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Grape pomace (GP) is a major solid waste resulting from the wine industry. GP is rich in structural carbohydrates, lignin, and other components such as oil and polyphenols, products with potential value. One of the major challenges to GP valorization is the lack of technology to fully utilize GP components and minimize waste generation. To overcome this challenge, we developed a novel, integrated process to fully utilize each component of GP for the production of oil, polyphenols, and biochemicals (acetone, butanol, and ethanol; ABE). GP was first subjected to pressurized liquid extraction to recover grape oil and polyphenols sequentially. The solid residue was pretreated with NaOH to partially dissolve lignin and was then hydrolyzed with enzymes to obtain reducing sugars. Finally, those reducing sugars were fermented to ABE by Clostridium beijerinckii. The key process conditions, including polyphenol extraction and pretreatment conditions, were optimized. Under optimized conditions, approximately 71.9 g ...

Objective To evaluate a digitally delivered, intensive behavioral counseling program for a workforce at risk for obesity-related chronic disease. Methods Employees were offered a digital health program modeled after the diabetes prevention program (DPP). Annual workforce health assessments were used to examine changes in chronic disease risk factors between participants (n = 634) relative to a matched comparison group (n = 1268). Results Overall, employees were gaining an average of 3.5 pounds annually before program inception. Program engagement was positive; 83% completed the majority of the curriculum and 31% lost at least 5% of their starting weight. Compared with non-participating peers, participants demonstrated reduced weight, improved fasting blood glucose, and improved nutritional intake after a year. Conclusions The digital health program was effective for engaging employees in health behavior change. Digital options facilitate widespread implementation.

To better evaluate potential uses for grape pomace (GP) waste, a comprehensive chemical composition analysis of GP in Virginia was conducted. Eight commercial white and red pomace samples (cv. Viognier, Vidal Blanc, Niagara, Petit Manseng, Petit Verdot, Merlot, Cabernet Franc, and Chambourcin) obtained from different wineries in Virginia, USA were used. For extractives, GPs contained 2.89%&ndash, 4.66% titratable acids, 4.32%&ndash, 6.60% ash, 4.62%&ndash, 12.5% lipids with linoleic acid being the predominant (59.0%&ndash, 70.9%) fatty acid, 10.4&ndash, 64.8 g total phenolic content (gallic acid equivalents)/kg GP, 2.09&ndash, 53.3 g glucose/kg GP, 3.79&ndash, 52.9 g fructose/kg GP, and trace sucrose. As for non-extractives, GPs contained 25.2%&ndash, 44.5% lignin, 8.04%&ndash, 12.7% glucan, 4.42%&ndash, 7.05% xylan, and trace amounts of galactan, arabinan, and mannan (less than 3% in total). Potential usages of these components were further examined to provide information on better valorization of GP. Considering the valuable extractives (e.g., polyphenols and oil) and non-extractives (e.g., lignin), designing a biorefinery process aiming at fully recover and/or utilize these components is of future significance.

To assess the impact crop load has on hard cider chemistry, ‘York’ apple (Malus ×domestica Borkh.) trees were hand thinned to three different crop loads: low [two apples per cm2 branch cross-sectional area (BCSA)], medium (four apples per BCSA), and high (six apples per BCSA). Higher crop loads produced smaller, less acidic fruit that were slightly more mature. In juice made from fruit from these treatments, the total polyphenol content did not differ at harvest, but, after fermentation, the medium crop load had 27% and the high crop load had 37% greater total polyphenol content than the low crop load. Yeast assimilable nitrogen (YAN) concentration in juice made from fruit from the low crop load treatment had 18% and 22% greater than the medium and high crop load, respectively. YAN concentrations in juice from the medium and high crop load treatments were similar. Our results provide apple growers and hard cider producers with a better understanding of how apple crop load impacts YAN concentrations in juice and total polyphenol concentrations in juice and cider.

