Strengthening laboratories in response to outbreaks in humanitarian emergencies and conflict settings: Results, challenges and lessons from expanding PCR diagnostic capacities for COVID-19 testing in Yemen

BACKGROUND

When the COVID-19 pandemic was declared, Yemen, a country facing years of conflict had only one laboratory with PCR testing capacity. In this article, we describe the outcome of the implementation of molecular based diagnostics platform in Yemen and highlight the key milestones the country went through to increase access to testing for its populations residing in a geographically vast and politically divided country.

METHODS

A retrospective assessment of COVID-19 laboratory response activities was done detailing the needs assessment process, timelines, geographical coverage, and outcomes of the activities. Laboratory data was analyzed to construct the geographical locations of COVID-19 testing laboratories and the numbers of tests performed in each facility to highlight the demands of testing for travelers. Finally, we discuss the impact these activities had in enabling the movement of people across international borders for economic gains and in delivery of critical humanitarian aid.

OUTCOME

PCR testing capacities in Yemen significantly improved, from one laboratory in Sanaa in April 2020 to 18 facilities across the country by June 2022. In addition, the number of functional Real-Time PCR thermocyclers increased from one to 32, the PCR tests output per day improved from 192 to 6144 tests per day. Results from analysis of laboratory data showed there were four peaks of COVID-19 in Yemen as October 2022. The majority of laboratory tests were performed for travelers than for medical or public health reasons. Demand for laboratory testing in Yemen was generally low and waned over time as the perceived risk of COVID-19 declined, in parallel with rollout of the COVID-19 vaccines.

DISCUSSION/CONCLUSION

The successful expansion of laboratory testing capacity was instrumental in the control and management of COVID-19 cases and critical in the implementation of public response strategies, including restrictions on gathering. Laboratory testing also facilitated the movement of humanitarian agencies and delivery of aid and enabled hundreds of thousands of Yemeni nationals to travel internationally. By virtue of these outcomes, the impact of laboratory strengthening activities was thus felt in the health sector and beyond.

Risk communication and community engagement as an emerging pillar of health emergency management in Iran: Achievements and the way forward

This article is part of the Research Topic Health Systems Recovery in the Context of COVID-19 and Protracted Conflict. Risk communication and community engagement (RCCE) is an essential component of emergency preparedness and response. In Iran, RCCE is a relatively new area of public health. During the COVID-19 pandemic in Iran, the national task force relied on conventional methods, which is to utilize existing primary health care (PHC) structure to implement RCCE activities around the country. The PHC network and the community health volunteers embedded in it enabled the country to bridge the health system and communities from the very beginning of the COVID-19 pandemic. The RCCE strategy to respond to COVID-19 was adapted over time with the development of a national program, commonly known as the "Shahid Qassem Soleimani" project. This project consisted of six steps including case detection, laboratory testing through the establishment of sampling centers, scale up of clinical care to vulnerable groups, contact tracing, home care for vulnerable population, and COVID-19 vaccination roll out. Nearly 3 years into the pandemic, the importance of designing RCCE for all types of emergencies, allocating a dedicated team to RCCE, coordinating with different stakeholders, improving the capacity of RCCE focal points, practicing more efficient social listening, and using social insight for better planning were identified as some lessons learned. Further, Iran's RCCE experience during the COVID-19 pandemic underscores the importance of continuing to invest in the health system, particularly PHC.

Fielding vaccines-challenges and opportunities in outbreaks, complex emergencies, and mass gatherings

With the recent COVID-19 pandemic, the importance of vaccine development, distribution, and uptake has come to the forefront of the public eye. Effectively fielding vaccines during an emergency-whether that emergency is a result of an infectious disease or not-requires an understanding of usual vaccine-related processes; the impact of outbreak, complex emergencies, mass gatherings, and other events on patients, communities, and health systems; and ways in which diverse resources can be applied to successfully achieve needed vaccine uptake. In this review, both the emergency setting and briefly vaccine product design are discussed in these contexts in order to provide a concise source of general knowledge from experts in fielding vaccines that can aid in future vaccine ventures and increase general awareness of the process and barriers in various settings.

