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Introduction Outcomes in colorectal cancer treatment are historically worse in Black people and residents of rural areas. Purported reasons include factors such as systemic racism, poverty, lack of access to care, and social determinants of health. We sought to determine whether outcomes worsened when race and rural residence intersected. Methods The National Cancer Database was queried for individuals with stage II–III colorectal cancer (2004-2018). To examine the intersectionality of race/rurality on outcomes, race (Black/White) and rurality (based on county) were combined into a single variable. Main outcome of interest was 5-year survival. Cox hazard regression analysis was performed to determine variables independently associating with survival. Control variables included age at diagnosis, sex, race, Charlson-Deyo score, insurance status, stage, and facility type. Results Of 463 948 patients, 5717 were Black-Rural, 50 742 were Black-Urban, 72 241 were White-Rural, and 33 5271 were White-Urban. Five-year mortality rate was 31.6%. Univariate Kaplan-Meier survival analysis demonstrated race-rurality was associated with overall survival ( P < .001), with White-Urban having the greatest mean survival length (47.9 months) and Black-Rural with the lowest (46.7 months). Multivariable analysis found that Black-Rural (1.26, 95% confidence interval [1.20-1.32]), Black-Urban (1.16, [1.16-1.18]), and White-Rural (HR: 1.05; (1.04-1.07) had increased mortality when compared to White-Urban individuals ( P < .001). Conclusion Although White-Rural individuals fared worse than White-Urban, Black individuals fared worst of all, with the poorest outcomes observed in Black individuals in rural areas. This suggests that both Black race and rurality negatively affect survival, and act synergistically to further worsen outcomes.

SARS-CoV-2 remains a global threat to human health particularly as escape mutants emerge. There is an unmet need for effective treatments against COVID-19 for which neutralizing single domain antibodies (nanobodies) have significant potential. Their small size and stability mean that nanobodies are compatible with respiratory administration. We report four nanobodies (C5, H3, C1, F2) engineered as homotrimers with pmolar affinity for the receptor binding domain (RBD) of the SARS-CoV-2 spike protein. Crystal structures show C5 and H3 overlap the ACE2 epitope, whilst C1 and F2 bind to a different epitope. Cryo Electron Microscopy shows C5 binding results in an all down arrangement of the Spike protein. C1, H3 and C5 all neutralize the Victoria strain, and the highly transmissible Alpha (B.1.1.7 first identified in Kent, UK) strain and C1 also neutralizes the Beta (B.1.35, first identified in South Africa). Administration of C5-trimer via the respiratory route showed potent therapeutic efficacy in the Syrian hamster model of COVID-19 and separately effective prophylaxis. The molecule was similarly potent by intraperitoneal injection.

Background Previous literature demonstrates correlations between comorbidities and failure to complete adjuvant chemotherapy. Frailty and socioeconomic disparities have also been implicated in affecting cancer treatment outcomes. This study examines the effect of demographics, comorbidities, frailty, and socioeconomic status on chemotherapy completion rates in colorectal cancer patients. Methods This was an observational case-control study using retrospective data from Stage II and III colorectal cancer patients offered chemotherapy between January 01, 2013 and January 01, 2018. Data was obtained using the cancer registry, supplemented with chart review. Patients were divided based on treatment completion and compared with respect to comorbidities, age, Eastern Cooperative Oncology Group (ECOG) score, and insurance status using univariate and multivariate analyses. Results 228 patients were identified: 53 Stage II and 175 Stage III. Of these, 24.5% of Stage II and 30.3% of Stage III patients did not complete chemotherapy. Neither ECOG status nor any comorbidity predicted failure to complete treatment. Those failing to complete chemotherapy were older (64.4 vs 60.8 years, P = .043). Additionally, those with public assistance or self-pay were less likely to complete chemotherapy than those with private insurance ( P = .049). Both factors (older age/insurance status) remained significant on multivariate analysis (increasing age at diagnosis: OR 1.03, P =.034; public insurance: OR 1.84, P = .07; and self-pay status: OR 4.49, P = .03). Conclusions No comorbidity was associated with failure to complete therapy, nor was frailty, as assessed by ECOG score. Though frailty was not significant, increasing age was, possibly reflecting negative attitudes toward chemotherapy in older populations. Insurance status also predicted failure to complete treatment, suggesting disparities in access to treatment, affected by socioeconomic factors.

