Tuberculosis-related mortality in people living with HIV in Europe and Latin America: an international cohort study

BACKGROUND Management of tuberculosis in patients with HIV in eastern Europe is complicated by the high prevalence of multidrug-resistant tuberculosis, low rates of drug susceptibility testing, and poor access to antiretroviral therapy (ART). We report 1 year mortality estimates from a multiregional (eastern Europe, western Europe, and Latin America) prospective cohort study: the TB:HIV study. METHODS Consecutive HIV-positive patients aged 16 years or older with a diagnosis of tuberculosis between Jan 1, 2011, and Dec 31, 2013, were enrolled from 62 HIV and tuberculosis clinics in 19 countries in eastern Europe, western Europe, and Latin America. The primary endpoint was death within 12 months after starting tuberculosis treatment; all deaths were classified according to whether or not they were tuberculosis related. Follow-up was either until death, the final visit, or 12 months after baseline, whichever occurred first. Risk factors for all-cause and tuberculosis-related deaths were assessed using Kaplan-Meier estimates and Cox models. FINDINGS Of 1406 patients (834 in eastern Europe, 317 in western Europe, and 255 in Latin America), 264 (19%) died within 12 months. 188 (71%) of these deaths were tuberculosis related. The probability of all-cause death was 29% (95% CI 26-32) in eastern Europe, 4% (3-7) in western Europe, and 11% (8-16) in Latin America (p<0·0001) and the corresponding probabilities of tuberculosis-related death were 23% (20-26), 1% (0-3), and 4% (2-8), respectively (p<0·0001). Patients receiving care outside eastern Europe had a 77% decreased risk of death: adjusted hazard ratio (aHR) 0·23 (95% CI 0·16-0·31). In eastern Europe, compared with patients who started a regimen with at least three active antituberculosis drugs, those who started fewer than three active antituberculosis drugs were at a higher risk of tuberculosis-related death (aHR 3·17; 95% CI 1·83-5·49) as were those who did not have baseline drug-susceptibility tests (2·24; 1·31-3·83). Other prognostic factors for increased tuberculosis-related mortality were disseminated tuberculosis and a low CD4 cell count. 18% of patients were receiving ART at tuberculosis diagnosis in eastern Europe compared with 44% in western Europe and 39% in Latin America (p<0·0001); 12 months later the proportions were 67% in eastern Europe, 92% in western Europe, and 85% in Latin America (p<0·0001). INTERPRETATION Patients with HIV and tuberculosis in eastern Europe have a risk of death nearly four-times higher than that in patients from western Europe and Latin America. This increased mortality rate is associated with modifiable risk factors such as lack of drug susceptibility testing and suboptimal initial antituberculosis treatment in settings with a high prevalence of drug resistance. Urgent action is needed to improve tuberculosis care for patients living with HIV in eastern Europe. FUNDING EU Seventh Framework Programme.

Abies – Circum-Mediterranean firs in Europe: distribution, habitat, usage and threats

Most European firs occur predominantly in small to medium-sized populations in the Mediterranean region, sometimes with fragmented and limited distributions, except for silver fir (Abies alba). They all are genetically closely related and can easily hybridise, perhaps as a consequence of late speciation during the late Quaternary. Circum-Mediterranean firs occur principally in mountain areas with medium to high precipitations rates which are mostly concentrated during the winter period. The species are able to tolerate long droughts in summer and tend to form pure stands when in optimal habitats. In the past firs have been extensively logged for construction and fire wood and their stands were replaced by other more disturbance adapted species or converted into rural areas. Nowadays with the exception of silver fir and Caucasian fir (Abies nordmanniana), circum-Mediterranean firs do not have a wide commercial interest. In Turkey they are still exploited for timber wood, while other firs have an ornamental use in gardening. Great importance is given to their preservation, especially to those populations which have very limited areas and specimens, with the creation of protected reserves and conservation programmes. Wild fires, livestock grazing and genetic drift represent actually their main threats.

