situation becomes even more important in healthcare organizations. We argue that time is not only important when it comes to crisis management but also that it is highly significant when it comes to leaders' resilience. Considering the aspect of time implies that different temporal demands, especially regarding the persistence of adversity, require different resilience strategies applied by the leader. Therefore, we call for future research on examining how different leaders' resilience strategies (short term vs. long term) affect crisis management outcomes as well as the resilience in healthcare and public health organizations.

United States Federal Emergency Management Agency regional clustering by disaster exposure: a new paradigm for disaster response

The Federal Emergency Management Agency (FEMA) divides the United States (US) into ten standard regions to promote local partnerships and priorities. These divisions, while longstanding, do not adequately address known hazard risk as reflected in past federal disaster declarations. From FEMA's inception in 1979 until 2020, the OpenFEMA dataset reports 4127 natural disaster incidents declared by 53 distinct state-level jurisdictions, listed by disaster location, type, and year. An unsupervised spectral clustering (SC) algorithm was applied to group these jurisdictions into regions based on affinity scores assigned to each pair of jurisdictions accounting for both geographic proximity and historical disaster exposures. Reassigning jurisdictions to ten regions using the proposed SC algorithm resulted in an adjusted Rand index (ARI) of 0.43 when compared with the existing FEMA regional structure, indicating little similarity between the current FEMA regions and the clustering results. Reassigning instead into six regions substantially improved cluster quality with a maximized silhouette score of 0.42, compared to a score of 0.34 for ten regions. In clustering US jurisdictions not only by geographic proximity but also by the myriad hazards faced in relation to one another, this study demonstrates a novel method for FEMA regional allocation and design that may ultimately improve FEMA disaster specialization and response.

Variance Analysis of Expatriate Pre-Hospital Provider Training in Bahrain

Introduction

The absence of local Emergency Medical Services (EMS) educational programs in Bahrain has given rise to an EMS workforce comprised predominantly of expatriate personnel with varying educational backgrounds that require further training before being licensed as EMS providers in Bahrain.

Methods

A qualitative variance analysis was performed comparing desired core competencies for EMS practice in neighbouring Saudi Arabia, used as a comparator for Bahrain, with core competencies extracted from national curricula of the major countries from which expatriate providers originate.

Results

Major core competencies not covered by the expatriate providers’ curricula were identified as follows: working in an autonomous environment, requiring different critical thinking and decision-making skills, assessment and treatment during transportation, disaster response, EMS knowledge base, and coping with the different stressors of the prehospital environment.

Conclusion

These results can form the basis for additional customized training programs for expatriate EMS providers working in Bahrain, with the goal of improving and standardizing EMS care in the country.

Chemical Warfare Agents in Terrorist Attacks: An Interregional Comparison, Tactical Response Implications, and the Emergence of Counterterrorism Medicine

BACKGROUND

Terrorist attacks are growing in frequency, increasing concerns about chemical warfare agents (CWAs). Asphyxiants (e.g., cyanide), opioids (e.g., carfentanyl), and nerve agents (e.g., ricin) represent some of the most lethal CWAs. Our aim was to define the epidemiology of CWA use in terrorism and detail specific agents used to allow for the development of training programs for responders.

METHODS

The open-source Global Terrorism Database (GTD) was searched for all chemical attacks from January 1, 1970, to December 31, 2018. Attacks were included when they fulfilled the terrorism-related criteria as set forth in the internal Codebook of the GTD. Events meeting only partial criteria were excluded.

RESULTS

A total of 347 terrorism-related chemical events occurred, with 921 fatalities and 13,361 nonfatal injuries (NFIs) recorded during the study period. South Asia accounted for nearly 30% (101 of 347) of CWA attacks, with 73 of 101 occurring in Afghanistan. The Taliban was implicated in 40 of 101 events utilizing a mixture of agents, including unknown chemical gases (likely representing trials of a number of different chemicals), contamination of water sources with pesticides, and the use of corrosive acid. The largest death toll from a single event (200 fatalities) was attributed to a cult-related mass murder in the Kasese District of Uganda in March 2000. East Asia sustained the highest NFI toll of 7,007 as a result of chemical attacks; 5,500 were attributed to the Tokyo subway sarin gas attack of 1995 by Aum Shinrikyo.

