Low-technology Solutions Research Articles

Integrated Approach Using Intuitionistic Fuzzy Multicriteria Decision-Making to Support Classifier Selection for Technology Adoption in Patients with Parkinson Disease: Algorithm Development and Validation.

Parkinson disease (PD) is reported to be among the most prevalent neurodegenerative diseases globally, presenting ongoing challenges and increasing burden on health care systems. In an effort to support patients with PD, their carers, and the wider health care sector to manage this incurable condition, the focus has begun to shift away from traditional treatments. One of the most contemporary treatments includes prescribing assistive technologies (ATs), which are viewed as a way to promote independent living and deliver remote care. However, the uptake of these ATs is varied, with some users not ready or willing to accept all forms of AT and others only willing to adopt low-technology solutions. Consequently, to manage both the demands on resources and the efficiency with which ATs are deployed, new approaches are needed to automatically assess or predict a user's likelihood to accept and adopt a particular AT before it is prescribed. Classification algorithms can be used to automatically consider the range of factors impacting AT adoption likelihood, thereby potentially supporting more effective AT allocation. From a computational perspective, different classification algorithms and selection criteria offer various opportunities and challenges to address this need. This paper presents a novel hybrid multicriteria decision-making approach to support classifier selection in technology adoption processes involving patients with PD. First, the intuitionistic fuzzy analytic hierarchy process (IF-AHP) was implemented to calculate the relative priorities of criteria and subcriteria considering experts' knowledge and uncertainty. Second, the intuitionistic fuzzy decision-making trial and evaluation laboratory (IF-DEMATEL) was applied to evaluate the cause-effect relationships among criteria/subcriteria. Finally, the combined compromise solution (CoCoSo) was used to rank the candidate classifiers based on their capability to model the technology adoption. We conducted a study involving a mobile smartphone solution to validate the proposed methodology. Structure (F5) was identified as the factor with the highest relative priority (overall weight=0.214), while adaptability (F4) (D-R=1.234) was found to be the most influencing aspect when selecting classifiers for technology adoption in patients with PD. In this case, the most appropriate algorithm for supporting technology adoption in patients with PD was the A3 - J48 decision tree (M3=2.5592). The results obtained by comparing the CoCoSo method in the proposed approach with 2 alternative methods (simple additive weighting and technique for order of preference by similarity to ideal solution) support the accuracy and applicability of the proposed methodology. It was observed that the final scores of the algorithms in each method were highly correlated (Pearson correlation coefficient >0.8). The IF-AHP-IF-DEMATEL-CoCoSo approach helped to identify classification algorithms that do not just discriminate between good and bad adopters of assistive technologies within the Parkinson population but also consider technology-specific features like design, quality, and compatibility that make these classifiers easily implementable by clinicians in the health care system.

Every breath counts: Lessons learned in developing a training NICU in Northern Tanzania.

IntroductionNeonatal mortality rates in resource-limited hospitals of Sub-Saharan Africa (SSA) remain disproportionately high and are likely underestimated due to misclassification of extremely preterm births as “stillbirths” or “abortions”, incomplete death registries, fear of repercussions from hospital and governmental authorities, unrecorded village deaths, and cultural beliefs surrounding the viability of premature newborns. While neonatology partnerships exist between high income countries and hospitals in SSA, efforts have largely been directed toward improving newborn survival through neonatal resuscitation training and provision of equipment to nascent neonatal intensive care units (NICUs). These measures are incomplete and fail to address the challenges which NICUs routinely face in low-resource settings. We draw on lessons learned in the development of a low-technology referral NICU in Tanzania that achieved an overall 92% survival rate among infants.Lessons learnedAchieving high survival rates among critically ill and preterm neonates in SSA is possible without use of expensive, advanced-skill technologies like mechanical ventilators. Evidence-based protocols adapted to low-resource hospitals, mentorship of nurses and physicians, changes in hierarchal culture, improved nurse-infant staffing ratios, involvement of mothers, improved procurement of consumables and medications, and bedside diagnostics are necessary steps to achieving high survival rates. Our NICU experience indicates that low-technology solutions of thermoregulation, respiratory support via continuous positive airway pressure, feeding protocols and infection control measures can ensure that infants not only survive, but thrive.ConclusionsNeonatal mortality and survival of preterm newborns can be improved through a long-term commitment to training NICU staff, strengthening basic neonatal care practices, contextually appropriate protocols, and limited technology.

