Treatment In Rural Areas Research Articles

Current situation and capacity of cancer diagnosis and treatment in county hospitals in China: a multicenter cross-sectional survey

Abstract Purpose County-level hospitals in China constitute a vital component of the healthcare system, delivering essential medical services, emergency care, and specialized treatments, particularly in oncology. This study aimed to comprehensively evaluate the current status of cancer diagnosis and treatment in county hospitals and assess their overall capacity. Methods A nationwide cross-sectional survey by the China Anti-cancer Association (CACA) from February to May 2023 assessed cancer diagnosis and treatment in mainland China's county hospitals. Using a multi-center approach, a fifty-five-question questionnaire was administered to oncology professionals and management staffs, focusing on hospital facilities, oncology specialists, cancer cases, treatment capabilities, and healthcare collaboration. Questionnaire reliability and validity were established in a 2022 national survey. Participants, aged 18 or older, were recruited through purposive sampling, receiving self-administered questionnaires for confidentiality. SAS 9.4 software facilitated statistical analysis. Results The study encompassed 76 county-level medical institutions, with 82.9% of them featuring established oncology departments providing comprehensive cancer care, including early screening, diagnosis, treatment, and long-term follow-up. Notably, a total of 56.6% of the institutions surveyed implemented programs for cancer screening and early diagnosis. A significant proportion of advanced cancer patients received treatment and follow-up at the county level. Persistent disparities in medical insurance policies at the county level were identified as a continuing challenge. Furthermore, 82.9% of hospitals had cultivated collaborative relationships with higher-level institutions to enhance patient care quality and treatment capacity. The study revealed a 56.6% shortage of remote collaboration platforms in these hospitals. The need for a patient-centered approach in county hospitals was underscored. Conclusion While county-level hospitals face challenges, such as a shortage of specialized oncologists and advanced resources, they exhibit progress in standardizing cancer care to enhance diagnosis and treatment in rural areas.

Sustainability Assessment of Agricultural Waste Biogas Production System in China Based on Emergy and Carbon Evaluation Methods

Biogas production is widely recognized as an effective solution for addressing agricultural waste treatment in rural areas. However, its development is often hindered by economic and environmental constraints. This study combined emergy evaluation and carbon footprint analysis methods to establish a new environmental radius assessment model for evaluating the ecological performance and optimization direction of an agricultural waste biogas production system, using a biogas production company in China as a case study. Compared with the straw return model and straw power generation model, the results of emergy indicators and carbon accounting showed that the biogas production model had a lower environmental load and higher economic output and level of emergy sustainability. Additionally, the biogas production system was found to reduce 0.47 kg of carbon emissions per 1 kg of agricultural waste utilized. The application of the biogas production model in rural areas had high ecological sustainability and carbon emission reduction benefits. Environmental radius assessment results confirmed that the reasonable changes in resource collection distance could further enhance the ecological sustainability, carbon mitigation ability, and economic benefits of the biogas production system. The environmental radius assessment method offers a new approach to the location planning of agricultural waste biogas utilization companies in rural areas.

Performance of vertical and horizontal treatment wetlands planted with ornamental plants in Central Chile: comparative analysis of initial operation stage for effluent reuse in agriculture.

This study comparatively evaluated effluent reuse from two TWs-a horizontal subsurface flow (HF) and a vertical subsurface flow (VF)-used for rural wastewater treatment in Central Chile during the initial operation stage. The two TWs were planted with Zantedeschia aethiopica and were operated for 10months at a pilot scale. The water quality of the influent and effluents was measured and compared with reuse regulations. The results showed similarities in the behavior of the effluents from the two TWs, presenting differences only in the chemical oxygen demand (COD) and different forms of nitrogen, suggesting the necessity of complementary treatment stages or modifications to the operation. The effluents from the HF better fulfilled the reuse standards for irrigation, as the VF faced problems associated with its size. However, a complementary disinfection system is necessary to improve pathogen removal in the effluents coming from the two TWs, especially to be reused as irrigation water for crops. Finally, this work showed the potential for applying subsurface TWs for wastewater treatment in rural areas and reusing their effluents as irrigation water, practice that can contribute to reducing the pressure on water resources in Chile, and that can be used as an example for other countries facing similar problems.

Low-cost, reliable, and highly efficient removal of COD and total nitrogen from sewage using a sponge-filled trickling filter.