Impact of the COVID-19 pandemic on the utilisation of health services at public hospitals in Yemen: a retrospective comparative study

BACKGROUND

The COVID-19 pandemic has led to a global crisis, creating an unprecedented situation, which has taken the world by storm, overshadowing on all life' aspects and having a significant impact on the health systems of most countries. In this study, the delivery of health services is investigated both before and during the outbreak of the COVID-19 pandemic at public hospitals in Yemen to assess the impact of COVID-19 on the utilisation of health services.

METHOD

Data collected from 127 hospitals in Yemen were reviewed using the DHIS2 system. The data represented 3 months before the outbreak of COVID-19 between January and March 2020 and during the outbreak of COVID-19 outbreak between April and June 2020. The results were then compared with the same period in 2019. The utilisation pattern of healthcare services during the period of investigation was compiled and analysed by applying a generalised estimating equation (GEE) to examine the effects of the COVID-19 outbreak in Yemen. The data collected from the targeted hospitals included information related to consultations, surgeries, deliveries, C-sections and penta-3rd dose immunisation.

RESULTS

The trendline of health services used during the pandemic showed a gradual decline beginning from April 2020 for consultations, surgeries and penta-3rd dose utilisation. The GEE model revealed a significant effect (p<0.05) during the outbreak compared with preoutbreak in the consultation services (B=-1,343.9; 95% CI -1,767.2 to -920.6; χ²=38.718), surgeries (B=-54.98; 95% CI -79.13 to -30.83, χ²=19.911) and penta-3rd dose (B=-24.47; 95% CI -30.56 to -18.38 and χ²=62.010). As for deliveries and C-sections, the results were shown to be statistically non-significant.

CONCLUSION

The impact of COVID-19 on continuity of health services delivery in Yemen has been distinct and profound, where the study revealed that the number of the consultations, surgeries and number of vaccinated children have been declined during the COVID-19 pandemic, likely due to the partially lockdown measures taken and fear of being infected. However, the deliveries and C-section services remained nearly in the same level and did not affect by the COVID-19 pandemic.

SARS-CoV-2 Seroprevalence in Aden, Yemen: A population-based study

Background

In Yemen, initial surveillance of coronavirus disease 2019 (COVID-19) focused primarily on patients with symptoms or severe disease. The full spectrum of the disease remains unclear. To the best of the authors’ knowledge, this is the first seroprevalence study performed in Yemen.

Methods

This cross-sectional investigation included 2001 participants from all age groups from four districts in Aden, southern Yemen. A multi-stage sampling method was used. Data were collected using a well-structured questionnaire, and blood samples were taken. Healgen COVID-19 IgG/IgM Rapid Diagnostic Test (RDT) Cassettes were used in all participants. All positive RDTs and 14% of negative RDTs underwent enzyme-linked immunosorbent assay (ELISA) testing (WANTAI SARS-CoV-2 Ab ELISA Kit) for confirmation.

Results

In total, 549 of 2001 participants were RDT positive and confirmed by ELISA, giving a prevalence of COVID-19 of 27.4%. The prevalence of immunoglobulin G was 25%. The prevalence of asymptomatic COVID-19 in the entire study group was 7.9%. The highest prevalence was observed in Al-Mansurah district (33.4%). Regarding sociodemographic factors, the prevalence of COVID-19 was significantly higher among females, housewives and subjects with a history of contact with a COVID-19 patient: 32%, 31% and 39%, respectively.

Conclusion

This study found high prevalence of COVID-19 in the study population. Household transmission was common.

The first 2 months of the SARS-CoV-2 epidemic in Yemen: Analysis of the surveillance data

INTRODUCTION

Yemen was one of the last countries in the world to declare the first case of the pandemic, on 10 April 2020. Fear and concerns of catastrophic outcomes of the epidemic in Yemen were immediately raised, as the country is facing a complex humanitarian crisis. The purpose of this report is to describe the epidemiological situation in Yemen during the first 2 months of the SARS-CoV-2 epidemic.

METHODS

We analyzed the epidemiological data from 18 February to 05 June 2020, including the 2 months before the confirmation of the first case. We included in our analysis the data from 10 out of 23 governorates of Yemen, located in southern and eastern part of the country.

