Background: Despite concerted research efforts, the collection of domestic waste remains poorly understood in terms of financial and environmental cost drivers. Detailed studies of specific systems, yielding limited broader understanding, remain the norm. Methods: This study presents flexible and generally applicable models for domestic waste transport logistics, based on economic cost and environmental impact calculations. Results: The calculations reveal key sensitivities by highlighting the most important cost and environmental drivers and linking these to key factors relating to the deployment of staff and collection vehicles, behaviour of consumers, and others. Conclusions: This study demonstrates these elements in a Norwegian context, showing that the models can inform tactical and operational decision-making for the logistics of domestic waste collection, and inform policy development in the area.

Sustainability and life-cycle assessment (LCA) studies of circular product value chains show evidence of considerable difficulty in capturing events such as product reuse and repair, because of unclear and uncertain representation of product displacement and behavioural-related factors. The present study examines how an approach based on displacement of product function and direct calculation of environmental impacts across partial life cycles might remedy these issues. A calculation framework based on the concept of environmental value and its depreciation along a life cycle is presented. Results for two value chains with qualitatively quite different features illustrate the utility and flexibility of the framework. The work offers significant conceptual advances in both recognising and measuring the relative impacts of using newer or older products providing the same function. As such it determines tangible environmental benefits for the use of older products which is a pre-requisite for reduced overall consumption and macro-level sustainability improvement.

OBJECTIVES:The main objective of this analysis was to evaluate the impact of pre-existing drug resistance by next-generation sequencing (NGS) on the risk of treatment failure (TF) of first-line regimens in participants enrolled in the START study. METHODS:Stored plasma from participants with entry HIV RNA >1000 copies/mL were analysed using NGS (llumina MiSeq). Pre-existing drug resistance was defined using the mutations considered by the Stanford HIV Drug Resistance Database (HIVDB v8.6) to calculate the genotypic susceptibility score (GSS, estimating the number of active drugs) for the first-line regimen at the detection threshold windows of >20%, >5%, and >2% of the viral population. Survival analysis was conducted to evaluate the association between the GSS and risk of TF (viral load >200 copies/mL plus treatment change). RESULTS:Baseline NGS data were available for 1380 antiretroviral therapy (ART)-naïve participants enrolled over 2009-2013. First-line ART included a non-nucleoside reverse transcriptase inhibitor (NNRTI) in 976 (71%), a boosted protease inhibitor in 297 (22%), or an integrase strand transfer inhibitor in 107 (8%). The proportions of participants with GSS <3 were 7% for >20%, 10% for >5%, and 17% for the >2% thresholds, respectively. The adjusted hazard ratio of TF associated with a GSS of 0-2.75 versus 3 in the subset of participants with mutations detected at the >2% threshold was 1.66 (95% confidence interval 1.01-2.74; p = 0.05) and 2.32 (95% confidence interval 1.32-4.09; p = 0.003) after restricting the analysis to participants who started an NNRTI-based regimen. CONCLUSIONS:Up to 17% of participants initiated ART with a GSS <3 on the basis of NGS data. Minority variants were predictive of TF, especially for participants starting NNRTI-based regimens.

Conclusions 10 Roadmap -toward better monitoring of waste prevention in the Nordic countries 10.1

The study was aimed at generating insight on the potential of circular economy in the Nordic region and providing recommendations for unlocking this potential. This report covers the first part of ...

This prospective cohort study enrolled people living with HIV initiating antiretroviral therapy (ART) containing the integrase inhibitors, dolutegravir (DTG) or elvitegravir (EVG) and administered the Montreal Cognitive Assessment (MoCA) at baseline and again after approximately six months to compare changes in MoCA scores. The proportion of patients found to have cognitive impairment, as indicated by a MoCA score <26/30, on each agent were also compared and comparisons were made between changes in each domain assessed by the MoCA (visuospatial/executive, naming, attention, language, abstraction, delayed recall, and orientation). Thirty-five evaluable participants were enrolled, 18 on DTG and 17 on EVG. The median [interquartile range(IQR)] age was 44 (32 to 54) years, 63% were male, 57% were African American. The median (IQR) MoCA score at baseline was 25 (23 to 27) with no difference between groups (p=0.249). The median (IQR) change in MoCA score was 0 (-1 to 2) for DTG and 1 (0 to 3) for EVG (p = 0.183). Of those on DTG, 8 (44%) had MoCA scores <26 on follow-up compared to 11 (65%) on EVG (p = 0.229). There were no significant differences in changes in any of the individual MoCA domains.

