Advancing the Economic and Environmental Sustainability of the NEWgenerator Nonsewered Sanitation System.

Achieving safely managed sanitation and resource recovery in areas that are rural, geographically challenged, or experiencing rapidly increasing population density may not be feasible with centralized facilities due to space requirements, site-specific concerns, and high costs of sewer installation. Nonsewered sanitation (NSS) systems have the potential to provide safely managed sanitation and achieve strict wastewater treatment standards. One such NSS treatment technology is the NEWgenerator, which includes an anaerobic membrane bioreactor (AnMBR), nutrient recovery via ion exchange, and electrochlorination. The system has been shown to achieve robust treatment of real waste for over 100 users, but the technology's relative life cycle sustainability remains unclear. This study characterizes the financial viability and life cycle environmental impacts of the NEWgenerator and prioritizes opportunities to advance system sustainability through targeted improvements and deployment. The costs and greenhouse gas (GHG) emissions of the NEWgenerator (general case) leveraging grid electricity were 0.139 [0.113-0.168] USD cap-1 day-1 and 79.7 [55.0-112.3] kg CO2-equiv cap-1 year-1, respectively. A transition to photovoltaic-generated electricity would increase costs to 0.145 [0.118-0.181] USD cap-1 day-1 but decrease GHG emissions to 56.1 [33.8-86.2] kg CO2-equiv cap-1 year-1. The deployment location analysis demonstrated reduced median costs for deployment in China (-38%), India (-53%), Senegal (-31%), South Africa (-31%), and Uganda (-35%), but at comparable or increased GHG emissions (-2 to +16%). Targeted improvements revealed the relative change in median cost and GHG emissions to be -21 and -3% if loading is doubled (i.e., doubled users per unit), -30 and -12% with additional sludge drying, and +9 and -25% with the addition of a membrane contactor, respectively, with limited benefits (0-5% reductions) from an alternative photovoltaic battery, low-cost housing, or improved frontend operation. This research demonstrates that the NEWgenerator is a low-cost, low-emission NSS treatment technology with the potential for resource recovery to increase access to safe sanitation.

Gait Device Treatment Using Telehealth for Individuals With Stroke During the COVID-19 Pandemic: Nonrandomized Pilot Feasibility Study.

BACKGROUND: During the COVID-19 pandemic, rehabilitation providers and consumers adopted telehealth practices at unprecedented rates. Multiple prepandemic studies demonstrate the feasibility and comparable efficacy between in-clinic and remote treatment for certain impairments caused by stroke, such as upper extremity weakness and impaired motor function. However, less guidance has been available regarding gait assessment and treatment. Despite this limitation, safe and effective gait treatment is fundamental to optimizing health and well-being after stroke and should be considered a treatment priority, including during the COVID-19 pandemic. OBJECTIVE: This study explores the feasibility of using telehealth to deliver gait treatment using a wearable gait device, the iStride device, to stroke survivors during the 2020 pandemic. The gait device is used to treat hemiparetic gait impairments caused by stroke. The device alters the user's gait mechanics and creates a subtle destabilization of the nonparetic limb; therefore, supervision is required during its usage. Before the pandemic, treatment with the gait device had been provided in person to appropriate candidates using a combination of physical therapists and trained personnel. However, upon the emergence of the COVID-19 pandemic, in-person treatment was halted in adherence to pandemic guidelines. This study investigates the feasibility of 2 remote delivery treatment models with the gait device for stroke survivors. METHODS: Participants were recruited during the first half of 2020 after the onset of the pandemic and included 5 individuals with chronic stroke (mean age 72 years; 84 months post stroke). Four participants were previous gait device users who transitioned to the telehealth delivery model to continue their gait treatment remotely. The fifth participant performed all study-related activities, from recruitment through follow-up, remotely. The protocol included virtual training for the at-home care partner, followed by 3 months of remote treatment with the gait device. Participants were instructed to wear gait sensors during all treatment activities. To assess feasibility, we monitored the safety of the remote treatment, compliance with protocol activities, acceptability of the telehealth treatment delivery, and preliminary efficacy of the gait treatment. Functional improvement was measured using the 10-Meter Walk Test, the Timed Up and Go Test, and the 6-Minute Walk Test, and quality of life was assessed using the Stroke-Specific Quality of Life Scale. RESULTS: No serious adverse events occurred, and participants rated high acceptance of the telehealth delivery. Protocol compliance averaged 95% of treatment sessions, 100% of assessments, and 85% of sensor usage during treatment. After 3 months of treatment, the average improvement in each functional outcome exceeded the minimal clinically important difference or minimal detectable change value. CONCLUSIONS: Remote treatment delivery with the gait device appeared feasible with care partner support. Gait treatment using telehealth may be useful to offset negative immobility impacts for those requiring or preferring remote care during the pandemic or otherwise. TRIAL REGISTRATION: ClinicalTrials.gov NCT04434313; https://clinicaltrials.gov/ct2/show/NCT04434313.

