Short- and long-term mortality and causes of death in HIV/tuberculosis patients in Europe

Mortality of HIV/tuberculosis (TB) patients in Eastern Europe is high. Little is known about their causes of death. This study aimed to assess and compare mortality rates and cause of death in HIV/TB patients across Eastern Europe and Western Europe and Argentina (WEA) in an international cohort study. Mortality rates and causes of death were analysed by time from TB diagnosis (<3 months, 3-12 months or >12 months) in 1078 consecutive HIV/TB patients. Factors associated with TB-related death were examined in multivariate Poisson regression analysis. 347 patients died during 2625 person-years of follow-up. Mortality in Eastern Europe was three- to ninefold higher than in WEA. TB was the main cause of death in Eastern Europe in 80%, 66% and 61% of patients who died <3 months, 3-12 months or >12 months after TB diagnosis, compared to 50%, 0% and 15% in the same time periods in WEA (p<0.0001). In multivariate analysis, follow-up in WEA (incidence rate ratio (IRR) 0.12, 95% CI 0.04-0.35), standard TB-treatment (IRR 0.45, 95% CI 0.20-0.99) and antiretroviral therapy (IRR 0.32, 95% CI 0.14-0.77) were associated with reduced risk of TB-related death. Persistently higher mortality rates were observed in HIV/TB patients in Eastern Europe, and TB was the dominant cause of death at any time during follow-up. This has important implications for HIV/TB programmes aiming to optimise the management of HIV/TB patients and limit TB-associated mortality in this region.

THE MULTIPLE LOCATION TIME WEIGHTED INDEX: USING PATIENT ACTIVITY SPACES TO CALCULATE PRIMARY CARE SERVICE AREAS

Geographic health planning analyses, such as service area calculations, are hampered by a lack of patient-specific geographic data. Using the limited patient address information in patient management systems, planners analyze patient origin based on home address. But activity space research done sparingly in public health and extensively in non-health related arenas uses multiple addresses per person when analyzing accessibility. Also, health care access research has shown that there are many non-geographic factors that influence choice of provider. Most planning methods, however, overlook non-geographic factors influencing choice of provider, and the limited data mean the analyses can only be related to home address. This research attempted to determine to what extent geography plays a part in patient choice of provider and to determine if activity space data can be used to calculate service areas for primary care providers. During Spring 2008, a convenience sample of 384 patients of a locally-funded Community Health Center in Houston, Texas, completed a survey that asked about what factors are important when he or she selects a health care provider. A subset of this group (336) also completed an activity space log that captured location and time data on the places where the patient regularly goes. Survey results indicate that for this patient population, geography plays a role in their choice of health care provider, but it is not the most important reason for choosing a provider. Other factors for choosing a health care provider such as the provider offering “free or low cost visits”, meeting “all of the patient’s health care needs”, and seeing “the patient quickly” were all ranked higher than geographic reasons. Analysis of the patient activity locations shows that activity spaces can be used to create service areas for a single primary care provider. Weighted activity-space-based service areas have the potential to include more patients in the service area since more than one location per patient is used. Further analysis of the logs shows that a reduced set of locations by time and type could be used for this methodology, facilitating ongoing data collection for activity-space-based planning efforts.

How are climate change adaptation strategies put into practice? A case study comparison of natural hazard prevention

Climate change affects increasingly the management of natural resources and has diverse impacts of environmental, social and economic nature. To take this complexity into account, climate change adaptation policies consider the principle of sustainable development. Sustainability is an integrative concept which should insure a long-term and multi-sectoral response to climate change. But the question appears if sustainable development is only retained at the conceptual level or effectively implemented in practice. This paper pursues this question by comparing three projects addressing natural hazard in Swiss mountains. The aim is to investigate how sustainable development is perceived by involved stakeholders and implemented in practice. Two dimensions are thus taken into account: the type of actors participating in these projects and their preferences and interests. The first dimension thus analyzes if diverse actors representing the environmental, economic and social arenas are integrated; the second dimension investigates if different interests and preferences in the sense of sustainability were incorporated in the design and implementation of climate change adaptation. Data were gathered through a standardized survey among all actors involved in the three projects. Preliminary results show that sustainability receives diverse weight and interest in the different cases.