Development of low-cost and reliable reactors demanding minimal supervision is a need-of-the-hour for sewage treatment in rural areas. This study explores the performance of a multi-stage sponge-filled trickling filter (SPTF) for sewage treatment, employing polyethylene (PE) and polyurethane (PU) media. Chemical oxygen demand (COD) and nitrogen transformation were evaluated at hydraulic loading rates (HLRs) ranging from 2 to 6 m/d using synthetic sewage as influent. At influent COD of ∼350 mg/L, PU-SPTF and PE-SPTF achieved a COD removal of 97% across all HLRs with most of the removal occurring in the first segments. Operation of PE-SPTF at an HLR of 6 m/d caused substantial wash-out of biomass, while PU-SPTF retained biomass and achieved effluent COD < 10 mg/L even at HLR of 8-10 m/d. The maximum Total Nitrogen removal by PE-SPTF and PU-SPTF reactors was 93.56 ± 1.36 and 92.24 ± 0.66%, respectively, at an HLR of 6 m/d. Simultaneous removal of ammonia and nitrate was observed at all the HLRs in the first segment of both SPTFs indicating ANAMMOX activity. COD removal data, media depth, and HLRs were fitted (R2 > 0.99) to a first-order kinetic relationship. For a comparable COD removal, CO2 emission by PU-SPTF was 3.5% of that of an activated sludge system.

Enhanced electrochemical disinfection for decentralized sewage treatment through nickel foam cathode modified with CoFe2O4-spinel ferrite and multi-way carbon nanotubes

Electrochemical disinfection is characterized by its simple operation and maintenance, along with effective sterilization capabilities, making it ideal for decentralized wastewater treatment in rural areas. As a bimetallic oxide, spinel ferrite exhibits excellent catalytic activity for the oxygen reduction reaction (ORR). Herein, a novel cathode was fabricated from nickel foam modified with spinel ferrite and multi-way carbon nanotubes (CoFe2O4-MWCNTs@NF). The modification successfully strengthens the electrochemical cathode reaction to generate strong oxidants such as hydrogen peroxide and Hydroxyl radical, enabling the disinfection of water bodies with low chloride concentrations. Compared to other influencing factors (including current density, aeration rate, and electrode spacing), the impact of conductivity on hydrogen peroxide generation is relatively minor. Modified electrodes still exhibited effective disinfection capabilities in water with low conductivity. At a current density of 2 mA/cm², the CoFe2O4-MWCNTs@NF electrode achieved 4.00 log removal of E.coli in real treated sewage within 15 minutes, with an energy consumption of 1.038 kWh/m³. Electrochemical disinfection also had a certain degradation ability for sulfonamides and quinolones antibiotics in water. The disinfection and antibiotic removal effects of the modified electrode demonstrated its potential for practical applications.

A Comprehensive Review on Scrub Typhus: Epidemiology, Transmission, Diagnosis and Management

Scrub typhus is a serious public health risk in areas where it is endemic. It is brought on by the bacterium Orientia tsutsugamushi and is spread via the bite of infected chiggers. The epidemiology, clinical symptoms, diagnosis, treatment, and prevention of scrub typhus are summarized in this overview, along with recent developments. The disease is most common in rural sections of Asia, the Pacific Islands, and portions of Australia, where chigger populations are encouraged by favorable environmental conditions. The clinical signs of chigger bites can range in severity from mild to severe, presenting with symptoms like fever, headaches, and the distinctive Escher at the bite site. Severe cases may result in consequences such as acute respiratory distress syndrome and organ failure, which call for prompt identification and treatment. Molecular techniques and serological testing are used as diagnostic tools. Molecular assays are a quick and reliable way to identify Orientia tsutsugamushi. Antibiotics are the cornerstone of treatment, and doxycycline is the drug of choice. Treatment must be started as soon as possible to avoid problems and enhance results. The importance of public health interventions, such as vector control and health education, is highlighted by issues like antibiotic resistance and restricted access to treatment in rural areas. Personal protection is the main focus of preventive measures, which include donning proper attire and applying insect repellents. Managing the environment and involving the community are important strategies for lowering chigger populations. Additional research is being done to create effective scrub typhus vaccines, even if there isn't one that is now generally authorized.

