An Analysis of Injured Patients Treated at Level 1 Trauma Centers Versus Other Centers: A Scoping Review.

INTRODUCTION: Trauma systems continue to evolve to create the best outcomes possible for patients who have undergone traumatic injury. OBJECTIVE: This review aims to evaluate the existing research on outcomes based on field triage to a Level 1 trauma center (L1TC) compared to other levels of hospitals and nontrauma centers. METHODS: A structured literature search was conducted using PubMed, CINAHL, Embase, and the Cochrane Database. Studies analyzing measures of morbidity, mortality, and cost after receiving care at L1TCs compared to lower-level trauma centers and nontrauma centers in the United States and Canada were included. Three independent reviewers reviewed abstracts, and two independent reviewers conducted full-text review and quality assessment of the included articles. RESULTS: Twelve thousand five hundred fourteen unique articles were identified using the literature search. 61 relevant studies were included in this scoping review. 95.2% of included studies were national or regional studies, and 96.8% were registry-based studies. 72.6% of included studies adjusted their results to account for injury severity. The findings from receiving trauma care at L1TCs vary depending on severity of injury, type of injury sustained, and patient characteristics. Existing literature suffers from limitations inherent to large de-identified databases, making record linkage between hospitals impossible. CONCLUSIONS: This scoping review shows that the survival benefit of L1TC care is largest for patients with the most severe injuries. This scoping review demonstrates that further research using high-quality data is needed to elucidate more about how to structure trauma systems to improve outcomes for patients with different severities of injuries and in different types of facilities.

Providers' Perceptions Versus Practices Inform Pediatric Colorectal Enhanced Recovery After Surgery Implementation.

INTRODUCTION: There are many barriers to the implementation of an enhanced recovery after surgery (ERAS) pathway. The aim of this study was to compare surgeon and anesthesia perceptions with current practices prior to the initiation of an ERAS protocol in pediatric colorectal patients and to use that information to inform ERAS implementation. METHODS: This was a mixed method single institution study of barriers to implementation of an ERAS pathway at a free-standing children's hospital. Anesthesiologists and surgeons at a free-standing children's hospital were surveyed regarding current practices of ERAS components. A retrospective chart review was performed of 5- to 18-y-old patients undergoing colorectal procedures between 2013 and 2017, followed by the initiation of an ERAS pathway, and a prospective chart review for 18 mo postimplementation. RESULTS: The response rate was 100% (n = 7) for surgeons and 60% (n = 9) for anesthesiologists. Preoperative nonopioid analgesics and regional anesthesia were rarely used. Intraoperatively, 54.7% of patients had a fluid balance of <10 cc/kg/h and normothermia was achieved in only 38.7%. Mechanical bowel prep was frequently utilized (48%). Median nil per os time was significantly longer than required at 12 h. Postoperatively, 42.9% of surgeons reported that patients could have clears on postoperative day zero, 28.6% on postoperative day one, and 28.6% after flatus. In reality, 53.3% of patients were started on clears after flatus, with a median time of 2 d. Most surgeons (85.7%) expected patients to get out of bed once awake from anesthesia; however, median time that patients were out of bed was postoperative day one. While most surgeons reported frequent use of acetaminophen and/or ketorolac, only 69.3% received any nonopioid analgesic postoperatively, with only 41.3% receiving two or more nonopioid analgesics. Nonopioid analgesia showed the highest rates of improvement from retrospective to prospective: preoperative use of analgesics increased from 5.3% to 41.2% (P < 0.0001), postoperative use of acetaminophen increased by 27.4% (P = 0.5), Toradol by 45.5% (P = 0.11), and gabapentin by 86.7% (P < 0.0001). Postoperative nausea/vomiting prophylaxis with >1 class of antiemetic increased from 8% to 47.1% (P < 0.001). The length of stay was unchanged (5.7 versus 4.4 d, P = 0.14). CONCLUSIONS: For the successful implementation of an ERAS protocol, perceptions versus reality must be assessed to determine current practices and identify barriers to implementation.

Stress across generations: A qualitative study of stress, coping, and caregiving among Mexican immigrant mothers.