Toward a circular economy for plastics

Toward a circular economy for plastics

Feasibility of Wearable Universal Serial Bus Utilization to Support Clinical Trial Participant Safety Management: A Pilot, Qualitative Descriptive Study.

Clinical trials are exploratory in nature and thus present a degree of risk for those individuals who participate in the trial. Risks include adverse events, which are undesirable experiences that arise from use of investigational products or devices that may cause participant injury or withdrawal from the clinical trial. The prevention of adverse events is a challenge given the lack of interoperability among organizational electronic health records and reliance on wallet cards to communicate safety-related information, leaving the burden of describing research-related information to external providers on the trial participant. This potential for ineffective communication propagates further risk of contraindicated medication administration and misaligned care management, which can negatively impact the trial participant's opportunity to safely engage in novel therapeutic research. This pilot, qualitative descriptive study explores a mobile, low-technology solution in the form of a wearable universal serial bus device to house deidentified, critical research-related information for clinical trial participants to wear and give external providers such that trial constraints on care management are effectively communicated. Eight participants wore a commercial universal serial bus device for 72 hours and described the meaning surrounding the participants' daily wearing of the universal serial bus bracelet via semistructured interviews. Four themes emerged: application to clinical trial participants, societal perception of wearing device, healthcare operations/workflow impact, and wearability of the universal serial bus device. Thematic findings included recommendations for device design improvements as well as key considerations for provider identification of the device.

Small-scale on-site treatment of fecal matter: comparison of treatments for resource recovery and sanitization

On-site small-scale sanitation is common in rural areas and areas without infrastructure, but the treatment of the collected fecal matter can be inefficient and is seldom directed to resource recovery. The aim of this study was to compare low-technology solutions such as composting and lactic acid fermentation (LAF) followed by vermicomposting in terms of treatment efficiency, potential human and environmental risks, and stabilization of the material for reuse in agriculture. A specific and novel focus of the study was the fate of native pharmaceutical compounds in the fecal matter. Composting, with and without the addition of biochar, was monitored by temperature and CO2 production and compared with LAF. All treatments were run at three different ambient temperatures (7, 20, and 38°C) and followed by vermicomposting at room temperature. Materials resulting from composting and LAF were analyzed for fecal indicators, physicochemical characteristics, and residues of ten commonly used pharmaceuticals and compared to the initial substrate. Vermicomposting was used as secondary treatment and assessed by enumeration of Escherichia coli, worm density, and physicochemical characteristics. Composting at 38°C induced the highest microbial activity and resulted in better stability of the treated material, higher N content, lower numbers of fecal indicators, and less pharmaceutical compounds as compared to LAF. Even though analysis of pH after LAF suggested incomplete fermentation, E. coli cell numbers were significantly lower in all LAF treatments compared to composting at 7°C, and some of the anionic pharmaceutical compounds were detected in lower concentrations. The addition of approximately 5 vol % biochar to the composting did not yield significant differences in measured parameters. Vermicomposting further stabilized the material, and the treatments previously composted at 7°C and 20°C had the highest worm density. These results suggest that in small-scale decentralized sanitary facilities, the ambient temperatures can significantly influence the treatment and the options for safe reuse of the material.

A dual technological tradition and its implications as observed in an iron assemblage from a medieval site in eastern Mongolia

The prevailing view of pastoral nomadic peoples is one in which their lifeway is perceived as a low technology and low investment solution to living in some of the world’s most marginal environments. Given this dominant stereotype, the discovery of a unique and sophisticated iron-making technology indigenous to Inner Asian herding communities would not be expected. Most anthropological and historical research on pastoralists of the steppes argue that such peripheral communities would have been dependent on long-distance imports of iron-finished goods originating from the industrial heartlands of neighboring sedentary societies such as that of ancient China. We test this technological premise by focusing on an assemblage containing eight cast iron and four bloomery iron fragments, all recovered from a medieval settlement site in eastern Mongolia. At one and the same site, our analysis reveals a blade of bloomery origin with clear evidence of well-controlled processes applied for carburization and quenching. In contrast, microstructures indicative of a small-scale steelmaking method, practiced either in the liquid or in the solid state, were observed in the cast iron objects examined. We present a detailed account of this dual technological tradition involving the manipulation of both bloomery and cast iron products along with pertinent radiocarbon data for the medieval site in question. We then place our results within a broader comparative perspective and propose that a diverse and innovative dual technological tradition constituted the primary mode of iron manufacture in Mongolia throughout the first and early second millennia AD.