CONCLUSION

The use of CWAs remains a concern given the rising rate of terrorist events. First responders and healthcare workers should be aware of potential chemical hazards that have been used regionally and globally and should train and prepare to respond appropriately.

Supervisory influence

Purpose

The purpose of this paper is to examine the development of leader potential in an extreme context – it develops and tests a model that describes how subordinate perceptions of individual-focused transformational leadership, subordinate trust in the leader and subordinate identification with the team influence supervisory evaluations of subordinate crisis leader potential.

Design/methodology/approach

Surveys were administered to emergency services personnel and their supervisors working in a large fire rescue organization in the Southeastern USA. Survey responses were analyzed using hierarchical regression.

Findings

Results support the theoretical model – subordinates reporting high levels of trust in their transformational leader were evaluated by their supervisors as having stronger potential to become crisis leaders. Lower levels of subordinate identification with the team strengthened the transformational leadership to trust association and the indirect effect of perceived transformational leadership on supervisory evaluations of subordinate crisis leader potential (through subordinate trust in the leader).

Practical implications

Supervisors who are viewed as transformational and fostering trusting relationships by subordinates are more likely to evaluate subordinates as having the potential to lead in crisis situations. In an extreme context within an organization facing change, subordinates who identify less with their team might build a more trusting relationship with a leader who is perceived as demonstrating transformational behaviors.

Social implications

Subordinate focus on the leader appears to enhance supervisory evaluations of subordinate potential (for leader development) in the study. Individual-level rewards for employees that involve competition might counter efforts toward shared mental models and remain the greatest challenge in the public emergency services setting.

Originality/value

Evaluating leader development, in terms of crisis leader potential, in an extreme context using a process model – to understand the interplay of individual-focused transformational leadership and trust given the moderating effect of team identification – is a key strength of the current study.

Strategies and perceived barriers to recruitment of underrepresented minority students in physician assistant programs

PURPOSE

The purpose of this descriptive cross-sectional study was to identify the characteristics and effectiveness of recruitment strategies for underrepresented minorities (URM) and barriers to URM applicants to physician assistant programs.

METHODS

A 108-question survey was e-mailed to 168 physician assistant programs; 36 partial and 67 fully completed surveys were returned. The fully completed surveys were used in the data analysis. Participants were asked about the use of 20 recruitment strategies and the importance of 34 perceived barriers to enrollment of URM applicants.

RESULTS

Of the 20 recruitment strategies, only 4 were used by close to 50% or more of programs: site visits (61.2%), preadmission counseling (58.2%), student loans (57.6%), and presentations targeted to minority students (47.8%). Only 9% of programs used enrichment courses, but this strategy was rated as most effective. Of the 34 barriers, the most frequent was low undergraduate grade point average (GPA) (82.5%). Self-reported success in recruitment was correlated with increased URM matriculation. Higher proportion of African American and Hispanic faculty on admissions committees was correlated with increased rates of URM matriculation. According to a similar survey, compared with medical schools, physician assistant programs use URM recruitment strategies less frequently and perceive financial barriers as a larger problem.

CONCLUSIONS

The academically competitive physician assistant applicant pool decreases the need for recruitment of all students. Use of GPA and standardized test scores as sole criteria for admission and lack of recruitment of URM students lead to a decrease in diversity. If the physician assistant profession desires to improve student diversity in programs, they should consider using a more holistic approach for the admission process, which may allow for a more flexible and individualized review of applicants.

Airway management in the air medical setting

BACKGROUND

Airway management is a key component of air medical care for seriously ill and injured patients. This meta-analysis of the prehospital airway management literature explored the pooled air-medical placement success rates for oral endotracheal intubation (OETI), including rapid sequence intubation (RSI) and drug-facilitated intubation (DFI), nasotracheal intubation (NTI), blind insertion airway devices (BIAD), and surgical cricothyrotomy (SCRIC).