Routine viral-load (VL) testing of HIV-infected individuals on antiretroviral therapy (ART) is used to monitor treatment efficacy. However, due to logistical challenges, implementation of VL has been difficult in resource-limited settings. The aim of this study was to evaluate the performance of the SAMBA semi-Q (simple amplification-based assay semiquantitative test for HIV-1) in London, Malawi, and Uganda. The SAMBA semi-Q can distinguish between patients with VLs above and below 1,000 copies/ml. The SAMBA semi-Q was validated with diluted clinical samples and blinded plasma samples collected from HIV-1-positive individuals. SAMBA semi-Q results were compared with results from the Roche COBAS AmpliPrep/COBAS TaqMan HIV-1 test, v2.0. Testing of 96 2- to 10-fold dilutions of four samples containing HIV-1 subtype C as well as 488 samples from patients in the United Kingdom, Malawi, and Uganda yielded an overall accuracy for the SAMBA semi-Q of 99% (95% confidence interval [CI], 93.8 to 99.9%) and 96.9% (95% CI 94.9 to 98.3%), respectively, compared to to the Roche test. Analysis of VL data from patients in Malawi and Uganda showed that the SAMBA cutoff of 1,000 copies/ml appropriately distinguished treated from untreated individuals. Furthermore, analysis of the viral loads of 232 patients on ART in Malawi and Uganda revealed similar patterns for virological control, defined as either Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach , 2010). This study suggests that the SAMBA semi-Q has adequate concurrency with the gold standard measurements for viral load. This test can allow VL monitoring of patients on ART at the point of care in resource-limited settings.

OBJECTIVE: Viral load testing is used in the HIV programme of Chiradzulu, Malawi, to confirm the diagnosis of immunological failure to prevent unnecessary switching to second-line therapy. Our objective was to quantify the benefit of this strategy for management of treatment failure in a large decentralized HIV programme in Africa. METHODS: Retrospective analysis of monitoring data from adults treated with first-line antiretroviral regimens for >1 year and meeting the WHO immunological failure criteria in an HIV programme in rural Malawi. The positive predictive value of using immunological failure criteria to diagnose virological failure (viral load >5000 copies/ml) was estimated. RESULTS: Of the 227 patients with immunological failure (185 confirmed with a repeat CD4 measurement), 155 (68.2%) had confirmatory viral load testing. Forty-four (28.4%) had viral load >5000 copies/ml and 57 (36.8%) >1000 copies/ml. Positive predictive value was 28.4% (95% CI 21.4-36.2%). Repeat CD4 count testing showed that 41% of patients initially diagnosed with immunological failure did no longer meet failure criteria. CONCLUSIONS: Our results support the need for confirming all cases of immunological failure with viral load testing before switching to second-line ART to optimize the use of resources in developing countries.

Summary objectives To ascertain the outcome of pre-Antiretroviral therapy (ART) and ART patients defaulting from care and investigate reasons for defaulting. methods Patients defaulting from HIV care in Chiradzulu between July 2004 and September 2007 were traced at last known home address. Deaths and moves were recorded, and patients found alive were interviewed. Defaulting was defined as missed last appointment by more than 1 month among patients of unknown vital status. results A total of 1637 individuals were traced (54%‐88% of eligible), 981 pre-ART and 656 ART patients. Of 694 pre-ART patients found, 49% had died (51% of adults and 38% of children), a median of 47 days after defaulting, and 14% had moved away. Of 451 ART patients found, 54% had died (54% of adults and 50% of children), a median of 52 days after defaulting, and 20% had moved away. Overall, 221 patients were interviewed (90% of those found alive), 42% had worked outside the district in the previous year; 49% of pre-ART and 19% of ART patients had not disclosed their HIV status to other household members. Main reasons for defaulting were stigma (43%), care dissatisfaction (34%), improved health (28%) and for ART discontinuation, poor understanding of disease or treatment (56%) and drug side effects (42%). conclusion This study in a rural African HIV programme reveals the dynamics related to health service access and use, and it provides information to correct programme mortality estimates for adults and children.