Removal, transformation and ecological risk assessment of pesticide in rural wastewater by field-scale horizontal flow constructed wetlands of treated effluent

Constructed wetlands (CWs) are widely used in sewage treatment in rural areas, but there are only a few studies on field-scale CWs in treating wastewater-borne pesticides. In this study, the treatment and metabolic transformation of 29 pesticides in rural domestic sewage by 10 field-scale horizontal flow CWs (HF-CWs), each with a treatment scale of 36‒5000 m3/d and operated for 2‒10 years, in Guangzhou, Southern China was investigated. The risk of pesticides in treated effluent and main factors influencing such risk were evaluated. Results demonstrated that HF-CWs could remove pesticides in sewage and reduce their ecological risk in effluent, but the degree varied among types of pesticides. Herbicides had the highest mean removal rate (67.35 %) followed by insecticides (60.13 %), and the least was fungicides (53.22 %). In terms of single pesticide compounds, the mean removal rate of butachlor was the highest (73.32 %), then acetochlor (69.41 %), atrazine (68.28 %), metolachlor (58.40 %), and oxadixyl (53.28 %). The overall removal rates of targeted pesticides in each HF-CWs ranged from 11 %‒57 %, excluding two HF-CWs showing increases in pesticides in treated effluent. Residues of malathion, phorate, and endosulfan in effluent had high-risks (RQ > 5). The pesticide concentration in effluent was mainly affected by that in influent (P = 0.042), and source control was the key to reducing risk. The main metabolic pathways of pesticide in HF-CWs were oxidation, with hydroxyl group to carbonyl group or to form sulfones, the second pathways by hydrolysis, aerobic condition was conducive to the transformation of pesticides. Sulfones were generally more toxic than the metabolites produced by hydrolytic pathways. The present study provides a reference on pesticides for the purification performance improvement, long-term maintenance, and practical sustainable application of field-scale HF-CWs.

Inequalities in time to diagnosis of Down Syndrome in Bolivia

Down Syndrome is the most common genetic condition and a leading cause of intellectual disability. Individuals in rural areas, particularly those with disabilities, often face disparities in healthcare access. Analyzing clinical records of patients diagnosed with Down Syndrome between 2013 and 2022 by the Institute of Genetics at the Universidad Mayor de San Andrés in La Paz, Bolivia, this study examined the time to diagnosis for 250 patients with Down Syndrome. The findings revealed that patients from rural areas with Down Syndrome take an average of five months to receive a diagnosis, compared to two months in urban areas (p<0.001). No significant differences were found in the time to diagnosis based on gender. However, a higher proportion of males from rural areas was observed (p=0.03). The results suggest that individuals in rural areas face challenges in receiving a timely diagnosis. On the other hand, women may not be brought to cities for proper diagnosis and treatment due to gender biases in certain communities. The importance of improving access to early diagnosis and treatment in rural areas is emphasized.

Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study

BackgroundIn 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or ‘rural’ areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States. MethodsWe conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes. ResultsAmong 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to “get things in order” before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration. ConclusionOur findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.

Bacterial community assessment of drinking water and downstream distribution systems in highland localities of Ecuador.

Bacterial communities in drinking water provide a gauge to measure quality and confer insights into public health. In contrast to urban systems, water treatment in rural areas is not adequately monitored and could become a health risk. We performed 16S rRNA amplicon sequencing to analyze the microbiome present in the water treatment plants at two rural communities, one city, and the downstream water for human consumption in schools and reservoirs in the Andean highlands of Ecuador. We tested the effect of water treatment on the diversity and composition of bacterial communities. A set of physicochemical variables in the sampled water was evaluated and correlated with the structure of the observed bacterial communities. Predominant bacteria in the analyzed communities belonged to Proteobacteria and Actinobacteria. The Sphingobium genus, a chlorine resistance group, was particularly abundant. Of health concern in drinking water reservoirs were Fusobacteriaceae, Lachnospiraceae, and Ruminococcaceae; these families are associated with human and poultry fecal contamination. We propose the latter families as relevant biomarkers for establishing local standards for the monitoring of potable water systems in highlands of Ecuador. Our assessment of bacterial community composition in water systems in the Ecuadorian highlands provides a technical background to inform management decisions.