Europeanization in parliament and in the press

Europeanization challenges national democratic systems. As part and parcel of the broader internationalization of politics, Europeanization is associated with a shift from policymaking within majoritarian, elected representative bodies towards technocratic decisions among non-majoritarian and non-elected bodies (Kohler-Koch and Rittberger 2008, Lavenex 2013). It is thus said to weaken the influence of citizens and parliaments on the making of policies and to undermine democratic collective identity (Lavenex 2013, Schimmelfennig 2010). The weakening of national parliaments has been referred to as “de-parliamentarisation” (Goetz and Meyer-Sahling 2008) and has nurtured a broader debate regarding the democratic deficit in the EU. While not being a member of the EU, Switzerland has not remained unaffected by these changes. As discussed in the contribution by Fischer and Sciarini, state executive actors take the lead in Switzerland's European policy. They are responsible for the conduct of international negotiations, they own the treaty making power, and it is up to them to decide whether they wish to launch a negotiation with the EU. In addition, the strong take-it or leave-it character of Europeanized acts limits the room for manoeuver of the parliamentary body also in the ratification phase. Among the public, the rejection of the treaty on the European constitution has definitely closed the era of “permissive consensus” (Hooghe and Marks 2009). However, the process of European unification remains far remote from the European public. In Switzerland, the strongly administrative character of international legislation hinders public discussion (Vögeli 2007). In such a context, the media may serve as cue for the public: By delivering information about the extent and nature of Europeanized policymaking, the media enable citizens to form their own opinions and to hold their representatives accountable. In this sense media coverage may not only be considered an indicator of the information delivered to the public, but it may also enhance the democratic legitimacy of Europeanized policymaking (for a similar argument, see Tresch and Jochum 2005). While the previous contributions to this debate have examined the Europeanization of Swiss (primary and secondary) legislation, we take a closer look at two additional domestic arenas that are both supposed to be under pressure due to Europeanization: The parliament and the media. To that end, we rely on data gathered in a research project that two of us carried out in the context of the NCCR Democracy.1 While this project was primarily interested in the mediatization of decision-making processes in Switzerland, it also investigated the conditional role played by internationalization/Europeanization. For our present purposes, we shall exploit the two data-sets that were developed as part of a study of the political agenda-setting power of the media (Sciarini and Tresch 2012, 2013, Tresch et al. 2013): A data-set on issue attention in parliamentary interventions (initiatives, motions, postulates,2 interpellations and questions) and a data-set on issue attention in articles from the Neue Zürcher Zeitung (NZZ). The data covers the years 1995 to 2003 and the coding of issues followed the classification system developed in the “Policy Agendas Project” (Baumgartner and Jones 1993).

Genetic consequences of habitat fragmentation during a range expansion

We investigate the effect of habitat fragmentation on the genetic diversity of a species experiencing a range expansion. These two evolutionary processes have not been studied yet, at the same time, owing to the difficulties of deriving analytic results for non-equilibrium models. Here we provide a description of their interaction by using extensive spatial and temporal coalescent simulations and we suggest guidelines for a proper genetic sampling to detect fragmentation. To model habitat fragmentation, we simulated a two-dimensional lattice of demes partitioned into groups (patches) by adding barriers to dispersal. After letting a population expand on this grid, we sampled lineages from the lattice at several scales and studied their coalescent history. We find that in order to detect fragmentation, one needs to extensively sample at a local level rather than at a landscape level. This is because the gene genealogy of a scattered sample is less sensitive to the presence of genetic barriers. Considering the effect of temporal changes of fragmentation intensities, we find that at least 10, but often >100, generations are needed to affect local genetic diversity and population structure. This result explains why recent habitat fragmentation does not always lead to detectable signatures in the genetic structure of populations. Finally, as expected, long-distance dispersal increases local genetic diversity and decreases levels of population differentiation, efficiently counteracting the effects of fragmentation.

The scaling of genetic diversity in a changing and fragmented world

Most species do not live in a constant environment over space or time. Their environment is often heterogeneous with a huge variability in resource availability and exposure to pathogens or predators, which may affect the local densities of the species. Moreover, the habitat might be fragmented, preventing free and isotropic migrations between local sub-populations (demes) of a species, making some demes more isolated than others. For example, during the last ice age populations of many species migrated towards refuge areas from which re-colonization originated when conditions improved. However, populations that could not move fast enough or could not adapt to the new environmental conditions faced extinctions. Populations living in these types of dynamic environments are often referred to as metapopulations and modeled as an array of subdivisions (or demes) that exchange migrants with their neighbors. Several studies have focused on the description of their demography, probability of extinction and expected patterns of diversity at different scales. Importantly, all these evolutionary processes may affect genetic diversity, which can affect the chance of populations to persist. In this chapter we provide an overview on the consequences of fragmentation, long-distance dispersal, range contractions and range shifts on genetic diversity. In addition, we describe new methods to detect and quantify underlying evolutionary processes from sampled genetic data.