RESULTS

A total of 469 laboratory confirmed, 552 probable and 55 suspected cases with onset of symptoms between 18 February and 5 June 2020 were reported through the surveillance system. The median age among confirmed cases was 46 years (range: 1-90 years), and 75% of the confirmed cases were male. A total of 111 deaths were reported among those with confirmed infection. The mean age among those who died was 53 years (range: 14-88 years), with 63% of deaths (n = 70) occurring in individuals under the age 60 years. A total of 268 individuals with confirmed SARS-CoV-2 infection were hospitalized (57%), among whom there were 95 in-hospital deaths.

CONCLUSIONS

The surveillance strategy implemented in the first 2 months of the SARS CoV 2 in the southern and eastern governorates of Yemen, captured mainly severe cases. The mild and moderate cases were not self-reported to the health facilities and surveillance system due to limited resources, stigma, and other barriers. The mortality appeared to be higher in individuals aged under 60 years, and most fatalities occurred in individuals who were in critical condition when they reached the health facilities. It is unclear whether the presence of other acute comorbidities contributed to the high death rate among SARS-CoV-2 cases. The findings only include the southern and eastern part of the country, which is home to 31% of the total population of Yemen, as the data from the northern part of the country was inaccessible for analysis. This makes our results not generalizable to the rest of the country.

Contact tracing performance during the Ebola virus disease outbreak in Kenema district, Sierra Leone

Contact tracing in an Ebola virus disease (EVD) outbreak is the process of identifying individuals who may have been exposed to infected persons with the virus, followed by monitoring for 21 days (the maximum incubation period) from the date of the most recent exposure. The goal is to achieve early detection and isolation of any new cases in order to prevent further transmission. We performed a retrospective data analysis of 261 probable and confirmed EVD cases in the national EVD database and 2525 contacts in the Contact Line Lists in Kenema district, Sierra Leone between 27 April and 4 September 2014 to assess the performance of contact tracing during the initial stage of the outbreak. The completion rate of the 21-day monitoring period was 89% among the 2525 contacts. However, only 44% of the EVD cases had contacts registered in the Contact Line List and 6% of probable or confirmed cases had previously been identified as contacts. Touching the body fluids of the case and having direct physical contact with the body of the case conferred a 9- and 20-fold increased risk of EVD status, respectively. Our findings indicate that incompleteness of contact tracing led to considerable unmonitored transmission in the early months of the epidemic. To improve the performance of early outbreak contact tracing in resource poor settings, our results suggest the need for prioritized contact tracing after careful risk assessment and better alignment of Contact Line Listing with case ascertainment and investigation.This article is part of the themed issue 'The 2013-2016 West African Ebola epidemic: data, decision-making and disease control'.

Middle East Respiratory Syndrome

Between September 2012 and January 20, 2017, the World Health Organization (WHO) received reports from 27 countries of 1879 laboratory-confirmed cases in humans of the Middle East respiratory syndrome (MERS) caused by infection with the MERS coronavirus (MERS-CoV) and at least 659 related deaths. Cases of MERS-CoV infection continue to occur, including sporadic zoonotic infections in humans across the Arabian Peninsula, occasional importations and associated clusters in other regions, and outbreaks of nonsustained human-to-human transmission in health care settings. Dromedary camels are considered to be the most likely source of animal-to-human transmission. MERS-CoV enters host cells after binding the dipeptidyl peptidase 4 (DPP-4) receptor and the carcinoembryonic antigen–related cell-adhesion molecule 5 (CEACAM5) cofactor ligand, and it replicates efficiently in the human respiratory epithelium. Illness begins after an incubation period of 2 to 14 days and frequently results in hypoxemic respiratory failure and the need for multiorgan support. However, asymptomatic and mild cases also occur. Real-time reverse-transcription–polymerase-chain-reaction (RT-PCR) testing of respiratory secretions is the mainstay for diagnosis, and samples from the lower respiratory tract have the greatest yield among seriously ill patients. There is no antiviral therapy of proven efficacy, and thus treatment remains largely supportive; potential vaccines are at an early developmental stage. There are multiple gaps in knowledge regarding the evolution and transmission of the virus, disease pathogenesis, treatment, and prospects for a vaccine. The ongoing occurrence of MERS in humans and the associated high mortality call for a continued collaborative approach toward gaining a better understanding of the infection both in humans and in animals. MERS-CoV was first identified in September 2012 in a patient from Saudi Arabia who had hypoxemic respiratory failure and multiorgan illness. Subsequent cases have included infections in humans across the Arabian Peninsula, occasional importations and associated clusters in other regions, and outbreaks of nonsustained human-to-human transmission in health care settings (Fig. 1).