"So sometimes, it looks like it's a neglected ward": Health worker perspectives on implementing kangaroo mother care in southern Malawi.

Kangaroo mother care (KMC) involves continuous skin-to-skin contact of baby on mother's chest to provide warmth, frequent breastfeeding, recognizing danger signs of illness, and early discharge. Though KMC is safe, effective and recommended by the World Health Organization, implementation remains limited in practice. The objective of this study is to understand barriers and facilitators to KMC practice at tertiary and secondary health facilities in southern Malawi from the perspective of health workers. This study is part of the "Integrating a neonatal healthcare package for Malawi" project in the Innovating for Maternal and Child Health in Africa initiative. In-depth interviews were conducted between May-Aug 2019 with a purposively drawn sample of service providers and supervisors working in newborn health at a large tertiary hospital and three district-level hospitals in southern Malawi. Data were analyzed using a thematic approach using NVivo 12 software (QSR International, Melbourne, Australia). A total of 27 nurses, clinical officers, paediatricians and district health management officials were interviewed. Staff attitudes, inadequate resources and reliance on families emerged as key themes. Health workers from Malawi described KMC practice positively as a low-cost, low-technology solution appropriate for resource-constrained health settings. However, staff perceptions that KMC babies were clinically stable was associated with lower prioritization in care and poor monitoring practices. Neglect of the KMC ward by medical staff, inadequate staffing and reliance on caregivers for supplies were associated with women self-discharging early. Though routine uptake of KMC was policy for stable low birthweight and preterm infants in the four hospitals, there were gaps in monitoring and maintenance of practice. While conceptualized as a low-cost intervention, sustainable implementation requires investments in technologies, staffing and hospital provisioning of basic supplies such as food, bedding, and KMC wraps. Strengthening hospital capacities to support KMC is needed as part of a continuum of care for premature infants.

Testing Testing (Grade) 1, 2, 3: Assessing the Crisis of Quality Education in Kenya Amid COVID-19

The Coronavirus pandemic has disrupted the education sector, and posed insurmountable challenges to achieving quality education. Learning has been impeded, causing regression in knowledge and skills, and learners remain excluded from the attendant social, safety and security benefits associated with school attendance. Equally, social and physical distancing regulations have inspired new education innovations, and stakeholders have come up with adaptive and innovation solutions to ensure that learning continues. This paper aims to assess the status of education in Kenya, and the implications of the pandemic on access, equity and quality of education. It draws on desktop and online research including legal research and analysis of case law, statutes and journal articles, to investigate quality standards in education in Kenya. The legal and policy analysis undertaken by this paper is instructive, and can provide valuable pointers to stakeholders seeking to implement quality assurance in education.This paper finds that in response to the pandemic, the government is seeking to leverage and expand on the its Digital Literacy Programme for basic education, and that higher education institutions are expanding open, distance and electronic learning in order to remain relevant, accessible and globally competitive amid the global public health crisis and the internationalization and globalization university education. As learning shifts to incorporate emerging learning technologies such as online or digital learning and low-technology solutions such as broadcast learning, members of vulnerable groups including persons differently-abled continue to face exclusion from access to education. The 2019 Census finds that only an estimated 47.3 per cent of Kenyans have access to mobile phones, and 10 percent have access to computer technology. Additionally, internet penetration rates are at a record low of 22 per cent. Kenya has adequate legal frameworks and human rights standards of protection of the right to education, and to equitable access of relevant, quality education. However, poor governance structures including weak implementation of policies, laws and accountability frameworks are threatening access, equity and quality education in Kenya. This paper suggests that adequate funding of education and with particular emphasis and priority to the needs of members of vulnerable groups, backed with political good, can help to advance national goals and aspirations of equity, inclusion and non-discrimination in all spheres of life, and especially in education.