Investigation of Wetland Performance for Sewage Treatment in Rural Areas

Investigation of Wetland Performance for Sewage Treatment in Rural Areas

Performance of Equisetum spp and Zantedeschia aethiopica on the evaluation of artificial wetlands as an alternative for wastewater treatment in rural areas of the Ecuadorian Andes

Constructed wetlands have been used worldwide as an alternative for wastewater treatment. The purpose of this study was to evaluate two constructed wetlands for wastewater treatment using two different species of macrophyte in order to reduce pollution levels in the Curiquingue Creek belonging to the Baños parish in Cuenca, Ecuador. A pilot plant was constructed using Equisetum spp and Zantedeschia aethiopica with a constant flow of 0.32m3d−1. Each unit was filled with sand and gravel as the porosity medium with a hydraulic retention time of 5 days. To analyze the efficiency of the wetlands, physical and chemical parameters were analyzed in the laboratory. The results obtained in the laboratory showed that the two species of macrophyte showed good efficiency in the removal of organic matter (100% COD-100% BOD5). On the other hand, Equisetum spp showed better efficiency in the removal of NO3− (80.28%) and PO43− (98.57%) meanwhile, Zantedeschia aethiopica showed better efficiency in the removal of TSS (85.71%). Constructed wetlands are an effective and sustainable option for wastewater treatment.

A Study on the Current Situation of Education of Rural Children with Serious Illnesses Who Go to the City for Medical Treatment A Case Study of WuJiaNong in Hefei City

This study analyzes the current situation of family education and school education of special children with major illnesses such as leukemia and malignant tumor who travel to the city specifically for medical treatment in rural areas, taking WujiaNong in Hefei as an example. After understanding the economic pressure, mental pressure, and social support of these special groups, and taking into account the situation of local voluntary organizations, the current situation of family education and schooling of children with leukemia in WuJiaNong, Hefei City is clarified, and the causes of their education problems are analyzed in the light of various factors, to draw the attention of the society and improve the current situation of the lack of family education and schooling of children with major diseases in rural areas.

Recent Incarceration, Substance Use, Overdose, and Service Use Among People Who Use Drugs in Rural Communities

Drug use and incarceration have a substantial impact on rural communities, but factors associated with the incarceration of rural people who use drugs (PWUD) have not been thoroughly investigated. To characterize associations between recent incarceration, overdose, and substance use disorder (SUD) treatment access among rural PWUD. For this cross-sectional study, the Rural Opioid Initiative research consortium conducted a survey in geographically diverse rural counties with high rates of overdose across 10 US states (Illinois, Wisconsin, North Carolina, Oregon, Kentucky, West Virginia, Ohio, Massachusetts, New Hampshire, and Vermont) between January 25, 2018, and March 17, 2020, asking PWUD about their substance use, substance use treatment, and interactions with the criminal legal system. Participants were recruited through respondent-driven sampling in 8 rural US regions. Respondents who were willing to recruit additional respondents from their personal networks were enrolled at syringe service programs, community support organizations, and through direct community outreach; these so-called seed respondents then recruited others. Of 3044 respondents, 2935 included participants who resided in rural communities and reported past-30-day injection of any drug or use of opioids nonmedically via any route. Data were analyzed from February 8, 2022, to September 15, 2023. Recent incarceration was the exposure of interest, defined as a report of incarceration in jail or prison for at least 1 day in the past 6 months. The associations between PWUD who were recently incarcerated and main outcomes of treatment use and overdose were examined using logistic regression. Of 2935 participants, 1662 (56.6%) were male, 2496 (85.0%) were White; the mean (SD) age was 36 (10) years; and in the past 30 days, 2507 (85.4%) reported opioid use and 1663 (56.7%) reported injecting drugs daily. A total of 1224 participants (41.7%) reported recent incarceration, with a median (IQR) incarceration of 15 (3-60) days in the past 6 months. Recent incarceration was associated with past-6-month overdose (adjusted odds ratio [AOR], 1.38; 95% CI, 1.12-1.70) and recent SUD treatment (AOR, 1.62; 95% CI, 1.36-1.93) but not recent medication for opioid use disorder (MOUD; AOR, 1.03; 95% CI, 0.82-1.28) or currently carrying naloxone (AOR, 1.02; 95% CI, 0.86-1.21). In this cross-sectional study of PWUD in rural areas, participants commonly experienced recent incarceration, which was not associated with MOUD, an effective and lifesaving treatment. The criminal legal system should implement effective SUD treatment in rural areas, including MOUD and provision of naloxone, to fully align with evidence-based SUD health care policies.

