Restoration versus transformative adaptation of community drinking water systems after Hurricanes Irma and Maria in Puerto Rico.

Hurricane Irma then Maria hit Puerto Rico in September 2017, exposing the heightened vulnerability of the island's Critical Infrastructure Systems and Processes (CRISPs) and putting the resilience of some of the most impoverished communities to the test. Being one of these CRISPs, the island's centralized drinking water system operated by the Puerto Rico Aqueduct and Sewer Authority suffered heavy damage leaving over 200,000 people off-grid for months. Decentralized community aqueducts were also affected. However, most were able to sustain operations, with only 15 percent incapacitated during the first few weeks after Maria. Of the 205 community aqueducts serving low-income communities in the island's central mountainous areas, only 35 failed. This article explores how and why these systems failed and what actions the communities should take to recover in a relatively short time in comparison to the centralized system. It defines the factors that account for the differences, the systems' capacity to meet water quality requirements, and potentially transformative adaptations generated to face future disturbances. We were interested in understanding (a) how system capacity was affected by the restoration process, (b) if adaptation resulted in significant operational changes, and (c) community member engagement. Finally, we explored governance transformations that increased stakeholder's participation, including community aqueducts representatives in decision-making and policy-making. Data collection included interviews with water system managers, government, and nongovernmental organization (NGO) representatives who regulate these systems or assisted communities in recovering their systems. We also surveyed water systems that had operational problems within the first 3 weeks. The data revealed a diversity of actions along the disaster cycle through which communities prepared for, restored, recovered, and cocreated transformative adaptations to their systems. Findings reflect that despite economic deficiencies and lack of emergency plans, many communities were able to improvise and restore their water systems soon after the disaster. As part of their postdisaster organization, communities increased their collaborative networks with governmental and NGOs to cocreate improvement projects to enhance resiliency. Adaptations included (1) increased community autonomy, (2) system redundancy, and (3) improved capacity to participate in government discussion forums related to their systems.

Phase II study of gemcitabine in combination with docetaxel in patients with advanced pancreatic carcinoma (E1298). A trial of the eastern cooperative oncology group.

BACKGROUND: Responses have been observed in several studies of docetaxel as treatment for advanced pancreatic carcinoma. This trial was designed to determine if the addition of docetaxel to gemcitabine therapy produced responses in >/=25% of patients with chemonaive advanced pancreatic cancer. PATIENTS AND METHODS: This trial involved patients with biopsy-proven, advanced carcinoma of the pancreas not amenable to surgical resection. Patients received docetaxel 75 mg/m(2) i.v. over 1 h followed by gemcitabine 2,000 mg/m(2) biweekly until progression or intolerable toxicity. The primary endpoint of the trial was to determine the objective response rate with secondary endpoints of progression-free survival and overall survival. RESULTS: Out of the 32 eligible patients, 2 patients had a complete response and 2 patients had a partial response for an observed objective response rate of 12.5% (90% CI: 4.4, 26.4%). Median survival was 4.7 months. Most toxicities were hematologic, with 48% of patients experiencing grade 4 toxicity. CONCLUSIONS: The confirmed complete response rate of 6% and partial response rate of 6% is encouraging, but the toxicity of this regimen appears significant. Based upon these results, this combination of gemcitabine and docetaxel is not worthy of further study. Different schedules and dosages may be more promising.

Organ preservation therapy using induction plus concurrent chemoradiation for advanced resectable oropharyngeal carcinoma: a University of Pennsylvania Phase II Trial.

PURPOSE: To determine the efficacy, feasibility, and toxicity of a new regimen for locally advanced oropharyngeal carcinoma. PATIENTS AND METHODS: Patients had technically resectable stage III/IV squamous cell carcinoma of the oropharynx, exclusive of T1-2N1. Induction chemotherapy consisted of carboplatin (area under the curve formula equal to 6) and paclitaxel 200 mg/m(2) for two cycles, followed by re-evaluation. Patients with major response continued to definitive radiotherapy (70 Gy over 7 weeks) plus concurrent once-weekly paclitaxel (30 mg/m(2)/wk). Patients with advanced neck disease also underwent post-radiation therapy neck dissection and two more chemotherapy cycles. RESULTS: Fifty-three patients were enrolled. Median follow-up was 31 months (minimum follow-up for survivors was 18 months). The major response rate to induction chemotherapy was 89%; 90% of patients had a complete response after concurrent chemoradiation. Actuarial survival at 3 years was 70%, and 3-year event-free survival was 59%. The 3-year actuarial locoregional control was 82% and the 3-year actuarial rate of distant metastases was 19%. Organ preservation was achieved in 77% of all patients. One patient (2%) died during therapy. Late grade 3 toxicity occurred in 24% of patients, consisting mainly of chronic dysphagia/aspiration and/or radiation soft tissue ulceration. The treatment-related mortality rate was 4% (two patients died from respiratory failure). CONCLUSION: Response to induction chemotherapy as studied in this trial was not useful as a predictive marker for ultimate outcome or organ conservation. Overall, however, this regimen offers good disease control and survival for patients with locally advanced oropharyngeal carcinoma, comparable with other concurrent chemoradiation programs. Further study of similar protocols is indicated.