Financial Viability and Environmental Sustainability of Fecal Sludge Treatment with Pyrolysis Omni Processors.

Omni Processors (OPs) are community-scale systems for non-sewered fecal sludge treatment. These systems have demonstrated their capacity to treat excreta from tens of thousands of people using thermal treatment processes (e.g., pyrolysis), but their relative sustainability is unclear. In this study, QSDsan (an open-source Python package) was used to characterize the financial viability and environmental implications of fecal sludge treatment via pyrolysis-based OP technology treating mixed and source-separated human excreta and to elucidate the key drivers of system sustainability. Overall, the daily per capita cost for the treatment of mixed excreta (pit latrines) via the OP was estimated to be 0.05 [0.03-0.08] USD·cap-1·d-1, while the treatment of source-separated excreta (from urine-diverting dry toilets) was estimated to have a per capita cost of 0.09 [0.08-0.14] USD·cap-1·d-1. Operation and maintenance of the OP is a critical driver of total per capita cost, whereas the contribution from capital cost of the OP is much lower because it is distributed over a relatively large number of users (i.e., 12,000 people) for the system lifetime (i.e., 20 yr). The total emissions from the source-separated scenario were estimated to be 11 [8.3-23] kg CO2 eq·cap-1·yr-1, compared to 49 [28-77] kg CO2 eq·cap-1·yr-1 for mixed excreta. Both scenarios fall below the estimates of greenhouse gas (GHG) emissions for anaerobic treatment of fecal sludge collected from pit latrines. Source-separation also creates opportunities for resource recovery to offset costs through nutrient recovery and carbon sequestration with biochar production. For example, when carbon is valued at 150 USD·Mg-1 of CO2, the per capita cost of sanitation can be further reduced by 44 and 40% for the source-separated and mixed excreta scenarios, respectively. Overall, our results demonstrate that pyrolysis-based OP technology can provide low-cost, low-GHG fecal sludge treatment while reducing global sanitation gaps.

Are You on the Right Platform? A Conjoint Analysis of Social Media Preferences in Aesthetic Surgery Patients.

BACKGROUND: Social media has become an indispensable tool for patients to learn about aesthetic surgery. Currently, procedure-specific patient preferences for social media platforms and content are unknown. OBJECTIVES: The authors sought to evaluate social media preferences of patients seeking aesthetic surgery. METHODS: We utilized a choice-based conjoint analysis survey to analyze the preferences of patients seeking 3 common aesthetic procedures: breast augmentation (BA), facial rejuvenation (FR), and combined breast/abdominal surgery (BAB). Participants were asked to choose among social media platforms (Facebook, Twitter, Instagram, Snapchat, Pinterest, Tumblr, YouTube), information extent (basic, moderate, comprehensive), delivery mechanism (prerecorded video, live video, photographs, text description), messenger (surgeon, nurse/clinic staff, patient), and option for interactivity (yes/no). The survey was administered using an Internet crowdsourcing service (Amazon Mechanical Turk). RESULTS: A total of 647 participants were recruited: 201 in BA, 255 in FR, and 191 in BAB. Among attributes surveyed, participants in all 3 groups (BA, FR, BAB) valued social media platform as the most important (30.9%, 33.1%, 31.4%), followed by information extent (23.1%, 22.9%, 21.6%), delivery mechanism (18.9%, 17.4%, 18%), messenger (16%, 17%, 17.2%), and interactivity (11.1%, 9.8%, 11.8%). Within these attributes, Facebook ranked as the preferred platform, with comprehensive information extent, live video as the delivery mechanism, and surgeon as the messenger as most preferred. CONCLUSIONS: The choice of social media platform is the most important factor for patients, and they indicated a preference for comprehensive information delivered by the surgeon via live video on Facebook. Our study elucidates social media usage in common aesthetic populations, which can help improve aesthetic patient outreach.

Management of the Chronic Burn Wound.

This article reviews the current evidence in using hyperbaric oxygen therapy (HBOT) in burn wounds. There is also separate consideration of diabetic foot burns and a protocol for use of HBOT in a specific case. The challenges of using HBOT in an acute burn care setting are reviewed. Next the pathophysiology of Marjolin ulcers is reviewed. The current thinking in diagnosis, treatment, and prevention of Marjolin ulcers is discussed. Finally, a background in using topical growth factors (tGF) is provided, followed by a summary of the current evidence of tGF in burn wounds.

Evaluation of Syncope in Older Adults.

The older adult patient with syncope is one of the most challenging evaluations for the emergency physician. It requires clinical skill, patience, and knowledge of specific older adult issues. It demands care in the identification of necessary resources, such as medication review, and potential linkage with several multidisciplinary follow-up services. Excellent syncope care likely requires reaching out to ensure institutional resources are aligned with emergency department patient needs, thus asking emergency physicians to stretch their administrative talents. This is likely best done as preset protocols prior to individual patient encounters. Emergency physicians evaluate elders with syncope every day and should rise to the challenge to do it well.