OBJECTIVE: Hispanic immigrants represent the largest and fastest growing ethnic minority within the US, justifying increased attention to identify factors that influence declining immigrant health across generations. This study investigates the range of psychosocial stress exposures and coping mechanisms of Mexican immigrant mothers, and implications for the health of their US-born children. DESIGN: We conducted 10 focus groups with 1st generation Mexican-born immigrant mothers (n = 32 women) in Nashville, TN, in the summer of 2014. Focus groups elicited challenges and benefits of life as an immigrant mother. Data were analyzed using a modified grounded theory approach. RESULTS: We identified four themes that indicate how maternal stressors could impact children's health: (1) work-family tradeoff, (2) limited freedom/mobility, (3) reduction of social networks, and (4) transmission of anxiety and fears to children. Women in our study also engage in a range of coping mechanisms, including the creation of new social networks, seeking support in religion, and seeking help from community resources. CONCLUSION: These results highlight the importance of developing new questionnaires to elicit stress exposures for Mexican immigrant mothers. Findings also suggest the value of intervention strategies and social policies that would ultimately improve maternal and child health in this marginalized population.

Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina.

OBJECTIVES: Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability. METHODS: This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural). RESULTS: Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends. CONCLUSIONS: In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources.

Frontal noradrenergic and cholinergic transients exhibit distinct spatiotemporal dynamics during competitive decision-making.

Norepinephrine (NE) and acetylcholine (ACh) are neuromodulators that are crucial for learning and decision-making. In the cortex, NE and ACh are released at specific sites along neuromodulatory axons, which would constrain their spatiotemporal dynamics at the subcellular scale. However, how the fluctuating patterns of NE and ACh signaling may be linked to behavioral events is unknown. Here, leveraging genetically encoded NE and ACh indicators, we use two-photon microscopy to visualize neuromodulatory signals in the superficial layer of the mouse medial frontal cortex during decision-making. Head-fixed mice engage in a competitive game called matching pennies against a computer opponent. We show that both NE and ACh transients carry information about decision-related variables including choice, outcome, and reinforcer. However, the two neuromodulators differ in their spatiotemporal pattern of task-related activation. Spatially, NE signals are more segregated with choice and outcome encoded at distinct locations, whereas ACh signals can multiplex and reflect different behavioral correlates at the same site. Temporally, task-driven NE transients were more synchronized and peaked earlier than ACh transients. To test functional relevance, using optogenetics we found that evoked elevation of NE, but not ACh, in the medial frontal cortex increases the propensity of the animals to switch and explore alternate options. Taken together, the results reveal distinct spatiotemporal patterns of rapid ACh and NE transients at the subcellular scale during decision-making in mice, which may endow these neuromodulators with different ways to impact neural plasticity to mediate learning and adaptive behavior.

Identifying predictors of E. coli in rural household water in sub-Saharan Africa using elimination regression.

Exposure to fecally contaminated drinking water contributes to the global disease burden, especially in sub-Saharan Africa (SSA). We used cross-sectional data and elimination regression analysis to examine factors influencing E. coli contamination in household drinking water samples from 4,499 rural households in nine countries in SSA (Malawi, Mozambique, and Zambia in Southern Africa; Ghana, Mali, and Niger in Western Africa; and Kenya, Rwanda, and Tanzania in Eastern Africa). The proportion of household water samples containing E. coli was 71%, ranging from 45% (Malawi) to 89% (Tanzania). Pooled and multi-country predictive logistic regression models showed that using an unimproved-type water source, the absence of a community water committee, and domestic animal ownership were significantly associated with household drinking water contamination. Household water treatment and storage practices, sanitation and hygiene practices, and payment for drinking water were not significantly associated with E. coli contamination in any model. The season was a significant predictor of E. coli in the pooled model; samples collected in the rainy season were 2.3 [2.0, 2.7] times as likely to be contaminated with E. coli. Practitioners and policymakers should prioritize implementing piped on-plot water services, establishing effective local water source management structures, and incorporating animal husbandry practices into water, sanitation, and hygiene interventions.

Delayed Tracheostomy After Cervical Fixation is Not Associated With Improved Outcomes: A Trauma Quality Improvement Program Analysis.