Betula pendula, Betula pubescens and other birches in Europe: distribution, habitat, usage and threats

Silver birch (Betula pendula Roth) and downy birch (Betula pubescens Ehrh.) are short-lived, relatively small broadleaved trees that occur throughout most of Europe, particularly in northern regions. In southern Europe, birch trees are confined to mountainous areas, as they do not tolerate prolonged summer drought. Birch has a light canopy of small serrated leaves, and characteristic smooth, white to grey bark. In northern regions, birch trees can dominate the landscape up to the tree-line, whereas in the centre of their range they often occur early in secondary succession because of their abundant seed production, low demands on soil quality, and intolerance of shade. Birch trees provide the predominant hard wood source in northern Europe, and some varieties of Betula pendula produce highly priced veneers, while Betula pubescens is mostly used for pulp and fire wood. Other rarer species of birch are endemic to Europe contributing to the continental biodiversity even at high elevations and latitudes.

Castanea sativa in Europe: distribution, habitat, usage and threats

The sweet chestnut (Castanea sativa Mill.) is the only native species of the genus in Europe. The broad diffusion and active management by man resulted in the establishment of the species at the limits of its potential ecological range, which makes it difficult to trace its original natural area. The present distribution ranges from North-Western Africa (e.g. Morocco) to North-Western Europe (southern England, Belgium) and from south-western Asia (e.g. Turkey) to Eastern Europe (e.g. Romania), the Caucasus (Georgia, Armenia) and the Caspian Sea. In Europe the main chestnut forests are concentrated in a few countries such as Italy, France and the Iberian Peninsula. The sweet chestnut has a remarkable multipurpose character, and may be managed for timber production (coppice and high forest) as well as for fruit production (traditional orchards), including a broad range of secondary products and ecosystem services.

Fraxinus excelsior in Europe: distribution, habitat, usage and threats

Common ash (Fraxinus excelsior L.) is a medium-sized deciduous tree with large compound leaves that develop relatively late in spring. It flowers before leaf-buds burst and trees can carry male, female, or hermaphrodite flowers, or different combinations of the flower types. It grows throughout the European temperate zone, but is absent from the driest Mediterranean areas because it does not tolerate extended summer drought, and from the northern boreal regions, with its seedlings in particular being vulnerable to late spring frost. Soils exert a strong control on common ash distribution locally. The species grows best on fertile soils where soil pH exceeds 5.5. It rarely forms pure stands, more often it is found in small groups in mixed stands. Ash trees produce high quality timber that combines light weight, strength, and flexibility. Before the mass use of steel, it was used for a wide range of purposes, from agricultural implements to construction of boat and car frames. Today

Larix decidua and other larches in Europe: distribution, habitat, usage and threats

The European larch (Larix decidua Mill.) is a pioneer, very long-lived, fast-growing coniferous tree, which occurs in the central and eastern mountains of Europe, forming open forests or pasture woods at the upper tree limits. Larch is the only deciduous conifer in Europe as an adaptation to continental alpine climates. In fact, it is able to tolerate very cold temperatures during winter and, by losing its needles, avoids foliage desiccation. It is a transitional species, colonising open terrain after natural disturbances. It forms pure stands but more often it is found with other alpine tree species, which tend to replace it if no other disturbances occur. Thanks to its adaptability and the durability of its wood, the European larch represents an important silvicultural tree species in the alpine regions, planted even outside its natural ranges. Its wood is largely used for carpentry, furniture and pulp for paper. In lower altitudes or with high precipitation rates, larch is more susceptible to fungal diseases. Outbreaks of insect defoliators, principally caused by the larch bud moth (Zeiraphera diniana), can limit tree development, with economic losses in plantations, but they rarely lead to the death of the trees.