Long distance dispersal shaped patterns of human genetic diversity in Eurasia

Most previous attempts at reconstructing the past history of human populations did not explicitly take geography into account, or considered very simple scenarios of migration and ignored environmental information. However, it is likely that the Last Glacial Maximum (LGM) affected the demography and the range of many species, including our own. Moreover, long-distance dispersal (LDD) may have been an important component of human migrations, allowing fast colonization of new territories and preserving high levels of genetic diversity. Here, we use a high-quality microsatellite dataset genotyped in 22 populations to estimate the posterior probabilities of several scenarios for the settlement of the Old World by modern humans. We considered models ranging from a simple spatial expansion to others including LDD and a LGM-induced range contraction, as well as Neolithic demographic expansions. We find that scenarios with LDD are much better supported by data than models without LDD. Nevertheless, we show evidence that LDD events to empty habitats were strongly prevented during the settlement of Eurasia. This unexpected absence of LDD ahead of the colonization wave front could have been caused by an Allee effect, either due to intrinsic causes such as an inbreeding depression built during the expansion, or to extrinsic causes such as direct competition with archaic humans. Overall, our results suggest only a relatively limited effect of the LGM-contraction on current patterns of human diversity. This is in clear contrast with the major role of LDD migrations, which have potentially contributed to the intermingled genetic structure of Eurasian populations.

The multiple location time weighted index: Using patient activity spaces to calculate primary care service areas

Geographic health planning analyses, such as service area calculations, are hampered by a lack of patient-specific geographic data. Using the limited patient address information in patient management systems, planners analyze patient origin based on home address. But activity space research done sparingly in public health and extensively in non-health related arenas uses multiple addresses per person when analyzing accessibility. Also, health care access research has shown that there are many non-geographic factors that influence choice of provider. Most planning methods, however, overlook non-geographic factors influencing choice of provider, and the limited data mean the analyses can only be related to home address. This research attempted to determine to what extent geography plays a part in patient choice of provider and to determine if activity space data can be used to calculate service areas for primary care providers. ^ During Spring 2008, a convenience sample of 384 patients of a locally-funded Community Health Center in Houston, Texas, completed a survey that asked about what factors are important when he or she selects a health care provider. A subset of this group (336) also completed an activity space log that captured location and time data on the places where the patient regularly goes. ^ Survey results indicate that for this patient population, geography plays a role in their choice of health care provider, but it is not the most important reason for choosing a provider. Other factors for choosing a health care provider such as the provider offering "free or low cost visits", meeting "all of the patient's health care needs", and seeing "the patient quickly" were all ranked higher than geographic reasons. ^ Analysis of the patient activity locations shows that activity spaces can be used to create service areas for a single primary care provider. Weighted activity-space-based service areas have the potential to include more patients in the service area since more than one location per patient is used. Further analysis of the logs shows that a reduced set of locations by time and type could be used for this methodology, facilitating ongoing data collection for activity-space-based planning efforts. ^

The effect of African Americans' ethnographic paradigms and cultural explanatory model of breast cancer in framing the male partner's attitudes and behaviors about the woman's breast cancer diagnosis