Factors Underlying Ebola Virus Infection Among Health Workers, Kenema, Sierra Leone, 2014-2015

BACKGROUND

Ebola virus disease (EVD) in health workers (HWs) has been a major challenge during the 2014-2015 outbreak. We examined factors associated with Ebola virus exposure and mortality in HWs in Kenema District, Sierra Leone.

METHODS

We analyzed data from the Sierra Leone National Viral Hemorrhagic Fever Database, contact tracing records, Kenema Government Hospital (KGH) staff and Ebola Treatment Unit (ETU) rosters, and burial logs.

RESULTS

From May 2014 through January 2015, 600 cases of EVD originated in Kenema District, including 92 (15%) HWs, 66 (72%) of whom worked at KGH. Among KGH medical staff and international volunteers, 18 of 62 (29%) who worked in the ETU developed EVD, compared with 48 of 83 (58%) who worked elsewhere in the hospital. Thirteen percent of HWs with EVD reported contact with EVD patients, while 27% reported contact with other infected HWs. The number of HW EVD cases at KGH declined roughly 1 month after implementation of a new triage system at KGH and the opening of a second ETU within the district. The case fatality ratio for HWs and non-HWs with EVD was 69% and 74%, respectively.

CONCLUSIONS

The cluster of HW EVD cases in Kenema District is one of the largest ever reported. Most HWs with EVD had potential virus exposure both inside and outside of hospitals. Prevention measures for HWs must address a spectrum of infection risks in both formal and informal care settings as well as in the community.

Caring for critically ill patients with ebola virus disease. Perspectives from West Africa

The largest ever Ebola virus disease outbreak is ravaging West Africa. The constellation of little public health infrastructure, low levels of health literacy, limited acute care and infection prevention and control resources, densely populated areas, and a highly transmissible and lethal viral infection have led to thousands of confirmed, probable, or suspected cases thus far. Ebola virus disease is characterized by a febrile severe illness with profound gastrointestinal manifestations and is complicated by intravascular volume depletion, shock, profound electrolyte abnormalities, and organ dysfunction. Despite no proven Ebola virus-specific medical therapies, the potential effect of supportive care is great for a condition with high baseline mortality and one usually occurring in resource-constrained settings. With more personnel, basic monitoring, and supportive treatment, many of the sickest patients with Ebola virus disease do not need to die. Ebola virus disease represents an illness ready for a paradigm shift in care delivery and outcomes, and the profession of critical care medicine can and should be instrumental in helping this happen.

Ebola virus disease in West Africa--the first 9 months of the epidemic and forward projections

BACKGROUND

On March 23, 2014, the World Health Organization (WHO) was notified of an outbreak of Ebola virus disease (EVD) in Guinea. On August 8, the WHO declared the epidemic to be a "public health emergency of international concern."

METHODS

By September 14, 2014, a total of 4507 probable and confirmed cases, including 2296 deaths from EVD (Zaire species) had been reported from five countries in West Africa--Guinea, Liberia, Nigeria, Senegal, and Sierra Leone. We analyzed a detailed subset of data on 3343 confirmed and 667 probable Ebola cases collected in Guinea, Liberia, Nigeria, and Sierra Leone as of September 14.