ObjectivesThe aim of this analysis was to characterize transmitted drug resistance (TDR) in Strategic Timing of Antiretroviral Treatment (START) study participants by next‐generation sequencing (NGS), a sensitive assay capable of detecting low‐frequency variants.MethodsStored plasma from participants with entry HIV RNA > 1000 copies/mL were analysed by NGS (Illumina MiSeq). TDR was based on the WHO 2009 surveillance definition with the addition of reverse transcriptase (RT) mutations T215N and E138K, and integrase strand transfer inhibitor (INSTI) surveillance mutations (Stanford HIVdb). Drug resistance mutations (DRMs) detected at three thresholds are reported: > 2%, 5% and 20% of the viral population.ResultsBetween 2009 and 2013, START enrolled 4684 antiretroviral therapy (ART)‐naïve individuals in 35 countries. Baseline NGS data at study entry were available for 2902 participants. Overall prevalence rates of TDR using a detection threshold of 2%/5%/20% were 9.2%/5.6%/3.2% for nucleoside reverse transcriptase inhibitors (NRTIs), 9.2%/6.6%/4.9% for non‐NRTIs, 11.4%/5.5%/2.4% for protease inhibitors (PIs) and 3.5%/1.6%/0.1% for INSTI DRMs and varied by geographic region. Using the 2% detection threshold, individual DRMs with the highest prevalence were: PI M46IL (5.5%), RT K103NS (3.5%), RT G190ASE (3.1%), T215ISCDVEN (2.5%), RT M41L (2.2%), RT K219QENR (1.7%) and PI D30N (1.6%). INSTI DRMs were detected almost exclusively below the 20% detection threshold, most commonly Y143H (0.4%), Q148R (0.4%) and T66I (0.4%).ConclusionsUse of NGS in this study population resulted in the detection of a large proportion of low‐level variants which would not have been detected by traditional Sanger sequencing. Global surveillance studies utilizing NGS should provide a more comprehensive assessment of TDR prevalence in different regions of the world.

Inefficiency in complex reverse-logistical operations, such as the collection and transport of various wastes, can often be traced to two related factors. Adversarial and arms-length relationships between service providers and customers are commonplace, alongside surprisingly limited understanding of the cost base. This study investigated transparency and shared understanding as drivers for higher efficiency and lower costs. Observation and intervention in contractual negotiations was combined with analyses of cost and sensitivity, and a post-contractual transparency exercise with bidders where findings were shared with all parties. The work yielded both immediate efficiency gains and a longer-term infrastructure for cost evaluation and negotiation. Ongoing work is extending the approach into yet more complex and broader areas of municipal waste management.

Rigorous and fair comparison of end-of-life handling options for domestic refrigerators is much more complicated than simple policy perspectives such as the waste hierarchy might suggest. The drive towards product reuse over material recycling merits particularly close attention. This study explores the factors that might influence policy and decision-making in this area, with a view to minimising overall environmental impact. The work combines life-cycle assessments of refrigerators with models for product performance over time to give a sector-wide perspective on these issues. Generally-accepted tenets such as the preferability of product reuse are shown to be provisional, heavily dependent on factors such as the electricity mix, and non-uniform for different measures of impact. A more general and complicated picture emerges, and recommendations for existing policy and ongoing work are developed.

Introduction Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). Materials and Methods ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and "hands on" clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Results Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. Conclusion The ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program's implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings.