The Gnangara groundwater system (Gnangara system) is an important source of groundwater for Perth, Western Australia: in the order of 350 GL of groundwater is abstracted annually. The Gnangara system also sustains groundwater dependent ecosystems (GDEs), mostly wetlands and native vegetation. Declining groundwater levels across the system have led to impacts on a number of key GDEs. Western Australia’s Department of Water recently prepared a Water Management Plan for the Gnangara system. Allocation limits were reviewed as part of the plan preparation. To assist in reviewing allocation limits, an adaptive Groundwater Level Response Management (GWLRM) methodology was developed and implemented. This paper describes the methodology and its application to the Gnangara system. The methodology was developed to be used as a corrective tool for the short- and medium-term, to assist in achieving long-term sustainability of groundwater management in the context of changing climate and declining groundwater levels. The GWLRM methodology is based on groundwater storage depletion and can be applied to existing allocation limits as an interim tool to assist in making management decisions aimed at recovering groundwater resources. The key to the GWRLM correction is that it will direct water allocation towards sustainable levels on the basis of measured trends. Allocations corrected through application of the GWRLM would therefore represent interim and improved water allocation figures. GWLRM can also identify potential problem areas where the principles or calculations used for long-term sustainable groundwater allocation would need to be reviewed. For the Gnangara system, the calculated storage changes or GWLRM corrections were considered together with results of predictive modelling as part of an expert panel process to derive a more sustainable interim groundwater allocation regime while further research is being completed.

A predictive model, incorporating macroinvertebrate and environmental data, similar to that developed for Australian rivers (AUSRIVAS) and British rivers (RIVPACS) was constructed using a dataset collected from 23 reference (least altered) wetlands on the Swan Coastal Plain, Western Australia, sampled in summer and spring, 1989 and spring, 1990. Four main groups of reference wetlands were identified by UPGMA classification (using the Bray–Curtis dissimilarity measure). Distinguishing environmental variables identified by Stepwise Multiple Discriminant Function Analysis were: calcium, colour (gilvin), latitude, longitude, sodium and organic carbon. Observed to expected ratios of taxa with a >50% chance of occurrence (OE50) derived from the model for a suite of 23 test wetlands sampled in spring, 1997, were significantly correlated with pH and the depth of the sampling sites. Greater discrimination between the test wetlands was provided by the OE50 ratios than either raw richness (number of families) or a biotic index (SWAMPS). Results obtained for a subset of 11 test wetlands sampled with both a rapid bioassessment protocol (incorporating field picking of 200 invertebrates collected in 2 min sweeps from selected habitats) and a semi-quantitative protocol (incorporating laboratory picking of all invertebrates collected in sweeps along 10 m transects at randomly allocated sites) were not significantly different, indicating that the former could be used to reduce the time and costs associated with macroinvertebrate-based wetland monitoring programs. In addition to providing an objective method of assessing wetland condition, predictive modelling provides a list of taxa expected to occur under reference conditions, which can be used as a target in wetland restoration programs. The probable impediment to widespread adoption of predictive modelling for wetland bioassessment is the need to produce models tailored to specific geographic regions and specific climatic conditions. This may incur significant costs in countries, such as Australia, which span a wide range of climatic zones.

This study examined the use of relational maintenance behaviors (i.e., positivity, openness, assurances, networks, sharing tasks) in the sibling relationship, with a specific focus on the association with sibling liking. Participants were 257 individuals who reported on their relationship with a sibling. Results indicate that (a) the tasks relational maintenance behavior is used the most frequently and the openness relational maintenance behavior is used the least frequently; (b) the five relational maintenance behaviors are positively correlated with sibling liking; (c ) sibling liking is predicted by the positivity, networks, and tasks relational maintenance behaviors; and (d) female siblings use relational maintenance behaviors at a higher rate than male siblings.