Improvement of Operative Vaginal Delivery Training in Residency: A Single Institution Experience [17G

INTRODUCTION: Operative vaginal delivery (OVD) rates are decreasing in the US, creating fewer opportunities for trainee participation. Residents, not adequately trained in OVD, are less likely to use this skill after training, contributing to a growing cesarean rate. We aimed to improve resident participation in OVD. METHODS: Retrospective analysis from July 2017 to December 2018 of an intervention bundle applied prospectively on all OVDs performed at Yale New Haven Hospital. Staff and clinicians were interviewed to assess barriers to resident participation. Interventions applied: 1) training of residents in didactics and simulations on OVD, 2) outreach to providers to create awareness and comfort with resident participation, and 3) change of workflow on the Labor & Birth unit to improve notification to the resident team about OVD events through a mobile texting tool. Our goal was to achieve >90%; resident participation in OVD, calculated to meet the ACGME minimum. Process control and run charts were used for analysis. RESULTS: There were 214 OVDs. Overall mean resident coverage was 83.6%. Prior to intervention, the median attendance rate of residents at OVD was 76%. After intervention, the median monthly coverage rate was 100%. Prior to intervention, process control chart analysis shows multiple points outside control limits (outside 3 standard deviations). After intervention, there were no points outside of control limits, and >8 points were above the median consecutively, showing achievement of process control. Mean attendance rate after intervention was 98.7%. CONCLUSION: Resident participation in OVD increased to the target rate with implementation of low cost, low technology solutions.

Assessment of Constructed Wetlands’ Potential for the Removal of Cyanobacteria and Microcystins (MC-LR)

Microcystis blooms and the subsequent release of hepatotoxic microcystins (MCs) pose a serious threat to the safety of water for human and livestock consumption, agriculture irrigation, and aquaculture worldwide. Microcystin-LR (MC-LR), the most toxic variant of MCs, has been widely detected in a variety of environments such as water, sediments, plants, and many aquatic organisms. Conventional solutions of water treatment are costly, requiring specific infrastructure, as well as specialized personnel and equipment. Therefore, these solutions are not feasible in many rural areas or in the treatment of large reservoirs. In this regard, low-cost and low-technology solutions, such as constructed wetlands (CWs), are attractive solutions to treat surface waters contaminated with toxic cyanobacteria blooms from lakes, ponds, reservoirs, and irrigation systems. In line with this, the main aim of this work was to evaluate the potential of CWs for the treatment of water contaminated with MC-LR produced by Microcystis aeruginosa—LEGE 91094. For that, microcosms (0.4 × 0.3 × 0.3 m) simulating CWs were assembled with Phragmites australis to treat lake water contaminated with Microcystis aeruginosa cells and MCs. Results showed removal percentages of M. aeruginosa cells above 94% and about 99% removal of MC-LR during 1 week treatment cycles. CWs maintained their functions, regardless the presence of MC-LR in the system, and also showed significant removal of nutrients (ammonium ion removal up to 86%) and organic matter (removal reaching 98%). The present work indicates that CWs have the potential for removal of cyanobacterial cells and cyanotoxins, which can be useful for the treatment of eutrophic waters and provide water of sufficient quality to be used, for instance, in agriculture.

Using low technology to improve the safety of informal-vended brukina – a fermented milk and millet smoothie in Ghana

Brukina , a fermented milk, and millet smoothie, is a popular indigenous beverage in Ghana. Its production is dominated within the Northern regions of Ghana. Brukina is considered as a complete meal due to its high nutrient and energy density. There are, however, quality and safety gaps associated with the traditional production of brukina which limits patronage, shelf-life and nutritional benefits. This study evaluated the microbiological quality at selected brukina production steps and the retailed brukina drink. Samples were taken along the production chain from four major traditional brukina producers within the Greater Accra region and analysed for the total viable count, total coliforms, Staphylococcus aureus, yeasts and moulds, and pH. The mean microbial concentrations for traditionally produced and marketed products were 7.48 Log CFU/mL for total viable counts, 2.91 Log CFU/mL for total coliforms, 4.68 Log CFU/mL for S. aureus and 5.25 Log CFU/mL for yeasts and moulds. Mean pH of the finished product on the market was 4.35. The microbial counts along the production chain were generally high, revealing poor hygienic handling and need for process optimization. Data generated from microbiological analyses of commercial brukina , food safety audits from previous studies and CODEX code of hygienic practices were used as guidelines to optimize the traditional process operations and develop a Standard Operating Procedure (SOP) for hygienic production of traditional brukina . Implementation of the SOP in a controlled environment reduced the total count by 4.28 Log CFU/mL at P=0.000 and total coliforms by 3.63 Log CFU/mL at P=0.035 at all the tested production steps. The optimized brukina had a mean total count of 4.06 Log CFU/mL and undetectable levels of total coliforms and S. aureus . Critical control steps in traditional production operations were identified as the steaming of milled and agglomerated millet and milk pasteurization. The SOP developed provides a low technology solution to improve quality and safety of traditional brukina . Key words : Brukina , Standard Operating Procedures (SOP), microbiological quality, hygiene, dairy