A simple recuperated cycle is studied and optimized in this paper. Geometrical parameters for a novel recuperator design are then optimized to minimize area density. The recuperator is where the s-CO2 is analyzed and simulated for both hot and cold sides. The design of the cycle is obtained through a study of a 100 MW net power output s-CO2 cycle, where this cycle features a turbine inlet temperature of 1023 K. The main objective of this paper is to couple a recuperated cycle with a heat exchanger. This is done through Pareto optimality to study the tradeoffs between conflicting variables. The geometry of the heat exchanger features two inlet headers attached to semirectangular channels. The thermal analysis used is based on one-dimensional finite enthalpy method, where discretization is made by equal heat transferred per element. In addition, pressure drops are calculated at both sides of main heat exchanger body. Optimized cycle based on practical parametric assumptions reveals an efficiency of 45.8% and specific power of 132.1 kJ/kg. Best design reveals channel side length of 7 mm with surrounding solid sidewall thickness of 1 mm. Pressure drops for the proposed design are 4.8% and 0.6% of the initial pressure for the hot and the cold sides, respectively. Overall length of the heat exchanger is found to be 10.7 m with an effectiveness of 96.2% and an area density of 363 m2/m3.

Ducts with turbulence-promoting ribs are common in heat transfer applications and can often found in the form of serpentine channels in gas turbine blades. This study uses a recent modal extraction technique called Dynamic Mode Decomposition (DMD) to determine mode shapes of the spatially and temporally complex flowfield inside a square ribbed (45 degree) duct at Reynolds number 32,400. One subject missing from current literature is a method of directly linking a mode to a certain engineering quantity of interest. Presented is a generalized methodology for producing such a link utilizing the data from the DMD analysis. Exciting the modes which are identified may cause the flow to change in such a way to promote the quantity of interest, in this case, heat transfer. This theory is tested by contouring the walls of the duct using the extracted mode shapes. An initial, unmodified geometry provides a baseline for comparison to later contoured models. The initial case is run as a steady-state RANS model. LES generates the necessary data for the DMD analysis. Several mode shapes extracted from the flow are applied to the duct walls and run again in the RANS model, then compared to the baseline, and their relative performance examined.

We report the results of a randomized controlled intervention study (September 2007 to March 2009) investigating the effect of solar disinfection (SODIS) of drinking water on the incidence of dysentery, nondysentery diarrhea, and anthropometric measurements of height and weight among children of age 6 months to 5 years living in peri-urban and rural communities in Nakuru, Kenya. We compared 555 children in 404 households using SODIS with 534 children in 361 households with no intervention. Dysentery was recorded using a pictorial diary. Incidence rate ratios (IRR) for both number of days and episodes of dysentery and nondysentery diarrhea were significantly (P0.001) reduced by use of solar disinfection: dysentery days IRR = 0.56 (95% CI 0.40 to 0.79); dysentery episodes IRR = 0.55 (95% CI 0.42 to 0.73); nondysentery days IRR = 0.70 (95% CI 0.59 to 0.84); nondysentery episodes IRR = 0.73 (95% CI 0.63 to 0.84). Anthropometry measurements of weight and height showed median height-for-age was significantly increased in those on SODIS, corresponding to an average of 0.8 cm over a 1-year period over the group as a whole (95% CI 0.7 to 1.6 cm, P = 0.031). Median weight-for-age was higher in those on SODIS, corresponding to a 0.23 kg difference in weight over the same period; however, the confidence interval spanned zero and the effect fell short of statistical significance (95% CI -0.02 to 0.47 kg, P = 0.068). SODIS and control households did not differ in the microbial quality of their untreated household water over the follow-up period (P = 0.119), but E. coli concentrations in SODIS bottles were significantly lower than those in storage containers over all follow-up visits (P0.001). This is the first trial to show evidence of the effect of SODIS on childhood anthropometry, compared with children in the control group and should alleviate concerns expressed by some commentators that the lower rates of dysentery associated with SODIS are the product of biased reporting rather than reflective of genuinely decreased incidence.