The evaluation of activities driving sustainability in the consumer product sphere, such as material recycling and product re-use, often appears to be over-optimistic. Replacement of primary resource production with secondary production, which is the source of most environmental improvements, is rarely evaluated rigorously and is often overstated. Significant progress on measuring replacement has been made in the clothing and related sectors. This study investigates the issue of whether further improvements are possible by introducing factors typically absent, such as the level of environmental burden associated with consumer purchases, and the consumer demand. Via consumer survey and consequent numerical analysis, the work establishes viable metrics to supplement those currently used for replacement. In particular, it is shown that it is not sufficient to simply examine how metrics are constructed; it is also essential to test metrics’ response and sensitivity to input data, from survey and numerical analysis. The metrics developed are shown to be robust and appropriately responsive to changes in key parameters. Operations and decision-making in the sector may be significantly improved by this line of analysis.

Medical AcupunctureVol. 29, No. 1 PhotoessayStrategic and Tactical Objectives Associated with the Continued United States–Chinese Military Acupuncture Exchanges: Outcomes of the 4th Exchange, September 2016Richard C. Niemtzow, Arnyce R. Pock, Lewis Hofmann, Thomas R. Piazza, Stephen M. Burns, and John S. BaxterRichard C. NiemtzowUnited States Air Force Acupuncture and Integrative Medicine Center, Joint Base Andrews, MD.Search for more papers by this author, Arnyce R. PockUniformed Services University of the Health Sciences, Bethesda, MD.Search for more papers by this author, Lewis HofmannUnited States Air Force Acupuncture and Integrative Medicine Center, Joint Base Andrews, MD.Search for more papers by this author, Thomas R. PiazzaUnited States Air Force Acupuncture and Integrative Medicine Center, Joint Base Andrews, MD.Search for more papers by this author, Stephen M. BurnsUnited States Air Force Acupuncture and Integrative Medicine Center, Joint Base Andrews, MD.Search for more papers by this author, and John S. BaxterUnited States Air Force Acupuncture and Integrative Medicine Center, Joint Base Andrews, MD.Search for more papers by this authorPublished Online:1 Feb 2017https://doi.org/10.1089/acu.2017.29043.rcnAboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 29Issue 1Feb 2017 InformationCopyright 2017, Mary Ann Liebert, Inc.To cite this article:Richard C. Niemtzow, Arnyce R. Pock, Lewis Hofmann, Thomas R. Piazza, Stephen M. Burns, and John S. Baxter.Strategic and Tactical Objectives Associated with the Continued United States–Chinese Military Acupuncture Exchanges: Outcomes of the 4th Exchange, September 2016.Medical Acupuncture.Feb 2017.3-6.http://doi.org/10.1089/acu.2017.29043.rcnPublished in Volume: 29 Issue 1: February 1, 2017PDF download

Efficiency in the collection and transport of waste electrical and electronic equipment (WEEE) is important for economic and environmental reasons. A detailed analysis of the logistical- and cost-effectiveness of the collection and transport of WEEE in Norway reveals regional geography to be a particularly important factor; it varies significantly across the country and heavily influences the cost of collection. The paper explores the influence of this, along with other parameters relating to operational effectiveness and customer service. Implications for all the key actors in the WEEE collection and transport business are outlined.

Protease inhibitors (PIs) are a potent class of antiretroviral agents which have been used to successfully treat many patients with HIV disease. As with other classes of antiretroviral agents, drug resistance has been described with each of the PIs. PI resistance can occur in newly infected individuals due to transmission of drug resistant strains or, more commonly, evolves from the selective pressure of antiretroviral therapy. When present, PI resistance results in an increased likelihood of drug failure. Individual protease gene mutations have been identified which are associated with phenotypic resistance to these agents. However, protease mutations can exert different effects on individual PIs, as some will produce resistance to one agent and may enhance susceptibility to another. In patients failing PIs, particularly in the setting of prior treatment with multiple agents, protease resistance patterns may be complex and result in broad cross-resistance to the class. Strategies to limit the development of resistance to these agents and manage its occurrence are important for the on-going care of individuals with HIV infection.