BACKGROUND: Patients with unstable cervical spine (C-spine) fractures are at a significant risk of respiratory failure. There is no consensus on the optimal timing of tracheostomy in the setting of recent operative cervical fixation (OCF). This study evaluated the impact of tracheostomy timing on surgical site infections (SSIs) in patients undergoing OCF and tracheostomy. METHODS: Trauma Quality Improvement Program (TQIP) was used to identify patients with isolated cervical spine injuries who underwent OCF and tracheostomy between 2017 and 2019. Early tracheostomy (<7 days from OCF) was compared with delayed tracheostomy (≥7 days from OCF). Logistic regressions identified variables associated with SSI, morbidity, and mortality. Pearson correlations evaluated time to tracheostomy and length of stay (LOS). RESULTS: Of 1438 patients included, 20 had SSI (1.4%). There was no difference in SSI between early vs delayed tracheostomy (1.6% vs 1.2%, P = .5077). Delayed tracheostomy was associated with increased ICU LOS (23.0 vs 17.0 days, P < .0001), ventilator days (19.0 vs 15.0, P < .0001), and hospital LOS (29.0 vs 22.0 days, P < .0001). Increased ICU LOS was associated with SSI (OR 1.017; CI 0.999-1.032; P = .0273). Increased time to tracheostomy was associated with increased morbidity (OR 1.003; CI 1.002-1.004; P < .0001) on multivariable analysis. Time from OCF to tracheostomy correlated with ICU LOS (r (1354) = .35, P < .0001), ventilator days (r (1312) = .25, P < .0001), and hospital LOS (r (1355) = .25, P < .0001). CONCLUSION: In this TQIP study, delayed tracheostomy after OCF was associated with longer ICU LOS and increased morbidity without increased SSI. This supports the TQIP best practice guidelines recommending that tracheostomy should not be delayed for concern of increased SSI risk.

Causes of Mortality of Dairy Cattle Diagnosed by Complete Necropsy.

This retrospective case series summarized the primary causes of death in 857 dairy cattle necropsied from 2008 to 2019 at the Utah Veterinary Diagnostic Laboratory, from dairy farms in Utah (76%), Idaho (16%) or other states (8%), primarily in the U.S. Intermountain West. Of cattle with age provided, 74% matched with body weight based estimates for those with no age stated. Cattle ranged from fetuses at 60 days of gestation to 9 years old. Primary cause of mortality was diagnosed in 833 cattle (97%); no cause was evident in 24 cattle (3%). Sexes were female 620 (72%), male 214 (25%), not recorded 23 (3%). Seven diseases killed 80% of the animals: gastrointestinal disease (most enteritis/colitis) 318 (37%); pneumonia 166 (19%); abortion 96 (11%), peritonitis 30 (4%), omphalophlebitis (navel ill) 27 (3%), abomasitis 23 (3%), and metritis 23 (3%). Etiologic agents and specific causes varied with age categories of the animals. Young calves that died from dystocia, omphalophlebitis, or congenital abnormality often presented with no suspicion of those causes by the owners because of no external signs. Some important fatal diseases of adult dairy cows that are often diagnosed ante-mortem were diagnosed at necropsy with no suspicion by those submitting the carcasses: metritis, hardware disease, and displaced abomasum. Multicentric lymphoma was a relatively important cause of death in cows more than 4 years old. Despite use of a toxicology laboratory, toxicity was only diagnosed as causing 1% of the deaths across all ages of dairy cattle. There were numerous other causes of mortality diagnosed as well. Necropsy is a vital tool to diagnose causes of death in dairy cattle and can guide changes in management or preventive practices to reduce the rate of deaths in dairy herds.

Multiple 9-1-1 complexes promote homolog synapsis, DSB repair, and ATR signaling during mammalian meiosis.

DNA damage response mechanisms have meiotic roles that ensure successful gamete formation. While completion of meiotic double-strand break (DSB) repair requires the canonical RAD9A-RAD1-HUS1 (9A-1-1) complex, mammalian meiocytes also express RAD9A and HUS1 paralogs, RAD9B and HUS1B, predicted to form alternative 9-1-1 complexes. The RAD1 subunit is shared by all predicted 9-1-1 complexes and localizes to meiotic chromosomes even in the absence of HUS1 and RAD9A. Here, we report that testis-specific disruption of RAD1 in mice resulted in impaired DSB repair, germ cell depletion, and infertility. Unlike Hus1 or Rad9a disruption, Rad1 loss in meiocytes also caused severe defects in homolog synapsis, impaired phosphorylation of ATR targets such as H2AX, CHK1, and HORMAD2, and compromised meiotic sex chromosome inactivation. Together, these results establish critical roles for both canonical and alternative 9-1-1 complexes in meiotic ATR activation and successful prophase I completion.