Heat storage wall made of concrete and encapsulated water applied to mass construction social housing in temperate climates

In Argentina there is a serious housing shortage. The National State responds to this shortage in a quantitative rather than in a qualitative way, avoiding low maintenance architectural and technological solutions for this problem. For this purpose, the passive solar technologies are a truly viable alternative. Therefore, this work presents the design and thermal performance of heat storage walls (HSW) made of mixed materials (concrete and water) for heating mass construction housing built by the National State of Argentina. They are prepared to be included in modules (1.2m×2.4m) on the equator-facing sides since they are made of storage mass made with industrialized stackable pieces. The storage mass is made of concrete with encapsulated water in PVC pipes and it is covered with a single-glazed covering. In this work, the technological design, the industrialization, manufacture and assembly stages, and its performance are presented. Simulations of the systems incorporated into a house were carried out and they were then compared to the most widespread technologies (solid concrete walls). Experimental scale measurements of these systems were also made in a 1.08m3 insulated enclosure. The simulations did not show very significant differences among the analyzed systems, but they allowed us to define the use of single glazing as a transparent covering. The measurements show the different loading dynamics of each type of wall and confirm a difference of 2°C among the internal temperatures, recorded inside the enclosures in favor of the mixed storage wall. The carried out works enabled us to install those systems in social housing in the Province of Buenos Aires, Argentina.

Recommendations and Low-Technology Safety Solutions Following Neuromuscular Blocking Agent Incidents

Neuromuscular blocking agents (NMBs) are high-risk medications used to facilitate endotracheal intubation and artificial ventilation. In an incident at a metropolitan tertiary referral and teaching public hospital in Australia, a neurosurgical patient became unresponsive at the start of surgery. It was determined that cisatracurium was administered in error in place of midazolam; the patient was ventilated and the emergency surgery continued. Two additional non-operating room (OR) drug-swap cases involving cisatracurium were reported within 12 months of this event, resulting in a comprehensive review of NMB safety. A root cause analysis (RCA) resulted in multiple interventions to decrease the risk of selection and administration errors: (1) review of NMB packaging and introduction of in-house NMB labeling by pharmacy procurement staff before distribution; (2) implementation of a medication administration in anesthetics guideline with ongoing education; (3) audit of storage with removal of NMBs; (4) review of new products by medication safety pharmacists and a senior anesthetist before distribution; and (5) use of red-barrel syringes for administering NMBs was expanded to all areas using NMBs to minimize syringe-swap incidents. In the four years since full implementation of interventions, there have been no reports of cisatracurum selection errors. An incident of atracurium administration resulted in further recommendations for review of OR cart storage. Ongoing monitoring via medication safety walkrounds, by OR staff, by the perioperative pharmacist, and through the hospital's medication incident monitoring system has not detected any further NMB incidents. Technological solutions have been shown to decrease the risk of NMB errors, yet multifaceted low-technology solutions may be an effective, cheaper alternative.

Ecohydrology, floodplain water bodies, European legal provisions and the future

Using the ecohydrology concept for mitigating or resolving pressures on the natural environment caused by human activities is a successful way to find low-technology solutions which comprise the use of ecosystem services provided by dedicated ecosystems. Today this approach faces constraints by lack of area in highly developed countries, or related to legal tools established by the European Community. Even more important are climate change effects and the inevitable response of ecological systems, which interfere with their present resilience. Science is called on providing new strategies and tools to better predict the future of ecosystem services and how climate change effects can be mitigated or transformation activities can be initiated.