Efficient removal of organic matters and typical odor substances in rural drinking water using Ozone-BAC-UF combined system to meet new water quality standards in China

China has just implemented new drinking water quality standards, canceling the provisions detailed in the previous standards that allowed relatively lenient water quality standards in rural areas, and unifying the water quality requirements for urban and rural areas. In rural areas of China, lakes are important sources of drinking water, but their water typically contain high concentrations of organic pollutants. In addition, removal odorous substances from such sources is challenging. In response to these issues, an ozone-biological activated carbon-ultrafiltration process is proposed and its efficiency in drinking water treatment is explored. The results indicate that O3-BAC pretreatment significantly improved the efficiency of the membrane process in removing organic and odor substances. At an ozone dosage of 2 mg/L, with granular activated carbon as filler and an EBCT of 25 min, the O3-BAC pretreatment allowed removal rates in the membrane system equal to 71.5% of CODMn, 84.2% of UV254, as well as 92.2% and 92.5% of GSM and 2-MIB, respectively, the latter being typical odor compounds. In addition, the function and diversity of the microbial communities in the reactor were evaluated under different pretreatment conditions at different stages: functionally specific microorganisms were enriched in different systems, and some microorganisms contributing to the removal of organic and odorous substances were identified. The effluent from the combined Ozone-BAC-UF process consistently met the new requirements for drinking water in China, implying that the combined system has significant potential for practical applications for drinking water treatment in rural areas.

AUTOMATIC MEDICAL DISPATCHER WITH DYNAMIC TELEMONITORING SYSTEM USING IOT IN RURAL AREAS

Tracking good doctors for treatment in rural areas is a very difficult job, they have to travel all the way to nearby towns or cities. Therefore, Anytime Medical Machine (AMM) is completely IOT based project and can be even considered as the IOMT (IOT based medical devices) and its primary deployment in rural areas. Using the AMM people will get quality consultation with good doctors on spot without travelling all the way to the cities. The doctor provides medicines and prescription for the patients through AMM which reduces the time consumption and expenses of travelling to the nearby cities. It collects patient data using Temperature sensor, Heart Beat sensor and SPO2 sensor, and sending the collected data of the patient to the doctor through wi-fi module. Interaction between the doctor and the patient is done by using video conferencing, which is secured by the login page with username and password dedicated to each user to avoid the misuse of the AMM. Finally, the Doctor analyzes the patient’s health parameters and suggests the appropriate medicine that will be dispatched through AMM. The patient's information is uploaded to the cloud server for future references. Admin re-fills the medicines in AMM. KeyWords: AMM, Medicine Dispatcher, Telemonitoring, Cloud Storage.

Assessment of Knowledge and Awareness among Urban and Rural Female Population about Malocclusion, Esthetics, and Orthodontic Treatment

Aims and Objective: The aim of this study is to assess the knowledge of the females about malocclusion, esthetic appearance, and orthodontic treatment among urban and rural female population. Materials and Methods: The present study was conducted as a cross-sectional study among the general population of Karnataka, India. A self-administered semistructured questionnaire consisting of a total of 18 questions were used to assess knowledge and awareness about dentist and orthodontist and knowledge about orthodontic treatment among urban and rural female population. The data were entered into Excel and were analyzed using IBM SPSS statistics V. 22. Results: In the present study, a total of 200 females participated comprising 100 participants in each rural and urban population. When awareness about dentist was assessed, 98% of urban population were aware of difference between general medical and dental profession compared to rural populations (65%). 85% of urban and 68% of rural population believed that healthy and well-arranged teeth are important for the good facial appearance. 45% of urban population and 18% of rural population had knowledge about orthodontic treatment. Conclusion: There is a moderate level of awareness among the female patients about dentist, orthodontist, and knowledge about irregular teeth. Malocclusion always has an impact on social and psychological behavior of the general population. Hence, there is a need to explore about how individuals perceive and react to malocclusion and also utmost important to create awareness about treatment for malocclusion. Clinical Significance: At present, orthodontic treatments are commonly recognized as a treatment for malocclusion. The dentists especially orthodontists play a major role in this aspect, and this can be achieved by conducting education programs for patients and having advisory hubs on orthodontic treatment in rural areas, which will discuss benefits and likely complications to spread awareness among public.