Healthcare provider satisfaction with environmental conditions in rural healthcare facilities of 14 low- and middle-income countries.

Healthcare provider (HCP) satisfaction is important for staff retention and effective health service delivery. Inadequate resources, understaffing, and ineffective organizational structure may reduce HCP satisfaction in low- and middle-income countries (LMICs). Some qualitative studies have described links between environmental conditions and job satisfaction in HCPs; however, few studies have explored this link using survey data. This study explores associations between HCP satisfaction and water, sanitation, and hygiene (WaSH) infrastructure, cleanliness, and infection prevention and control (IPC) practices in rural healthcare facilities (HCFs) in LMICs. This study analyzes 2002 HCFs in rural areas of 14 LMICs. Generalized linear mixed-effects logistic regression models were used to analyze the association between HCP satisfaction, WaSH infrastructure, and cleanliness and IPC practices. Most respondents reported that they were unsatisfied with water (65%), sanitation (68%), and hygiene infrastructure (54%) at their HCF. Insufficient supply and poor quality of WaSH resources were the most commonly reported reasons for provider dissatisfaction. Respondents were less likely to report dissatisfaction with cleanliness and IPC practices (36%). Dissatisfaction with cleanliness and IPC were most reported because patients and staff did not wash their hands at the correct times or with proper materials, or because the facility was not clean. Several characteristics of the WaSH environment were significantly associated with provider satisfaction at their HCFs, including acceptable water quality, readily available supply of water (on premises and improved), accessible supply of WaSH infrastructure to people with reduced mobility, accessible supplies of sanitation and hygiene materials, and sufficient training and budgeting for WaSH or IPC needs. Our results suggest that the provision of on premises, improved water service accessible to people with reduced mobility, interventions that prioritize the acceptability of sanitation facilities within the local context, and the provision of hygienic materials are key interventions to improve HCP satisfaction. Dedicated funding and oversight should be established at the HCF level to ensure access to consumable hygiene and IPC products and maintenance of WASH infrastructure. Improvements to WaSH in HCF may improve HCP satisfaction and ultimately patient outcomes.

Exploration of the Effects of Rural Obstetric Unit Closures on Birth Outcomes in North Carolina.

PURPOSE: Closures of rural labor and delivery (L/D) units have prompted national and state-based efforts to assess the impact on birth outcomes. This study explores local effects of L/D closures in rural areas of North Carolina (NC). METHODS: This is a retrospective cohort study of birth outcomes of 4,065 women in 5 rural areas of NC with L/D unit closures between 2013 and 2017. Outcomes were abstracted from birth certificate data from the NC Vital Statistics Reporting System. Localized outcomes 1 year prior to L/D unit closure were compared with outcomes 1 and 2 years post closure, including: (1) birth location and demographics, (2) change in travel patterns for birth, and (3) birth outcomes, including rates of labor induction, cesarean deliveries, maternal morbidity, and neonatal outcomes. FINDINGS: Before closures, 25%-56% of deliveries occurred outside county of residence. Commercially insured and college-educated women were more likely to deliver out-of-area. Closures increased travel distance to delivery hospital an average of 7-27 miles. In 2 areas, cesarean delivery rates decreased despite an increase in labor inductions. There was also variability between areas in prenatal care adequacy and breastfeeding. CONCLUSIONS: We found that L/D unit closures in rural NC disproportionately affected women on Medicaid. The impact showed area-specific variability, highlighting effects potentially masked by statewide or national analyses. Implications for future L/D closures would be eased by regional coordination and planning to mitigate negative effects, and state and national policies should address the excess burden placed on vulnerable populations.

Occurrence of Lead and Other Toxic Metals Derived from Drinking-Water Systems in Three West African Countries.