METHODS

We performed a systematic literature search for all English language articles reporting success rates for airway procedures performed in the prehospital setting. After identifying articles specific to the air-medical environment, pooled estimates of success rates for each airway technique were calculated using a random effects meta-analysis model.

RESULTS

Thirty-six unique studies, encompassing 4,574 procedures, reported airway management success rates in the air medical environment. The pooled estimates (95% CI) for intervention success across all clinicians and patients were: OETI (without RSI/DFI): 86.4% (81.2%-90.3%); DFI: 95.1% (84.1%-98.6%); RSI: 96.7% (94.8%-97.9%); NTI: 76.1% (71.9%-79.9%); BIAD: 94.0% (85.8%-97.6%); and SCRIC: 90.8% (80.6%-95.9%).

CONCLUSION

We provide pooled estimates for airway management procedural success rates in the air medical setting. These data can be used by program managers and medical directors in determining the most appropriate airway management procedures to incorporate into their services and for benchmarking in quality improvement activities.

A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates

BACKGROUND

Airway management is a key component of prehospital care for seriously ill and injured patients. Oral endotracheal intubation (OETI) is the definitive airway of choice in most emergency medical services (EMS) systems. However, OETI may not be an approved skill for some clinicians or may prove problematic in certain patients because of anatomic abnormalities, trauma, or inadequate relaxation. In these situations alternative airways are frequently employed. However, the reported success rates for these devices vary widely, and established benchmarks are lacking.

OBJECTIVE

We sought to determine pooled estimates of the success rates of alternative airway devices (AADs) and needle cricothyrotomy (NCRIC) and surgical cricothyrotomy (SCRIC) placement through a meta-analysis of the literature.

METHODS

We performed a systematic literature search for all English-language articles reporting success rates for AADs, SCRIC, and NCRIC. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique were calculated using a random-effects meta-analysis model.

RESULTS

Of 2,005 prehospital airway titles identified, 35 unique studies were retained for analysis of AAD success rates, encompassing a total of 10,172 prehospital patients. The success rates for SCRIC and NCRIC were analyzed across an additional 21 studies totaling 512 patients. The pooled estimates (and 95% confidence intervals [CIs]) for intervention success across all clinicians and patients were as follows: esophageal obturator airway-esophageal gastric tube airway (EOA-EGTA) 92.6% (90.1%-94.5%); pharyngeotracheal lumen airway (PTLA) 82.1% (74.0%-88.0%); esophageal-tracheal Combitube (ETC) 85.4% (77.3%-91.0%); laryngeal mask airway (LMA) 87.4% (79.0%-92.8%); King Laryngeal Tube airway (King LT) 96.5% (71.2%-99.7%); NCRIC 65.8% (42.3%-83.59%); and SCRIC 90.5% (84.8%-94.2%).

CONCLUSIONS

We provide pooled estimates for prehospital AAD, NCRIC, and SCRIC airway interventions. Of the AADs, the King LT demonstrated the highest insertion success rate (96.5%), although this estimate is based on limited data, and data regarding its ventilatory effectiveness are lacking; more data are available for the ETC and LMA. The ETC, LMA, and PTLA all had similar-but lower-success rates (82.1%-87.4%). NCRIC has a low rate of success (65.8%); SCRIC has a much higher success rate (90.5%) and should be considered the preferred percutaneous rescue airway.

Disorders of temperature regulation: prehospital implications

Humans are warm-blooded mammals and must maintain a constant internal temperature. Body temperature is controlled by the hypothalamus in the brain, with input from sensory receptors throughout the body. At any given time, body temperature is a function of heat production and heat loss. Temperature-regulation problems can result in several conditions. These include fever, hyperthermia and hypothermia. EMTs and paramedics must be familiar with the physiological and pathophysiological processes resulting from these disorders. By close observation of the patient, it should be fairly easy to determine which underlying processes are causing the observed signs and symptoms. With this knowledge, you can provide competent, compassionate prehospital care.