Objective To describe patient antiretroviral therapy (cART) outcomes associated with intensive decentralization of services in a rural HIV program in Malawi. Methods Longitudinal analysis of data from HIV-infected patients starting cART between August 2001 and December 2008 and of a cross-sectional immunovirological assessment conducted 12 (±2) months after therapy start. One-year mortality, lost to follow-up, and attrition (deaths and lost to follow-up) rates were estimated with exact Poisson 95% confidence intervals (CI) by type of care delivery and year of initiation. Association of virological suppression (

Objective: We investigated the association between immune response and mortality in four HIV African programs supported by Medecins Sans Frontieres. Design: Multicentric retrospective cohort study. Methods: All antiretroviral therapy (ART) naive adults (>15 years) who initiated therapy between March 2001 and November 2010 and receiving therapy for 9 months or more were included. We described the evolution of mortality over time. Mixed Poisson models were used to assess the effect of updated CD4 cell counts and other potential risk factors on mortality. Findings: A total of 24 037 patients, of which 68% were women, contributed 69 516.2 person-years of follow-up. At ART initiation, 5718 patients (23.7%) were classified as WHO clinical stage 4, 1587 (6.6%) had a BMI below 16 kg/m2 and 2568 (10.7%) had CD4 cell count below 50 cells/μl. A total of 568 (2.4%) deaths were recorded during the study period. In the CD4 response categories 500 cells/μl or more, 350–499, 200–349, 50–199 cells/μl and less than 50 cells/μl, unadjusted mortality rates were 0.36; 0.58; 0.88; 1.91 and 7.43 per 100 person-years, respectively. In multivariate analysis, higher mortality was observed in patients with CD4 response levels 350–499 cells/μl [adjusted hazard ratio (aHR) 1.70, 95% confidence interval (CI) 1.26–2.30] and for those between 200–349 (aHR 2.56; 95% CI 1.93–3.38), compared to those with 500 cells/μl or more. Interpretation: The observed higher survival of patients with a CD4 response to ART higher than 500 cells/μl supports the need of further research to evaluate the individual benefit of initiating ART at higher CD4 levels in sub-Saharan Africa.

Viral load testing is used in the HIV programme of Chiradzulu, Malawi, to confirm the diagnosis of immunological failure to prevent unnecessary switching to second-line therapy. Our objective was to quantify the benefit of this strategy for management of treatment failure in a large decentralized HIV programme in Africa.Retrospective analysis of monitoring data from adults treated with first-line antiretroviral regimens for1 year and meeting the WHO immunological failure criteria in an HIV programme in rural Malawi. The positive predictive value of using immunological failure criteria to diagnose virological failure (viral load5000 copies/ml) was estimated.Of the 227 patients with immunological failure (185 confirmed with a repeat CD4 measurement), 155 (68.2%) had confirmatory viral load testing. Forty-four (28.4%) had viral load5000 copies/ml and 57 (36.8%)1000 copies/ml. Positive predictive value was 28.4% (95% CI 21.4-36.2%). Repeat CD4 count testing showed that 41% of patients initially diagnosed with immunological failure did no longer meet failure criteria.Our results support the need for confirming all cases of immunological failure with viral load testing before switching to second-line ART to optimize the use of resources in developing countries.

To ascertain the outcome of pre-Antiretroviral therapy (ART) and ART patients defaulting from care and investigate reasons for defaulting.Patients defaulting from HIV care in Chiradzulu between July 2004 and September 2007 were traced at last known home address. Deaths and moves were recorded, and patients found alive were interviewed. Defaulting was defined as missed last appointment by more than 1 month among patients of unknown vital status.A total of 1637 individuals were traced (54%-88% of eligible), 981 pre-ART and 656 ART patients. Of 694 pre-ART patients found, 49% had died (51% of adults and 38% of children), a median of 47 days after defaulting, and 14% had moved away. Of 451 ART patients found, 54% had died (54% of adults and 50% of children), a median of 52 days after defaulting, and 20% had moved away. Overall, 221 patients were interviewed (90% of those found alive), 42% had worked outside the district in the previous year; 49% of pre-ART and 19% of ART patients had not disclosed their HIV status to other household members. Main reasons for defaulting were stigma (43%), care dissatisfaction (34%), improved health (28%) and for ART discontinuation, poor understanding of disease or treatment (56%) and drug side effects (42%).This study in a rural African HIV programme reveals the dynamics related to health service access and use, and it provides information to correct programme mortality estimates for adults and children.