Adoption of sustainable retrofit in UK social housing

PurposeThe study was designed to assess the knowledge, adoption and perceived effectiveness of sustainable retrofit technologies within the UK social housing sector.Design/methodology/approachThe study was undertaken using a structured questionnaire that was completed by 130 providers of social housing.FindingsThe study showed that social housing providers were evenly split in their reliance on internal or external information for sustainable retrofit knowledge. In terms of adoption identified that this was strongly driven by government‐funded programmes, leading to widespread adoption of low technology solutions. The respondents identified that many leading edge technologies were perceived to be less effective.Research limitations/implicationsThe study represents a snap‐shot of adoption and effectiveness issues, therefore does not show the trajectory of adoption which should be addressed in a follow‐up study.Practical implicationsThe social housing sector has been viewed as a market maker for some of the newer technologies. It indicates that some of the newer technologies, such as heat pumps are viewed as less effective than more established technologies.Social implicationsThe study has implications for the adoption of technology to address fuel poverty and climate change, as well as informing future policy such as Green Deal.Originality/valueThe study includes 130 responses from the social housing stock and gives a perspective of current views on adoption and effectiveness of retrofit technologies within the social housing sector. This is useful for both other social housing providers and policy makers.

Affordable Nutrient Solutions for Improved Food Security as Evidenced by Crop Trials

The continuing depletion of nutrients from agricultural soils in Sub-Saharan African is accompanied by a lack of substantial progress in crop yield improvement. In this paper we investigate yield gaps for corn under two scenarios: a micro-dosing scenario with marginal increases in nitrogen (N) and phosphorus (P) of 10 kg ha−1 and a larger yet still conservative scenario with proposed N and P applications of 80 and 20 kg ha−1 respectively. The yield gaps are calculated from a database of historical FAO crop fertilizer trials at 1358 locations for Sub-Saharan Africa and South America. Our approach allows connecting experimental field scale data with continental policy recommendations. Two critical findings emerged from the analysis. The first is the degree to which P limits increases in corn yields. For example, under a micro-dosing scenario, in Africa, the addition of small amounts of N alone resulted in mean yield increases of 8% while the addition of only P increased mean yields by 26%, with implications for designing better balanced fertilizer distribution schemes. The second finding was the relatively large amount of yield increase possible for a small, yet affordable amount of fertilizer application. Using African and South American fertilizer prices we show that the level of investment needed to achieve these results is considerably less than 1% of Agricultural GDP for both a micro-dosing scenario and for the scenario involving higher yet still conservative fertilizer application rates. In the latter scenario realistic mean yield increases ranged between 28 to 85% in South America and 71 to 190% in Africa (mean plus one standard deviation). External investment in this low technology solution has the potential to kick start development and could complement other interventions such as better crop varieties and improved economic instruments to support farmers.

The Current Status of Bolus Calculator Decision-Support Software

The purpose of self-monitoring of blood glucose is to take action based on the results of the tests. The three actions that must be taken by insulin-using diabetes patients in response to blood glucose self-testing are, first, to record the blood glucose level, second, to calculate an appropriate dose of insulin, and, third, to administer the dose of insulin. A low-technology solution exists for each of these three actions. In addition, a commonly used high-technology solution exists for the first and third of these three actions (recording the blood glucose level and administering the insulin dose), but no high-technology product is currently approved by the Food and Drug Administration (FDA) for calculating an insulin dose (Figure 1). The currently unavailable high-technology approach to glucose-directed insulin dosing is approved software for calculating a bolus dose of insulin. Figure 1 Technology to apply to blood glucose data for administering an appropriate dose of insulin. In the first article to report a premeal bolus calculator was a system that was intended for use by insulin pump users.1 The bolus formula in that article incorporated five elements: (1) the carbohydrate/insulin ratio (carbo-hydrate bolus dose); (2) the insulin/carbohydrate ratio (correction bolus dose); (3) the target postprandial blood glucose; (4) the current blood glucose level; and (5) the carbohydrate content of the planned meal. The first four of these elements were known in advance and could be preprogrammed. Only the meal content would need to be entered at the time of the meal. Four factors that could affect the dose calculation, but were not accounted for, were as follows: (1) any correction bolus insulin onboard from a recently administered correction bolus insulin dose; (2) any carbohydrate bolus insulin onboard from a recently administered correction bolus insulin dose; (3) exercise either recently since the last dose of insulin or planned soon; or (4) any food onboard since the last dose of insulin. Accounting for these four factors could make for a more accurate bolus calculator to match a lifestyle, food, or physical activity choice with a correct dose.