Decentralized Constructed Wetlands for Wastewater Treatment in Rural and Remote Areas of Semi-arid Regions

Vertical-flow constructed wetlands (VFCWs) are an innovative and sustainable nature-based technology for wastewater treatment in rural areas. This work aimed to evaluate the treatment performance of VFCWs using real wastewater, which can provide more accurate and reliable results compared with field-based experiments, and to investigate the use of Paulownia trees in VFCWs for wastewater treatment. To compare the efficiency of the plants based on the treatment performance of the VFCWs, three units were prepared and composed of Paulownia, the commonly used Phragmites Australis, and an unplanted unit used as a control during the experimental program. The results show significant reductions in both the chemical oxygen demand (COD) and biochemical oxygen demand (BOD5) levels for both planted units, with removal ratios for COD and BOD5 of 60% to 98%, respectively. Both Paulownia and Phragmites Australis significantly reduced the levels of COD and BOD5 in the effluent, with removal percentages ranging from 57.1% to 98% for COD and 49.1% to 98% for BOD5. The control unit, without plantings, showed a lower but still significant removal percentage for both COD (from 55.1% to 96.1%) and BOD5 (from 48.3% to 97.8%). Thus, the results reveal that the efficiency of constructed wetlands can be significantly enhanced by the presence of suitable plant species, such as Paulownia and Phragmites Australis, and constructed wetlands can be a viable and cost-effective option for the treatment of wastewater in various settings, with the added benefit of using the relevant biodiversity.

Identification of Populations at Risk for "Choosing Un-Wisely": A SEER Population-Based Study.

Since 2016, the Choosing Wisely campaign has recommended against routine axillary surgery in elderly patients with early stage, hormone receptor positive (ER+) breast cancer. The objective was to evaluate factors associated with axillary surgery in breast cancer patients meeting criteria for sentinel lymph node biopsy (SLNB) omission and identify potential disparities. Female patients age ≥70years with cT1-2N0M0, ER+, HER2-negative breast cancer diagnosed after publication of the Choosing Wisely recommendations, between 2016 and 2019, were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Patient demographics and tumor characteristics associated with axillary surgery were analyzed. Of the 31756 patients meeting omission criteria, 25771 (81.2%) underwent axillary surgery. Hispanic ethnicity, median household income between $35,000 and $70,000, treatment in rural areas, poor differentiation, lobular and mixed lobular with ductal histology, T2 tumors, radiation therapy, and systemic therapy were factors associated with receiving axillary surgery on multivariable analysis. In the axillary surgery cohort, a median of 2 (IQR = 2) nodes were examined and 529 (2.1%) patients were found to have 1 or more positive lymph nodes. Among elderly patients meeting Choosing Wisely criteria for SLNB omission, particular racial, ethnic, socioeconomic, and geographic populations may be at increased risk for potential over treatment. Identification of these factors provides specific opportunities for education and implementation of de-escalation of unnecessary procedures.

Bubbleless aerated-biological activated carbon as a superior process for drinking water treatment in rural areas

Drinking water supply in rural areas remains a substantial challenge due to complex natural, technical and economic conditions. To provide safe and affordable drinking water to all, as targeted in the UN Sustainable Development Goals (2030 Agenda), low-cost, efficient water treatment processes suitable for rural areas need to be developed. In this study, a bubbleless aeration BAC (termed ABAC) process is proposed and evaluated, involving the incorporation of a hollow fiber membrane (HFM) assembly within a slow-rate BAC filter, to provide dissolved oxygen (DO) throughout the BAC filter and an increased DOM removal efficiency. The results showed that after a 210-day period of operation, the ABAC increased the DOC removal by 54%, and decreased the disinfection byproduct formation potential (DBPFP) by 41%, compared to a comparable BAC filter without aeration (termed NBAC). The elevated DO (> 4 mg/L) not only reduced secreted extracellular polymer, but also modified the microbial community with a stronger degradation ability. The HFM-based aeration showed comparable performance to 3 mg/L pre-ozonation, and the DOC removal efficiency was four times greater than that of a conventional coagulation process. The proposed ABAC treatment, with its various advantages (e.g., high stability, avoidance of chemicals, ease of operation and maintenance), is well-suited to be integrated as a prefabricated device, for decentralized drinking water systems in rural areas.