What Is the Evidence Base for Climate-Smart Agriculture in East and Southern Africa? A Systematic Map

More than 500 million USD will soon be invested in climate-smart agriculture (CSA) programmes in sub-Saharan Africa. Improving smallholder farm management is the core of most of these programmes. However, there has been no comprehensive information available to evaluate how changing agricultural practices increases food production, improves resilience of farming systems and livelihoods, and mitigates climate change—the goals of CSA. Here, we present a systematic map—an overview of the availability of scientific evidence—for CSA in five African countries: Tanzania, Malawi, Mozambique, Zimbabwe and Zambia. We conducted a systematic literature search of the effects of 102 technologies, including farm management practices (e.g., leguminous intercropped agroforestry, increased protein content of livestock diets, etc.), on 57 indicators consistent with CSA goals (e.g., yield, water use efficiency, carbon sequestration, etc.) as part of an effort called the "CSA Compendium". Our search of peer-reviewed articles in Web of Science and Scopus produced 150,567 candidate papers across developing countries in the global tropics. We screened titles, abstracts and full texts against predetermined inclusion criteria, for example that the investigation took place in a tropical developing country and contains primary data on how both a CSA practice and non-CSA control affect a preselected indicator. More than 1500 papers met these criteria from Africa, of which, 153 contained data collected in one of the five countries. Mapping the studies shows geographic and topical clustering in a few locations, around relatively few measures of CSA and for a limited number of commodities, indicating potential for skewed results and highlighting gaps in the evidence. This study sets the baseline for the availability of evidence to support CSA programming in the five countries

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Tephrosia biomass yield and soil fertility in one season relay intercropping with maize in Semiarid Gairo, Tanzania

No Abstract.Discovery and Innovation Vol. 19 (1&2) 2007: pp. 25-3

Understanding the multidimensionality of climate-smartness: Examples from agroforestry in Tanzania

Climate-smart agriculture (CSA) has three goals—productivity, resilience and mitigation. Rarely are these accounted for in CSA programming or the scientific evidence that supports it. Here, we evaluate the climate smartness of CSA-based agroforestry practices in Tabora and Dodoma, Tanzania using unpublished data from earlier studies. Firstly, a study of on-farm wood production and its use with the improved cook stove (ICS) was used to ascertain the productivity and mitigation effects of CSA. Next, intercropping experiments of maize or cassava with pigeonpea and/or G. sepium provided information on the production and resilience benefits of CSA. It was found that agroforestry practices (shelterbelt, trees on contours and intercropping) supplied up eight tons per hectare (t ha−1) of wood—enough to support a five-member family for up to 6 years when using ICS. Employing ICS also reduced the time spent in cooking (20%) and fuelwood collection (32%), and reduced gas emissions by 62%. Generally, intercropping pigeonpea or G. sepium enhanced farm production (as noted by a land equivalent ratio greater than 1) and agroecosystem resilience through crop diversification by using suitable intercropping arrangements and including a drought-resistant crop. Using the latter two in semi-arid Dodoma enhanced crop production across seasons and sites. Our analysis shows that adopting CSA-based agroforestry and intercropping practices is beneficial. However, these benefits are not universal. It also illustrates other key principles for understanding multidimensionality of CSA objectives, including the need to: select appropriate indicators, ensure designs are robust for heterogeneity, examine trade-offs, and conduct participatory evaluation of CSA