BACKGROUND: Exposure to toxic metals (TMs) such as lead can cause lifelong neurodevelopmental impairment and other adverse outcomes. TMs enter drinking water from human activity, geogenic contamination, and corrosion of water system components. Several studies report TM contamination in piped systems and private wells in high-income countries (HICs). However, few robust studies report on TM contamination in low- and middle-income countries (LMICs). OBJECTIVES: We characterized the occurrence and investigated sources of TM contamination in 261 rural water systems in three West African LMICs to inform prevention and management. METHODS: Water samples were collected from 261 community water systems (handpumps and public taps) across rural Ghana, Mali, and Niger. Scrapings were collected from accessible components of a subset of these systems using a drill with acid-washed diamond-tipped bits. Samples were analyzed by inductively coupled plasma (ICP) mass spectrometry or ICP optical emission spectroscopy. RESULTS: Of the TMs studied, lead most frequently occurred at levels of concern in sampled water system components and water samples. Lead mass fractions exceeded International Plumbing Code (IPC) recommended limits (0.25% wt/wt) for components in 82% (107/130) of systems tested; brass components proved most problematic, with 72% (26/36) exceeding IPC limits. Presence of a brass component in a water system increased expected lead concentrations in drinking-water samples by 3.8 times. Overall, lead exceeded World Health Organization (WHO) guideline values in 9% (24/261) of drinking-water samples across countries; these results are broadly comparable to results observed in many HICs. Results did not vary significantly by geography or system type. DISCUSSION: Ensuring use of lead-free (<0.25%) components in new water systems and progressively remediating existing systems could reduce drinking-water lead exposures and improve health outcomes for millions. However, reflexive decommissioning of existing systems may deprive users of sufficient water for health or drive them to riskier sources. Because supply chains for many water system components are global, TM monitoring, prevention, and management may be warranted in other LMICs beyond the study area as well. https://doi.org/10.1289/EHP7804.

Response-dependent contributions of human primary motor cortex and angular gyrus to manual and perceptual sequence learning.

Motor sequence learning on the serial reaction time task involves the integration of response-, stimulus-, and effector-based information. Human primary motor cortex (M1) and the inferior parietal lobule (IPL) have been identified with supporting the learning of effector-dependent and -independent information, respectively. Current neurocognitive data are, however, exclusively based on learning complex sequence information via perceptual-motor responses. Here, we investigated the effects of continuous theta-burst transcranial magnetic stimulation (cTBS)-induced disruption of M1 and the angular gyrus (AG) of the IPL on learning a probabilistic sequence via sequential perceptual-motor responses (experiment 1) or covert orienting of visuospatial attention (experiment 2). Functional effects on manual sequence learning were evident during 75% of training trials in the cTBS M1 condition, whereas cTBS over the AG resulted in interference confined to a midpoint during the training phase. Posttraining direct (declarative) tests of sequence knowledge revealed that cTBS over M1 modulated the availability of newly acquired sequence knowledge, whereby sequence knowledge was implicit in the cTBS M1 condition but was available to conscious awareness in the cTBS AG and control conditions. In contrast, perceptual sequence learning was abolished in the perceptual cTBS AG condition, whereas learning was intact and available to conscious awareness in the cTBS M1 and control conditions. These results show that the right AG had a critical role in perceptual sequence learning, whereas M1 had a causal role in developing experience-dependent functional attributes relevant to conscious knowledge on manual but not perceptual sequence learning.

How we assess water safety: A critical review of sanitary inspection and water quality analysis.

Sanitary inspection is used in low-, medium- and high-income settings to assess the risk of microbial contamination at water sources. However, the relationship between sanitary inspection and water quality is not well understood. We conducted a critical literature review and synthesized the findings of 25 studies comparing the results of sanitary inspection and microbial water quality analysis. Most studies used sub-standard sanitary inspection and water quality analysis methods, and applied simplistic comparisons that do not characterize the complexity of the relationship. Sanitary risk score was used to represent sanitary inspection results in 21 (84%) studies; of which 12 (57%) found a significant association between score and microbial water quality and nine (43%) did not. Participatory sanitary inspection (12%) and reporting results back to communities (24%) were uncommon. Most studies relied on laboratory-based water quality analysis as an independently sufficient measure of safety, but reported inadequate quality control (52%) and/or sub-standard sample processing methods (66%). We found that sanitary inspections could contribute to improving water safety through four mechanisms: guiding remedial action at individual water sources, allowing operators and external support programs to prioritize repairs, identifying programmatic issues, and contributing to research. The purpose of the sanitary inspection should be considered when planning sanitary inspection execution, data analysis, and reporting to ensure appropriate methods are employed and results are fit for purpose. Further exploration should recognize that sanitary risk factors represent sources of contamination, pathways for contaminants to enter water supplies, and breakdowns in barriers to contamination. These different sanitary risk factor types have different and inter-dependent effects on water quality.