Picea abies in Europe: distribution, habitat, usage and threats

Among the coniferous species, Norway spruce (Picea abies (L.) Karst.) is one of the most important trees in Europe both for economic and ecological aspects, with a long tradition of cultivation. It can be a big tree, reaching 50-60 m in height with a straight and regular trunk, particularly used for timber constructions, pulpwood for paper and furniture. This widespread species dominates the Boreal forests in Northern Europe and the subalpine areas of the Alps and Carpathian Mountains. Thanks to its high performances in different site conditions, it can also be found outside its natural distribution on lower elevations in more temperate forests. Norway spruce has been massively planted up to its niche limits, where it is particularly susceptible to heat and drought, due to its shallow root system. For this reason it is expected to be severely affected under global warming conditions. Disturbed and weakened plants can be easily attacked by rot fungi such as Heterobasidion annosum and Armillaria, or by the bark beetles Ips typographus, one of the most destructive spruce forest pests.

Juglans regia in Europe: distribution, habitat, usage and threats

Juglans regia L., commonly known as common, English or Persian walnut, is an economically very important tree species, prized both for its nuts and for its attractive high-quality timber. It is the most widespread nut tree worldwide.

Ophthalmic epidemiology in Europe: the "European Eye Epidemiology" (E3) consortium.

The European Eye Epidemiology (E3) consortium is a recently formed consortium of 29 groups from 12 European countries. It already comprises 21 population-based studies and 20 other studies (case-control, cases only, randomized trials), providing ophthalmological data on approximately 170,000 European participants. The aim of the consortium is to promote and sustain collaboration and sharing of data and knowledge in the field of ophthalmic epidemiology in Europe, with particular focus on the harmonization of methods for future research, estimation and projection of frequency and impact of visual outcomes in European populations (including temporal trends and European subregions), identification of risk factors and pathways for eye diseases (lifestyle, vascular and metabolic factors, genetics, epigenetics and biomarkers) and development and validation of prediction models for eye diseases. Coordinating these existing data will allow a detailed study of the risk factors and consequences of eye diseases and visual impairment, including study of international geographical variation which is not possible in individual studies. It is expected that collaborative work on these existing data will provide additional knowledge, despite the fact that the risk factors and the methods for collecting them differ somewhat among the participating studies. Most studies also include biobanks of various biological samples, which will enable identification of biomarkers to detect and predict occurrence and progression of eye diseases. This article outlines the rationale of the consortium, its design and presents a summary of the methodology.

Tree architecture in a Bornean lowland rain forest: intraspecific and interspecific patterns

Intraspecific and interspecific architectural patterns were studied for eight tree species of a Bornean rain forest. Trees 5--19 m tall in two 4-ha permanent sample plots in primary forest were selected, and three light descriptors and seven architectural traits for each tree were measured. Two general predictions were made: (1) Slow growing individuals (or short ones) encounter lower light, and have flatter crowns, fewer leaf layers, and thinner stems, than do fast growing individuals (or tall ones). (2) Species with higher shade-tolerance receive less light and have flatter crowns, fewer leaf layers, and thinner stems, than do species with lower shade-tolerance. Shade-tolerance is assumed to decrease with maximum growth rate, mortality rate, and adult stature of a species.

The Secular State Under Siege: Religion and Politics in Europe and America

Throughout human history, religion and politics have entertained the most intimate of connections as systems of authority regulating individuals and society. While the two have come apart through the process of secularization, secularism is challenged today by the return of public religion. This cogent analysis unravels the nature of the connection, disconnection, and attempted reconnection between religion and politics in the West. In a comparison of Western Europe and North America, Christianity and Islam, Joppke advances far-reaching theoretical, historical, and comparative-political arguments. With respect to theory, it is argued that only a “substantive” concept of religion, as pertaining to the existence of supra-human powers, opens up the possibility of a historical-comparative perspective on religion. At the level of history, secularization is shown to be the distinct outcome of Latin Christianity itself. And at the level of comparative politics, the Christian Right in America which has attacked the “wall of separation” between religion and state and Islam in Europe with the controversial insistence on sharia law and other “illiberal” claims from some quarters are taken to be counterpart incarnations of public religion and challenges to the secular state. This clearly argued, sweeping book will provide an invaluable framework for approaching an array of critical issues at the intersection of religion, law and politics for advanced students and researchers across the social sciences and legal studies, as well as for the interested public.