Purpose: To present a case of successful endovascular retrieval of a monorail predilation balloon fused to an embolic protection device (EPD) in the distal internal carotid artery (ICA) of a high-risk symptomatic patient. Case Report: A 60-year-old man with documented systemic atherosclerotic disease had a severe (>70%) restenosis in the left ICA 3 years after endarterectomy. He was scheduled for carotid artery stenting (CAS) with cerebral protection; however, he developed unstable angina and was transferred to our facility, where the admitting team decided that staged CAS followed by coronary bypass grafting would be the best option. During the CAS procedure, a 6-mm AccuNet filter was passed across the lesion via a 6-F carotid sheath and deployed in the distal ICA without incident. However, the 4-×20-mm predilation monorail balloon was then advanced without visualizing the markers, resulting in inadvertent aggressive interaction that trapped the balloon's tip in the filter. Several maneuvers to separate the devices were unsuccessful. Finally, the filter/balloon combination was moved gently retrograde until the balloon was straddling the subtotal ICA lesion. The lesion was dilated to 4 mm with the balloon, and the sheath was gently advanced across the lesion as the balloon was deflated. Angiography excluded interval occlusion of the filter from the embolic debris during the aforementioned aggressive maneuvers and documented antegrade flow. The filter was slowly withdrawn into the 6-F sheath with simultaneous aspiration. A second 6-mm filter was deployed, and the procedure was completed satisfactorily. The patient did well, with no neurological sequelae. Conclusion: EPDs are an essential in carotid artery stenting and, keeping in mind the potential risks associated with their use, will help the operator avoid complications such as this one.

In Kenya in 1999, an estimated 6.9% of women nationally said they had exchanged sex for money, gifts or favours in the previous year. In 2000 and 2001, in collaboration with sex workers who had formed a network of self-help groups, we conducted an exploratory survey among 475 sex workers in four rural towns and three Nairobi townships, regarding where they worked, the number of clients they had and the risks they were exposed to. Participants were identified by a network of social contacts in the seven centres. Most of the women (88%) worked from bars, hotels, bus stages and discos; 57% lived with a stable partner and almost 90% had dependent children. In the previous month, 17% had been assaulted and 35% raped by clients. Unwanted pregnancy was common; 86% had had at least one abortion. Compared with women in rural towns, township sex workers were younger (median age 22 vs. 26), saw more clients (median 9 vs. 4 per week) and earned more from sex work (up to €63–90 vs. €12 per week). Issues of alternative sources of income, safety for sex workers and the conditions which create the necessity for sex work are vital to address. The question of number of clients and the nature of sex work have obvious implications for HIV/STI prevention policy.

A series of experiments is reported to identify and characterize the inactivation process in operation when drinking water, heavily contaminated with a Kenyan isolate of Escherichia coli, is stored in transparent plastic bottles that are then exposed to sunlight. The roles of optical and thermal inactivation mechanisms are studied in detail by simulating conditions of optical irradiance, water turbidity and temperature, which were recorded during a series of solar disinfection measurements carried out in the Kenyan Rift Valley. Optical inactivation effects are observed even in highly turbid water (200 ntu) and at low irradiances of only 10 mW cm-2. Thermal inactivation is found to be important only at water temperatures above 45 degrees C, at which point strong synergy between optical and thermal inactivation processes is observed. The results confirm that, where strong sunshine is available, solar disinfection of drinking water is an effective, low cost method for improving water quality and may be of particular use to refugee camps in disaster areas. Strategies for improving bacterial inactivation are discussed.

Progress towards understanding the molecular basis of virulence in Clostridium difficile has been hindered by the lack of effective gene transfer systems. We have now, for the first time, developed procedures that may be used to introduce autonomously replicating vectors into this organism through their conjugative, oriT-based mobilization from Escherichia coli donors. Successful transfer was achieved through the use of a plasmid replicon isolated from an indigenous C. difficile plasmid, pCD6, and through the characterization and subsequent circumvention of host restriction/modification (RM) systems. The characterized replicon is the first C. difficile plasmid replicon to be sequenced and encodes a large replication protein (RepA) and a repetitive region composed of a 35 bp iteron sequence repeated seven times. Strain CD6 has two RM systems, CdiCD6I/M.CdiCD6I and CdiCD6II/M. CdiCD6II, with equivalent specificities to Sau96I/M. Sau96I (5'-GGNMCC-3') and MboI/M. MboI (5'-GMATC-3') respectively. A second strain (CD3) possesses a type IIs restriction enzyme, Cdi I, which cleaves the sequence 5'-CATCG-3' between the fourth and fifth nucleotide to give a blunt-ended fragment. This is the first time that an enzyme with this specificity has been reported. The sequential addition of this site to vectors showed that each site caused between a five- and 16-fold reduction in transfer efficiency. The transfer efficiencies achieved with both strains equated to between 1.0 x 10-6 and 5.5 x 10-5 transconjugants per donor.