The psychosocial complexities of acute burn patients in an Australian trauma hospital.

INTRODUCTION: Psychosocial risk and protective factors specific to acute burn patients have been shown to impact on longer-term health outcomes. Yet the nature and impact of such factors throughout the acute hospital admission phase have not been extensively examined to date. This study analysed the psychosocial pre-admission, hospitalisation and discharge factors for a sample of burn patients at an Australian specialist acute burns unit (The Alfred) and the relationship with their admission length. METHODS: A retrospective audit was undertaken of psychosocial factors documented in patient medical records, Victorian Adult Burns Service registry data, and social work files (January-December 2014). RESULTS: Two hundred and forty-nine patients were identified, with a mean age of 42.83 years and a preponderance of men (73.9%). The majority (71%) had a low burn severity (<10%), and an average of eight psychosocial factors. Independent of the severity of the burn, two psychosocial domains were strongly predictive of length of stay - coping with treatment and discharge planning - along with pre-existing psychosocial factors and family support. CONCLUSION: A diversity of psychosocial factors was identified, highlighting the clinical complexity of this patient group. Given three domains of admission-related psychosocial factors were predictive of the length of patient stay, more targeted psychosocial interventions in these areas may ensure patients and their families are supported more effectively throughout an admission, and length of stay costs may also be reduced.

Geographical inequalities in drinking water in the Solomon Islands.

Sustainable Development Goal 6.1 seeks to "by 2030, achieve universal and equitable access to safe and affordable drinking water", which is challenging particularly in Small Island Developing States (SIDS) and Pacific Island Countries (PIC). We report drinking water sources and services in the Solomon Islands and examine geographical inequalities. Based on two quantitative baseline datasets of n = 1,598 rural and n = 1,068 urban households, we analyzed different drinking water variables (source type, collection time, amount, use, perceived quality, storage, treatment) and a composite index, drinking water service level. We stratified data by urban and rural areas and by province, mapped, and contextualized them. There are substantive rural-urban drinking water inequalities in the Solomon Islands. Overall, urban households are more likely to: use improved drinking water sources, need less time to collect water, collect more water, store their water more safely, treat water prior to consumption, perceive their water quality as better and have an at least basic drinking water service than rural households. There are also provincial and center-periphery inequalities in drinking water access, with more centrally located provinces using piped water supplies and more distant and remote provinces using rainwater and surface water as their primary source. There are also inter-national inequalities. Out of all PICs, the Solomon Islands have among the lowest access to basic drinking water services: 92% of urban and 55% of rural households. Of all SIDS, PICs are least serviced. This study shows that drinking water inequality is a critical issue, and highlights that all identified dimensions of inequality - rural-urban, provincial, center-periphery and inter-national - need to be explicitly recognized and addressed and included in pro-equity monitoring, policy and programming efforts by the Solomon Islands Government and stakeholders to reduce inequalities as per the Agenda 2030.

External support programs to improve rural drinking water service sustainability: A systematic review.

Achieving sufficient, safe, continuously-available drinking water services in rural areas is a challenge, in high- and especially low-and middle-income countries. External support programs (ESPs) - which may include administrative, financial, and technical assistance - have been hypothesized to contribute to sustainable rural water services. While there are many descriptions of ESPs, a standard terminology and typology of ESP activities does not exist and the effect of ESP activities on system sustainability remains inadequately characterized. We conducted a systematic review of ESPs for rural drinking water systems to identify ESP terminology and describe ESP activities. Findings from 218 publications from low-, middle-, and high-income countries were analyzed. ESP terms were used inconsistently between regions and income classifications. There were few studies describing ESP activities related to mechanized piped water systems. Few studies quantitatively assess the effect of ESPs. Those that did found positive associations with functionality, household satisfaction, household participation, and financial stability. This review is the first comprehensive evaluation of the ESP literature and we derive a definition of external support programs and typology of ESP activities from the descriptions of ESPs. A common understanding of ESPs facilitates discussion and knowledge transfer between stakeholders. Consistent terminology creates a foundation for adapting ESPs to water services in community institutions and for mechanized piped water systems.