Objectives To explore sex workers9 accounts of condom use and their recommendations about how condoms might be improved. Methods In-depth interviews were conducted with 22 female sex workers in sex work premises in London, UK and Amsterdam, The Netherlands. Results The consistent and effective use of condoms was dependent upon client selection, sex worker control of the condom, communication skills and on condom- and sex-related skills. The design of facilities, the way the encounter was structured and alarm call systems were key to generating an environment in which sex worker control of the interaction was feasible. A wide range of practices used for 9safer sex9, including the use of simulated vaginal sex, skills in fitting the condom in a sexually arousing way, checking the condom placement during intercourse and holding onto the condom during withdrawal, were described but awareness of such practices was piecemeal. Several sex workers said that particular care is needed when using condoms in men with a small penis and pointed out to the authors that a smaller condom would be useful. Conclusions The sex workers told us about the importance of environmental factors and a range of sex- and condom-related skills in ‘safer sex’. Environmental ‘safety’ features could be addressed through a licensing system for sex work premises. Communication, condom- and sex-related skills should be more broadly disseminated through health promotion initiatives with sex workers. The issue of condom fit deserves further attention.

BACKGROUND: Expanding access to antiretroviral therapy (ART) in sub-Saharan Africa requires implementation of alternative care delivery models to traditional physician-centered approaches. This longitudinal analysis compares outcomes of patients initiated on antiretroviral therapy (ART) by non-physician and physician providers. METHODS: Adults (≥15 years) initiating ART between September 2007 and March 2010, and with >1 follow-up visit were included and classified according to the proportion of clinical visits performed by nurses or by clinical officers (≥ 80% of visits). Multivariable Poisson models were used to compare 2-year program attrition (mortality and lost to follow-up) and mortality by type of provider. In sensitivity analyses only patients with less severe disease were included. RESULTS: A total of 10,112 patients contributed 14,012 person-years to the analysis: 3386 (33.5%) in the clinical officer group, 1901 (18.8%) in the nurse care group and 4825 (47.7%) in the mixed care group. Overall 2-year program retention was 81.8%. Attrition was lower in the mixed care and higher in the clinical officer group, compared to the nurse group (adjusted incidence rate ratio [aIRR]=0.54, 95%CI 0.45-0.65; and aIRR=3.03, 95%CI 2.56-3.59, respectively). While patients initiated on ART by clinical officers in the mixed care group had lower attrition (aIRR=0.36, 95%CI 0.29-0.44) than those in the overall nurse care group; no differences in attrition were found between patients initiated on ART by nurses in the mixed care group and those included in the nurse group (aIRR=1.18, 95%CI 0.95-1.47). Two-year mortality estimates were aIRR=0.72, 95%CI 0.49-1.09 and aIRR=5.04, 95%CI 3.56-7.15, respectively. Slightly higher estimates were observed when analyses were restricted to patients with less severe disease. CONCLUSION: The findings of this study support the use of a mixed care model with well trained and regularly supervised nurses and medical assistants to provide HIV care in countries with high HIV prevalence.