RESULTS

The majority of patients are 15 to 44 years of age (49.9% male), and we estimate that the case fatality rate is 70.8% (95% confidence interval [CI], 69 to 73) among persons with known clinical outcome of infection. The course of infection, including signs and symptoms, incubation period (11.4 days), and serial interval (15.3 days), is similar to that reported in previous outbreaks of EVD. On the basis of the initial periods of exponential growth, the estimated basic reproduction numbers (R0 ) are 1.71 (95% CI, 1.44 to 2.01) for Guinea, 1.83 (95% CI, 1.72 to 1.94) for Liberia, and 2.02 (95% CI, 1.79 to 2.26) for Sierra Leone. The estimated current reproduction numbers (R) are 1.81 (95% CI, 1.60 to 2.03) for Guinea, 1.51 (95% CI, 1.41 to 1.60) for Liberia, and 1.38 (95% CI, 1.27 to 1.51) for Sierra Leone; the corresponding doubling times are 15.7 days (95% CI, 12.9 to 20.3) for Guinea, 23.6 days (95% CI, 20.2 to 28.2) for Liberia, and 30.2 days (95% CI, 23.6 to 42.3) for Sierra Leone. Assuming no change in the control measures for this epidemic, by November 2, 2014, the cumulative reported numbers of confirmed and probable cases are predicted to be 5740 in Guinea, 9890 in Liberia, and 5000 in Sierra Leone, exceeding 20,000 in total.

CONCLUSIONS

These data indicate that without drastic improvements in control measures, the numbers of cases of and deaths from EVD are expected to continue increasing from hundreds to thousands per week in the coming months.

Effectiveness of educational and social worker interventions to activate patients' discussion and pursuit of preemptive living donor kidney transplantation: a randomized controlled trial

BACKGROUND

Many patients with chronic kidney disease (CKD) have difficulty becoming actively engaged in the pursuit of preemptive living donor kidney transplantation.

STUDY DESIGN

The Talking About Live Kidney Donation (TALK) Study was a randomized controlled trial of the effectiveness of educational and social worker interventions designed to encourage early discussions and active pursuit of preemptive living donor kidney transplantation in patients with progressive CKD.

SETTING & PARTICIPANTS

We recruited participants with progressive CKD from academically affiliated nephrology practices in Baltimore, MD.

INTERVENTION

Participants randomly received: (1) usual care (routine care with their nephrologists), the (2) TALK education intervention (video and booklet), or the (3) TALK social worker intervention (video and booklet plus patient and family social worker visits).

OUTCOMES

We followed participants for 6 months to assess their self-reported achievement of behaviors reflecting their discussions about and/or pursuit of living donor kidney transplantation (discussions with family, discussions with physicians, initiating recipient evaluation, completing recipient evaluation, and identifying a potential living donor).

MEASUREMENTS

We assessed outcomes through a questionnaire at 1-, 3-, and 6-months follow-up.

RESULTS

Participants receiving usual care with their nephrologists (n = 44), TALK education (n = 43), and the TALK social worker (n = 43) were similar at baseline. TALK Study interventions improved participants' living donor kidney transplantation discussion and pursuit behaviors, with the social worker leading to greater patient activation (participants' predicted probability of achieving living donor kidney transplantation discussions, evaluations, or donor identification over 6 months): probabilities were 30% (95% CI, 20%-46%), 42% (95% CI, 33%-54%), and 58% (95% CI, 41%-83%), respectively, in the usual care, TALK education, and TALK social worker groups (P = 0.03).

LIMITATIONS

Our population was well educated and mostly insured, potentially limiting generalizability of our findings.

CONCLUSIONS

TALK interventions improved discussion and active pursuit of living donor kidney transplantation in patients with progressive CKD and may improve their use of preemptive living donor kidney transplantation.

African American and non-African American patients' and families' decision making about renal replacement therapies

We conducted focus group meetings of African American and non-African American patients with end-stage renal disease (six groups) and their family members (six groups), stratified by race/ethnicity and treatment. We elicited differences in participants' experiences with shared decision making about initiating renal replacement therapy (RRT; that is, hemodialysis, peritoneal dialysis, or a kidney transplant). Patients were often very sick when initiating RRT, and had little, if any, time to make a decision about what type of RRT to initiate. They also lacked sufficient information about alternative treatment options prior to initiation. Family members played supportive roles and shared in decision making when possible. Reports were similar for African American and non-African American participants. Our findings suggest that a greater emphasis on the improved engagement of patients and their families in shared decision making about RRT initiation is needed for both ethnic/racial minorities and nonminorities.