349 Maasai children younger than 6 years old were randomised by alternate household to drink water either left in plastic bottles exposed to sunlight on the roof of the house or kept indoors (control). The trial was run in Maasai by Maasai community elders. Children drinking solar disinfected water had a significantly lower risk of severe diarrhoeal disease over 8705 two weekly follow up visits; two week period prevalence was 48.8% compared with 58.1% in controls, corresponding to an attributable fraction of 16.0%. While this reduction is modest, it was sustained over a year in free living children. It confirms solar disinfection as effective in vivo as a free, low technology, point of consumption method of improving water quality. The continuing use of solar disinfection by the community underlines the value of community participation in research.

Solar radiation reduces the bacterial content of water, and may therefore offer a method for disinfection of drinking water that requires few resources and no expertise.We distributed plastic water bottles to 206 Maasai children aged 5-16 years whose drinking water was contaminated with faecal coliform bacteria. Children were instructed to fill the bottle with water and leave it in full sunlight on the roof of the hut (solar group), or to keep their filled bottles indoors in the shade (control group). A Maasai-speaking fieldworker who lived in the community interviewed the mother of each child once every 2 weeks for 12 weeks. Occurrence and severity of diarrhoea was recorded at each follow-up visit.Among the 108 children in households allocated solar treatment, diarrhoea was reported in 439 of the 2-week reporting periods during the 12-week trial (average 4.1 [SD 1.2] per child). By comparison, the 98 children in the control households reported diarrhoea during 444 2-week reporting periods (average 4.5 [1.2] per child). Diarrhoea severe enough to prevent performance of duties occurred during 186 reporting periods in the solar group and during 222 periods in the control group (average 1.7 [1.2] vs 2.3 [1.4]). After adjustment for age, solar treatment of drinking water was associated with a reduction in all diarrhoea episodes (odds ratio 0.66 [0.50-0.87]) and in episodes of severe diarrhoea (0.65 [0.50-0.86]).Our findings suggest that solar disinfection of water may significantly reduce morbidity in communities with no other means of disinfection of drinking water, because of lack of resources or in the event of a disaster.During December 1995-March 1996 in Kajiado Province, Kenya, 206 Maasai children, 5-16 years old, whose drinking water was contaminated with fecal coliform bacteria, were assigned 1.5 liter plastic bottles in which to store their drinking water. These bottles were re-used commercial table water bottles. The families of the children had only community sources for drinking water: 2 open water-holes and 1 tank fed from a piped supply. These water sources were not suited to chlorination. Scarce fuel and indoor air pollution precluded boiling water inside the hut. In the presence of their mothers, 108 children (the solar group) were told to fill the bottles with water at dawn, leave them in full sunlight on the roofs of their homes, and wait until midday before drinking from the bottles. The remaining 98 children (the control group) were told to leave the bottles in their homes. The purpose of the study was to evaluate the effect of solar disinfection on diarrheal disease in these Maasai children. Over a 12-week period, children in the solar group suffered fewer diarrhea episodes than those in the control group (4.1 vs. 4.5; adjusted odds ratio [AOR] = 0.66). They also were less likely to have diarrhea episodes severe enough to prevent them from doing their chores (1.7 vs. 2.3; AOR = 0.65). These findings suggest that solar disinfection of water may reduce diarrhea in communities with no access to other means of disinfection.