Objective The evaluation of HIV treatment programs is generally based on an estimation of survival among patients receiving antiretroviral treatment (ART). In large HIV programs, loss to follow-up (LFU) rates remain high despite active patient tracing, which is likely to bias survival estimates and survival regression analyses. Methods We compared uncorrected survival estimates derived from routine program data with estimates obtained by applying six correction methods that use updated outcome data by a field survey targeting LFU patients in a rural HIV program in Malawi. These methods were based on double-sampling and differed according to the weights given to survival estimates in LFU and non-LFU subpopulations. We then proposed a correction of the survival regression analysis. Results Among 6,727 HIV-infected adults receiving ART, 9% were LFU after one year. The uncorrected survival estimates from routine data were 91% in women and 84% in men. According to increasing sophistication of the correction methods, the corrected survival estimates ranged from 89% to 85% in women and 82% to 77% in men. The estimates derived from uncorrected regression analyses were highly biased for initial tuberculosis mortality ratios (RR; 95% CI: 1.07; 0.76–1.50 vs. 2.06 to 2.28 with different correction weights), Kaposi sarcoma diagnosis (2.11; 1.61–2.76 vs. 2.64 to 3.9), and year of ART initiation (1.40; 1.17–1.66 vs. 1.29 to 1.34). Conclusions In HIV programs with high LFU rates, the use of correction methods based on non-exhaustive double-sampling data are necessary to minimise the bias in survival estimates and survival regressions.

Background: In sub-Saharan Africa, men living with HIV often start ART at more advanced stages of disease and have higher early mortality than women. We investigated gender difference in long-term immune reconstitution. Methods/Principal Findings: Antiretroviral-naive adults who received ART for at least 9 months in four HIV programs in sub-Saharan Africa were included. Multivariate mixed linear models were used to examine gender differences in immune reconstitution on first line ART. A total of 21,708 patients (68% women) contributed to 61,912 person-years of follow-up. At ART start,. Median CD4 at ART were 149 [IQR 85-206] for women and 125 cells/mu L [IQR 63-187] for men. After the first year on ART, immune recovery was higher in women than in men, and gender-based differences increased by 20 CD4 cells/mu L per year on average (95% CI 16-23; P250cells/mu L (difference between patients with 250 was 284 cells/mu L; 95% CI 272-296; LR test for interaction with time p = 0.63). Among patients with initial CD4 count of 150-200 cells/mu L, women reached 500 CD4 cells after 2.4 years on ART (95% CI 2.4-2.5) and men after 4.5 years (95% CI 4.1-4.8) of ART use. Conclusion: Women achieved better long-term immune response to ART, reaching CD4 level associated with lower risks of AIDS related morbidity and mortality quicker than men.

EDITOR—The dedication of the World Health Organization's World Health Day 2004 to road safety is recognition of the global threat of road traffic injuries. Increasing population size, vehicle ownership, road infrastructure, and transnational transportation have created a substantial public health burden. However, little epidemiological research has been conducted into …

Alternative-states theory commonly applied, for aquatic systems, to shallow lakes that may be dominated alternately by macrophytes and phytoplankton, under clear-water and enriched conditions, respectively, has been used in this study as a basis to define different states that may occur with changes in wetland salinity. Many wetlands of the south-west of Western Australia are threatened by rapidly increasing levels of salinity as well as greater water depths and permanency of water regime. We identified contrasting aquatic vegetation states that were closely associated with different salinities. Salinisation results in the loss of freshwater species of submerged macrophytes and the dominance of a small number of more salt-tolerant species. With increasing salinity, these systems may undergo further change to microbial mat-dominated systems composed mostly of cyanobacteria and halophilic bacteria. The effect of other environmental influences in mediating switches of vegetation was also examined. Colour and turbidity may play important roles at low to intermediate salinities [concentration of total dissolved solids (TDS) 10 000 mg L–1 TDS). The role of nutrients remains largely unquantified in saline systems. We propose that alternative-states theory provides the basis of a conceptual framework for predicting impacts on wetlands affected by secondary salinisation. The ability to recognise and predict a change in state with changes in salinity adds a further tool to decision-making processes. A change in state represents a fundamental change in ecosystem function and may be difficult to reverse. This information is also important for the development of restoration strategies. Further work is required to better understand the influence of temporal variation in salinity on vegetation states and probable hysteresis effects.