Identifying and addressing barriers to African American and non-African American families' discussions about preemptive living related kidney transplantation

CONTEXT

Ethnic/racial minority and nonminority families' perceived barriers to discussing preemptive living related kidney transplantation (LRKT) and their views on the potential value of health care professionals trained to address barriers are unknown. OBJECTIVE, SETTING, AND PARTICIPANTS: To collect pilot data for evaluating perceived barriers to preemptive LRKT and to inform the development of a culturally sensitive intervention to improve families' consideration of LRKT. In 4 structured group interviews of African American and non-African American patients (2 groups) with progressing chronic kidney disease and their family members (2 groups), participants' perceived barriers to initiating LRKT discussions and their views regarding the value of social workers to support discussions were explored.

RESULTS

Patients' barriers included concerns about their (1) ability to initiate discussions, (2) discussions being misinterpreted as donation requests, (3) potential burdening of family members, (4) uncertainty about when to initiate discussions, and (5) inducing guilt or coercing family members. Family members' barriers included (1) feeling overwhelmed by patients' illness, (2) patients' denial about their illness, (3) caregiver stress, and (4) uncertainty about their own health or the health of other family members who might donate or need a kidney in the future. Participants reported that social workers could facilitate difficult or awkward discussions and help families understand the LRKT process, address financial concerns, and cope emotionally. Themes were similar between African Americans and non-African Americans.

CONCLUSIONS

Families identified several barriers to discussing preemptive LRKT that could be addressed by social workers. Further research must be done to determine whether social workers need to tailor interventions to address families' cultural differences.

Protocol of a randomized controlled trial of culturally sensitive interventions to improve African Americans' and non-African Americans' early, shared, and informed consideration of live kidney transplantation: the Talking About Live Kidney Donation (TALK) Study

Background

Live kidney transplantation (LKT) is underutilized, particularly among ethnic/racial minorities. The effectiveness of culturally sensitive educational and behavioral interventions to encourage patients' early, shared (with family and health care providers) and informed consideration of LKT and ameliorate disparities in consideration of LKT is unknown.

Methods/Design

We report the protocol of the Talking About Live Kidney Donation (TALK) Study, a two-phase study utilizing qualitative and quantitative research methods to design and test culturally sensitive interventions to improve patients' shared and informed consideration of LKT. Study Phase 1 involved the evidence-based development of culturally sensitive written and audiovisual educational materials as well as a social worker intervention to encourage patients' engagement in shared and informed consideration of LKT. In Study Phase 2, we are currently conducting a randomized controlled trial in which participants with progressing chronic kidney disease receive: 1) usual care by their nephrologists, 2) usual care plus the educational materials, or 3) usual care plus the educational materials and the social worker intervention. The primary outcome of the randomized controlled trial will include patients' self-reported rates of consideration of LKT (including family discussions of LKT, patient-physician discussions of LKT, and identification of an LKT donor). We will also assess differences in rates of consideration of LKT among African Americans and non-African Americans.

Discussion

The TALK Study rigorously developed and is currently testing the effectiveness of culturally sensitive interventions to improve patients' and families' consideration of LKT. Results from TALK will provide needed evidence on ways to enhance consideration of this optimal treatment for patients with end stage renal disease.

Trial Registration

ClinicalTrials.gov number, NCT00932334

Identifying and Addressing Barriers to African American and Non—African American Families' Discussions about Preemptive Living Related Kidney Transplantation

Context

Ethnic/racial minority and nonminority families' perceived barriers to discussing preemptive living related kidney transplantation (LRKT) and their views on the potential value of health care professionals trained to address barriers are unknown.

Objective, Setting, and Participants

To collect pilot data for evaluating perceived barriers to preemptive LRKT and to inform the development of a culturally sensitive intervention to improve families' consideration of LRKT. In 4 structured group interviews of African American and non—African American patients (2 groups) with progressing chronic kidney disease and their family members (2 groups), participants' perceived barriers to initiating LRKT discussions and their views regarding the value of social workers to support discussions were explored.