Clean Water, Sanitation, and the Millennium Development Goals

In nineteenth century London, four large cholera outbreaks killed some 37,000 people. Completion of the capital’s sewer system contributed significantly to later reductions in gastrointestinal infections and increased life expectancy. This achievement was a team effort, but one driving force was the physician John Snow, the 150th anniversary of whose death was marked by a small ceremony on June 16, 2008, in a London public house close to the site of Dr. Snow’s main study of cholera transmission. Despite the venue, the celebratory libation was with water, not just out of respect for Snow’s abhorrence of alcohol but also because one of the occasion’s cosponsors was the international charity WaterAid. Water remains a key factor in disease worldwide. In the last year of his life, Snow wrote: “If the general use of water-closets is to continue and increase, it will be desirable to have two supplies of water in large towns, one for the water-closets and another, of soft spring or well water from a distance.”1 This simple principle of separation is today taken for granted in the developed world, where cholera is largely of historical interest only while globally we still need a World Health Organization task force on Vibrio cholerae infection as the disease refuses to go away.2 Cholera is not the only waterborne infection, of course, and not all illnesses from unclean water are microbial in origin (e.g., contamination with arsenic or man-made chemicals). In the UK, 99.96% of routine water tests now meet national and European standards.3 Any sustained falling off in water quality would be met with public outrage, and a spot check revealing cryptosporidium in a reservoir is headline news. Recognizing the continuing problems for less fortunate parts of the world the World Health Organization now has pragmatic “guidelines” (rather than “standards”) for water quality. Poor sanitation and lack of access to safe drinking water are still contributing to significant and avoidable morbidity and mortality, especially in children. One billion people do not have clean water, and 2.6 billion lack basic sanitation.4,5 United Nations (UN) agencies (and other parties) have long been aware of this situation. Remember the International Decade for Clean Drinking Water? That was 1981–1990 and had the absurdly ambitious target of “safe water and sanitation for everybody by 1990.” That failed. Former UN Secretary-General Kofi Annan then tried the human rights argument: “access to safe water is a fundamental need and therefore a basic human right,” he declared. Now, in 2008, we are roughly halfway through yet another ambitious project, the International Water Decade (2005–2015). This is linked to the 2008 International Year of Sanitation, mischievously referred to by some as the “year of the toilet.” The aim of the latest water decade is more modest than the one for 1981–1990—namely, “to halve, by 2015, the proportion of the world’s population without sustainable access to basic sanitation.” This roughly translates into a reduction from 40% to 20%, and the target is associated with the UN’s millennium development goals (MDGs). It is not, however, one of the primary eight goals. Perhaps, it ought to have been. It is difficult to see how the UN’s ambition of reducing mortality in the under-fives by two-thirds and halving and starting to reverse the incidence of malaria and other major diseases can be achieved without dramatic improvements in the two linked water-related factors of access to safe drinking water and the disposal of human excrement. So, at half-time in the decade, how are we doing? Not brilliantly. Only one of the UN’s regions is on track to achieve all eight MDGs,6 and the latest monitoring exercise records results as “mixed” and “uneven” and notes a “lack of progress in child survival.” Failure in the earlier International Decade for Clean Drinking Water was in part ascribed to an inability to keep up with the rapid pace of urbanization. Unfortunately, two decades on the same argument is being used. Urbanization, together with a rural backlog, means that targets are going to be missed.7 Drinking water and sanitation have not been neglected by UN agencies, but those agencies must be frustrated by the slow progress, especially since the know-how has been around for more than 150 years and cheaper, low-technology solutions are also available.

What Endoscopic Accessories Do We Really Need?

This article is a speculative essay that reviews the current limitations of existing flexible endoscopic accessories. Suggestions are offered on future developments that may change endoscopic practice as it adopts an increasingly therapeutic role. There may be a potential for development in flexible endoscopic surgical techniques that will be comparable to those seen in rigid laparoscopic surgery. Low and high technology solutions are considered. Invention, common sense, and engineering efforts are needed to take flexible endoscopic surgery to a higher level of functional efficacy.

High- and Low-technology Solutions for Massive Cavernous Hemangioma of the Face: Lasers and Leeches to the Rescue

A massive cavernous hemangioma of the face has been resected using a combination of old and new techniques. The ability of the neodymium: YAG laser to cut with excellent hemostasis formed the basis for the resection. Adjuncts to the surgical excision included such high-technology modalities as laser Doppler flowmeters and tissue expanders. Flap viability was salvaged by the lowly but essential common leech. This case is presented to illustrate the fantastic array of modalities available to plastic surgeons for major resections and reconstructions.