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

Functional agrobiodiversity and agroecosystem services in sustainable wheat production. A review

Agrobiodiversity can improve the sustainability of cropping systems in a context of low external inputs and unpredictable climate change. Agrobiodiversity strategies to grow wheat are breeding ad hoc cultivars for organic and low-input systems, wheat–legume intercrops and living mulches, cultivar mixtures, and the use of genetically heterogeneous populations. However, applying those strategies can fail due the lack of a well-focused framework. Therefore, we need a better integration between breeding and management and a clear focus on crop traits related to key agroecosystem services. Here, we review the use of agrobiodiversity in wheat production, focusing on breeding and management. We discuss five agroecosystem services: (1) weed reduction, (2) nitrogen use efficiency, (3) abiotic stress tolerance, (4) disease and pest reduction and (5) yield and yield stability. We categorise agrobiodiversity into functional identity, functional composition, and functional diversity, in order to link crop traits to agroecosystem services. Linking crop traits to agroecosystem services could in turn lead to concrete options for farmers and policy. We discuss the relations between crop identity and crop heterogeneity. We also discuss the partitioning of crop heterogeneity between functional composition and functional diversity