Results

Patients' barriers included concerns about their (1) ability to initiate discussions, (2) discussions being misinterpreted as donation requests, (3) potential burdening of family members, (4) uncertainty about when to initiate discussions, and (5) inducing guilt or coercing family members. Family members' barriers included (1) feeling overwhelmed by patients' illness, (2) patients' denial about their illness, (3) caregiver stress, and (4) uncertainty about their own health or the health of other family members who might donate or need a kidney in the future. Participants reported that social workers could facilitate difficult or awkward discussions and help families understand the LRKT process, address financial concerns, and cope emotionally. Themes were similar between African Americans and non—African Americans.

Conclusions

Families identified several barriers to discussing preemptive LRKT that could be addressed by social workers. Further research must be done to determine whether social workers need to tailor interventions to address families' cultural differences.

[A case of acute mediastinitis with pyothorax secondary to peritonsillar abscess]

A 41-year-old man was admitted to a hospital elsewhere because of tonsillitis with high grade fever. On the 9th day of hospitalization, the patient complained of dysphagia and dyspnea. A chest X-ray film and a CT scan showed right pleural effusion and pericardial effusion, and he was referred to our hospital. Immediately after admission, he underwent pericardiotomy to relieve cardiac tamponade, and a right thoracic tube was inserted for pyothorax. Next day, mediastinal drainage was accomplished through a cervical incision and a right thoracotomy. Eight drainage tubes were left in place. Cultures revealed alpha-Streptococcus, Neisseria and group F Streptococci. Continuous closed irrigation with diluted Isodine (povidone iodine) solution was performed. The last extubation of the drainage tube was done on the 140th day after operation. He was cured and discharged on the 162nd day after operation. In patients with extensive acute mediastinitis secondary to deep cervical infection, early complete mediastinal drainage via a cervical and a transthoracic incision is essential.

[A case of aortic valve rupture due to blunt chest trauma]

A case of aortic valve rupture due to blunt chest trauma is presented. 19-year-old man was in good health until he sustained traumatic injury in a traffic accident. He was admitted to a hospital elsewhere because of blunt chest trauma and fractures of the bilateral lower extremities. A heart murmur was detected and echocardiogram revealed marked aortic regurgitation. Then he was referred to our hospital. Progressive congestive heart failure developed. He underwent aortic valve replacement with 25 mm SJM prosthesis 9 days after the injury. The noncoronary cusp was found to be ruptured parallel to and 2 mm from its attachment. His postoperative course was uneventful and he is doing well 4 years and 6 months after operation.

[A case of tricuspid regurgitation due to blunt chest trauma]

A case of tricuspid regurgitation due to blunt chest trauma is presented. A 35-year-old man was in good health until he sustained blunt chest trauma in a traffic accident 17 years ago (in 1972). After that easy fatiguability developed. In 1977, slight tricuspid regurgitation was detected, but he was clinically well and no treatment seemed necessary. In October 1989, he was admitted due to right heart failure. The chest X-ray film showed marked cardiomegaly and ECG revealed atrial fibrillation and complete right bundle branch block. Two-dimensional echocardiogram showed a flail anterior leaflet of the tricuspid valve and severe tricuspid regurgitation. In December 1989, he underwent tricuspid valve replacement with Carpentier-Edwards bioprosthesis. The chordae tendineae to the anterior leaflet of the tricuspid valve were ruptured. Furthermore, an artificial cardiac pacemaker was implanted because of slow atrial fibrillation. His postoperative course was uneventful.

[A case of synchronous multiple primary cancers of the stomach and kidney]

In line with an increase in the incidence of multiple primary cancers, we have encountered a case of synchronous multiple primary cancers of the stomach and the left kidney. The patient, a 69-year-old male, visited our hospital after experiencing epigastric discomfort for three months. An advanced gastric cancer, Borrmann III type, was detected by endoscopic examination. Preoperative abdominal computed tomography also revealed a large low density mass occupying the upper part of the left kidney. On angiography, the left kidney showed a hypervascular mass, showing pooling and tumoral stains, thereby suggesting a renal cell carcinoma. The patient thus underwent a subtotal gastrectomy with an R2 lymph node dissection and a left radical nephrectomy. Histologically, the gastric lesion was a poorly-differentiated adenocarcinoma and the left renal lesion was a renal cell carcinoma of the clear cell type.