Urban and rural sanitation in the Solomon Islands: How resilient are these to extreme weather events?

The Solomon Islands, like other small island developing states in the Pacific, face significant challenges from a changing climate, and from increasing extreme weather events, while also lagging behind the rest of the world in terms of drinking water, sanitation and hygiene (WaSH) services. In order to support planning for the implementation of national WaSH strategies and policies, this study contextualizes representative urban and rural baselines for Sustainable Development Goal (SDG) 6 ("by 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation"). We highlight specific threats to the current sanitation services under extreme weather events such as flooding and drought, both of which are commonly observed in the country, and provide suggestions for structural improvements to sanitation facilities to increase resiliency. As the first detailed nationally representative cross-sectional sanitation study in urban and rural areas in the Solomon Islands, the results of this paper inform national WaSH policy, strategic planning and programming by the Solomon Islands Government and stakeholders.

Treatment of Paradoxical Adipose Hyperplasia following Cryolipolysis: A Single-Center Experience.

Paradoxical adipose hyperplasia is a rare adverse event associated with cryolipolysis. No evidence of spontaneous resolution has been described and little has been written about its treatment. The purpose of this report is to share the authors' experience treating patients with paradoxical adipose hyperplasia after cryolipolysis. A retrospective chart review was performed for all paradoxical adipose hyperplasia patients seen in the authors' practice between May of 2013 and May of 2016. The treatment parameters, demographics, onset of findings, and subsequent treatment were chronicled. Eleven cases of paradoxical adipose hyperplasia were identified (eight men and three women). All patients were of Hispanic background. Seven patients were treated surgically (six cases of liposuction alone and one case of liposuction and abdominoplasty). Average follow-up was 9.6 months (range, 2 to 32 months). Three of the patients treated with liposuction required a secondary procedure. All surgically treated patients were very satisfied with their final appearance. Paradoxical adipose hyperplasia is a rare complication of cryolipolysis that may occur more frequently than in the manufacturer's reported data. Treatment is best delayed until the affected area has softened, which normally occurs in 6 to 9 months after the initial cryolipolysis procedure. Power-assisted liposuction is the preferred method of treatment, but in some cases, abdominoplasty may be necessary. Secondary treatments might be needed for recurrence or persistent bulge. One must be sensitive to heightened patient concerns when offering an invasive procedure to correct the complications from a noninvasive one. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Seasonality, water use and community management of water systems in rural settings: Qualitative evidence from Ghana, Kenya, and Zambia.

The sustainability of rural, community-managed water systems in sub-Saharan Africa depends in part on the ability of local water committees to repair breakdowns and carry out the operation and maintenance (O&M) of the system. Much of sub-Saharan Africa has two distinct seasons that affect the availability of water sources and how people use water. Little is known about how seasonality affects water system management. This qualitative study is based on 320 interviews and focus group discussions and examines the effects of season on community water use and management in Ghana, Kenya and Zambia. Participants revealed that seasonality affects water availability, water system breakdowns, resource mobilization, committee activity, and external support availability. In the rainy season, participants typically reported spending less time and money on water collection because rainwater harvesting and seasonal streams, ponds, wells and reservoirs are available. In the dry season, people used improved groundwater sources more often and spent more money and time collecting water. Although seasonal changes in household water demand and use have been examined previously, our data suggest that seasonality also influences community management through differential water system use, system breakdowns and management characteristics. We found that water committees generally have less money, time and access to external support during the rainy season, making them less able to carry out O&M. Our results suggest that community engagement should take place over a long period of time so that seasonal patterns in management can be understood and incorporated into water committee training. External support actors should make a more targeted effort to understand the cultural and economic patterns in a community in order to train committees with appropriate management strategies.