The disparate burden of breast cancer-related morbidity and mortality experienced by African American women compared with women of other races is a topic of intense debate in the medical and public health arenas. The anomaly is consistently attributed to the fact that at diagnosis, a large proportion of African American women have advanced-stage disease. Extensive research has documented the impacts of cultural factors and of socioeconomic factors in shaping African American women's breast-health practices; however, there is another factor of a more subtle influence that might have some role in establishing these women's vulnerability to this disease: the lack of or perceived lack of partner support. Themes expressed in the research literature reflect that many African American breast cancer patients and survivors consider their male partners as being apathetic and nonsupportive. ^ The purpose of this study was to learn how African American couples' ethnographic paradigms and cultural explanatory model of breast cancer frame the male partners' responses to the women's diagnosis and to assess his ability to cope and willingness to adapt to the subsequent challenges. The goal of the study was to determine whether these men's coping and adaptation skills positively or negatively affect the women's self-care attitudes and behaviors. ^ This study involved 4 African American couples in which the woman was a breast cancer survivor. Participants were recruited through a community-based cancer support group and a church-based cancer support group. Recruitment sessions were held at regular meetings of these organizations. Accrual took 2 months. In separate sessions, each male partner and each survivor completed a demographic survey and a questionnaire and were interviewed. Additionally, the couples were asked to participate in a communications activity (Adinkra). This activity was not done to fulfill any part of the study purpose and was not included in the data analysis; rather, it was done to assess its potential use as an intervention to promote dialogue between African American partners about the experience of breast cancer. ^ The questionnaire was analyzed on the basis of a coding schema and the interview responses were analyzed on the principles of hermeneutic phenomenology. In both cases, the instruments were used to determine whether the partner's coping skills reflected a compassionate attitude (positive response) versus an apathetic attitude (negative response) and whether his adaptation skills reflected supportive behaviors (the positive response) versus nonsupportive behaviors (the negative response). Overall, the women's responses showed that they perceived of their partners as being compassionate, yet nonsupportive, and the partner's perceived of themselves likewise. Only half of the women said that their partners' coping and adaptation abilities enabled them to relinquish traditional concepts of control and focus on their own well-being. ^ The themes that emerged indicate that African American men's attitudes and behaviors regarding his female partner's diagnosis of breast cancer and his ability to cope and willingness to adapt are influenced by their ritualistic mantras, folk beliefs, religious teachings/spiritual values, existential ideologies, socioeconomic status, and environmental factors and by their established perceptions of what causes breast cancer, what the treatments and outcomes are, and how the disease affects the entire family, particularly him. These findings imply that a culturally specific intervention might be useful in educating African American men about breast cancer and their roles in supporting their female partners, physically and psychologically, during diagnosis, treatment, and recovery. ^

Family Preservation in Child Welfare: Its Base and Its Future

This is the eleventh issue of the Family Preservation Journal, and we have chosen to focus this special issue on the use of family preservation services in child welfare. While family preservation services, as a philosophy and as a service model, are provided to families in a variety of service settings and sectors, including juvenile justice and mental health arenas, they have their basis and origin in services to children and families. We think it is time, in this 11th issue of the Journal, to take stock of the state of family preservation services in child welfare and assess where they might be heading.

Productividad del pasto llorón con riego limitado : oasis norte de Mendoza (Argentina)

Ante la realidad de la cada vez más aguda escasez de agua en el oasis norte mendocino durante la primavera, que dificulta el manejo racional de los cultivos existentes, surge la necesidad -en el ámbito de la producción forrajera- de una especie de reducido requerimiento hídrico y que compita lo menos posible con los cultivos tradicionales, en particular en la época más crítica. Se ha experimentado con el pasto llorón para averiguar su respuesta a la aplicación de riegos limitados durante el período invernal. Se presentan los resultados de producción de materia seca así como las observaciones de la dinámica vegetacional. Se concluye que para el oasis norte de Mendoza la aplicación de riegos durante el período invernal que completen 200 mm, permite la supervivencia del cultivo con una densidad de aproximadamente 60 plantas por m2 y una producción entre 3 200 y 4 000 kg de materia seca por ha y por año.

Gramática para todos : proyecto pedagógico con modalidad a distancia para la terminalidad de estudios de EGB3 y Educación Polimodal EDITEP

Los contenidos de este material de estudio (en torno a las palabras y el sentido) se refieren a la gramática como "sistema que permite describir y explicar oraciones y enunciados sin necesidad de contenerlos todos en un inventario". Están organizados en dos ejes. El eje 1 contiene temas como el sustantivo y su clasificación, el enunciado, los adjetivos, los verbos, los adverbios y los pronombres. El eje 2 se refiere a la sintaxis y el análisis de oraciones. Se editó como material de aprendizaje destinado al personal de seguridad pública de la Provincia de Mendoza en el marco del proyecto pedagógico con modalidad a distancia para la terminalidad de estudios de EGB3 y Educación Polimodal –EDITEP–, implementado a partir de la firma del Convenio entre la Universidad Nacional de Cuyo y el Gobierno de la Provincia de Mendoza, en octubre de 2003.