[Kearns-Sayre syndrome]

The authors describe a rare group of symptoms, resulting in progressive external ophthalmoplegia, retinal pigment epithelial dysfunction and cardiac conduction disturbance. The illness belongs to the group of mitochondrial cytopathies. The case extends over the diagnostic possibilities, with special attention on electromyographic diagnostic, clinical symptoms, pathomechanism of the disease, and the therapic possibilities.

[A case of herpes simplex encephalitis requiring surgical management]

The authors report about surgical treatment of herpes simplex encephalitis, although conservative management of this disease is the method of choice in the first place. They draw a lesson from this case that certain cases of large space occupying lesions of infectious origin leading to brain stem compression may require surgical management, even if they customary treatment is conservative.

[Management of polycystic liver by cyst puncture and alcoholic sclerosing]

A case of a 51-year-old female suffering in polycystic liver disease is presented. The patient had bulging upper abdomen, pain in the right subcostal region originating perhaps from the stretching liver capsule and a considerably shortened prothrombin time. Only minor portions of liver tissue could be detected by imaging methods, therefore surgical solution was not suggested. In order to maintain the hepatic function by reducing the compression of the functioning tissue, US-guided multiple cyst punctures were performed with sclerotisation of the cysts. Following the multi-stage procedures the size of liver decreased, the hepatic function gradually improved. In accordance with the literature the authors recommend the multi-stage cyst puncture and sclerotisation as beneficial therapy of polycystic liver disease with minor risk, without burden general anesthesia and minimal on the patients.

[Total gastrectomy with esophageal exclusion following corrosive injury to the upper gastrointestinal tract]

A case report of a young male patient is demonstrated who has drunk hydrochloric acid with intention of suicide. Because of an extensive necrosis of the stomach, total gastrectomy with double exclusion of the esophagus and with jejunostomy was performed as an acute intervention. 6 weeks after the acute operation, a successful esophagojejunal bypass was carried out using the right colon. It is well-known from the literature that a mucocele can develop in the excluded esophagus after such an operation. In some cases the mucocele causes compression signs. For this reason, a regular control of these patients is suggested.

[Diagnostic imaging of the subdiaphragmatic lymphatic system in malignant lymphoma: confusion of abundance?]

Staging of malignant lymphomas, monitoring of response to therapy and regular follow-up of treated patients can properly be performed by new diagnostic imaging modalities. Diagnosis of subdiaphragmatic nodal involvement by ultrasonography and computed tomography is based on enlargement of lymph nodes. Lymphography is the only method which can depict pathologic internal architecture in normal sized lymph nodes. Of 82 patients there were 72 on admission without known subdiaphragmatic nodal disease. Of these 22 (30.5%) were found to have nodal involvement in this region. Suggested diagnostic algorhythm is shown on flow diagram.

Renal cell carcinoma: value of imaging examinations in diagnosis and staging

Authors analyse the value of intravenous pyelography, ultrasonography, computed tomography, angiography and fine needle aspiration biopsy in the detection, differentiation and staging of renal space-occupying lesions, on the basis of examinations performed in 158 patients, in comparison with results of surgery and/or clinical follow up. Their conclusion is that ultrasonography plays a major role in the detection and differentiation of these lesions, intravenous pyelography is only a complementary method, while computed tomography can provide diagnosis in cases with uncertain ultrasonographic findings. Staging has to be based on computed tomography. The role of angiography and fine needle aspiration biopsy is limited they need to be performed in a few selected cases only.

Hodgkin's disease in the Waldeyer's ring

Amongst 128 patients with Hodgkin's disease six were found to have involvement of Waldeyer's lymphoid ring, one in tonsil and five in nasopharynx. Of these, three were histologically verified by biopsies taken from Waldeyer's ring, whilst three had histology only from upper cervical lymph nodes. Disease was confined to head and neck area by five, one had a more widespread process. Discussing diagnostic difficulties of nasopharyngeal involvement the importance of roentgentomography is stressed. Principles of radiotherapy are expounded and a more diligent search for detecting nasopharyngeal disease is proposed.