This book puts forward the findings of a 4-year investigation by an independent global commission. The ambitious remit of the commission was funded by seven governments, the United Nations, the World Bank, and five American foundations. The report presents the most recent demographic and socioeconomic data and useful summaries of global economic and ecological challenges. The text presents coherent systematic arguments leading toward a series of fresh responses and suggestions. The strategies for achieving sustained improvement in the quality of life echo the Global 2000 Report to the President commissioned by Carter and draw extensively on some 60 studies prepared for the commission. Innovative approaches in assessing the quality of life are put forward, and the carrying capacity of the earth is discussed clearly and informatively. The greatest contribution of this work lies in its humanity and the call for us to return through understanding to caring. Parts of Caring

The use of land mines has evolved from a predominantly defensive battlefield tactic designed to impede the movement of enemy artillery to an offensive weapon that terrorizes entire civilian populations. Clearing the Fields is the first serious attempt at exploring solutions and answers to a problem that kills hundreds of civilians every week around the world. Here is a book that should be read by every political and military decision maker.Clearing the Fields is a rich source of up-to-date information. More than 100 million mines have been deployed in over 60 countries. In the former Yugoslavia an estimated 3 million mines have been planted without maps during the past four years, with 50 000 more hidden each week. In Cambodia one of every 253 people is an amputee. On average, antipersonnel mines can be bought for $10 to $20, with many available for less than $3. In contrast, it

In Reply. —Walker et al make some very helpful points. There are complex differences between evolving African countries. South Africa's mortality rate for children under 5 years of age is 72 per 1000 live births compared with 180 in least-developed countries and a mean of 101 in developing countries. 1 Forty-nine percent of South Africa's population is urbanized compared with a mean of 28% in sub-Saharan Africa, 1 while the maternal mortality rate stands at 83% in South Africa and 600 for sub-Saharan Africa. In most of Africa, 80% of the population remains rural. It is a tribute to the great advances in South Africa that it is so nonrepresentative of most of the continent. Walker et al are, of course, correct that there must be a strengthening of health facilities and infrastructure; nor must we forget referral mechanisms and secondary care. A great failing of many donors and funding

FOR SUB-SAHARAN Africa, the past 20 years have been disastrous. The region has been beset by famines, droughts, civil wars, political corruption, AIDS, a rapidly increasing population, decreased food production, environmental degradation, a fall in the value of exports, an increase in the costs of imports, and massive government indebtedness. In addition, Africa now faces increasingly intense competition from other regions for scarce international aid, most notably from Eastern Europe. Aid experts are unanimous in their prediction that further economic decline, poverty, and suffering are inevitable, at least in the short term. 1-8 Despite ominous economic and demographic trends, there are indications that genuine political and economic reform may be about to take place. The opportunities for Western countries and institutions to contribute to the long-term humanitarian progress of the continent may be greater now than at at any time since the end of the colonial era. 1-3 However, if

Hepatotoxicity associated with intravenous clindamycin phosphate therapy is reported in a drug abuser cured of staphylococcal endocarditis. Coincident with the administration of large doses of clindamycin, marked hepatic enzyme abnormalities were noted, and liver biopsy showed lobular disruption, pseudogranulomas, hepatocyte necrosis, eosinophilic bodies and mononuclear cell infiltration. Cessation of clindamycin therapy resulted in return of liver enzymes to normal, and a second liver biopsy performed 15 days later showed improvement. Reports of clindamycin-associated hepatic enzyme changes are reviewed; further observation for clindamycin-associated hepatotoxicity is warranted.

Enteroclysis is an examination in which barium is infused directly into the small intestine, and compression radiographs are taken on each segment. This method eliminates many of the inherent limitations of the conventional small bowel follow-through examination. This report concerns 45 patients with 48 small bowel lesions. They were missed on the conventional examination but detected within 3 months by subsequent enteroclysis and confirmed surgically. There were 15 patients with Meckel's diverticula, 7 with obstructive adhesive bands, 5 with Crohn's disease, 5 with blind pouch syndrome (1 with a leiomyoma inside the blind pouch), 2 with other leiomyomas, 3 with metastatic carcinoma, two with primary carcinoma 3 with radiation stricture, two with sinus tract lesions and fistulas, and 1 with another lesion. Improved intubation techniques and better barium mixtures make enteroclysis possible in most hospitals. As surgeons appreciate the value of enteroclysis, they can request this examination for appropriate patients to sooner find many surgical lesions of the small bowel which frequently go undiagnosed.