Crop-livestock integration provides opportunities to mitigate environmental trade-offs in transitioning smallholder agricultural systems of the Greater Mekong Subregion

CONTEXT: The Greater Mekong Subregion has been undergoing rapid agricultural transformation over the last decades, as traditional diverse subsistence-oriented agriculture is evolving towards intensified commercial production systems. Negative environmental impacts often include deforestation, nutrient pollution, and greenhouse gas (GHG) emissions. OBJECTIVE: This study aims to explore the potential of crop-livestock integration to mitigate trade-offs between economic and environmental impacts of smallholder farming systems at different stages of agricultural transition and degrees of agricultural diversity across the Greater Mekong Subregion. METHODS: We chose a ‘middle ground’ between detailed modeling of few, representative farming systems and modeling of large household populations. 24 low and high diversity farms were selected in Laos (Xieng Khouang province), Cambodia (Ratanakiri province) and Vietnam (Central Highlands) from a survey dataset of 1300 households. These farming systems were simulated with the whole-farm bio-economic and multi-objective optimization model FarmDESIGN, calculating operating profit, GHG emissions and nitrogen (N) balance. Two optimizations (‘business as usual’ vs. ‘crop-livestock integration’) were performed, generating ‘solution spaces’ or alternative configurations aiming to maximize profitability, keep farm N balanced and minimize GHG emissions. RESULTS AND CONCLUSIONS: Agricultural systems across the sites differed in their production orientation and management practices, representing various stages of agricultural transition. Nitrogen balances varied between sites, being negative in Ratanakiri (average 20.5 kg N ha 1 y 1) and Xieng Khouang ( 36.5 kg N ha 1 y 1) and positive in the Central Highlands (73 kg N ha 1 y 1). Negative balances point to unsustainable mining of nutrients due to sale of cash crops without sufficient inputs, and positive balances to the risk of environmental contamination. Total GHG emissions ranged from 0.52–8.12 t CO2e ha 1 and were not significantly impacted by stage of agricultural transformation or agricultural diversity. GHG sources in Ratanakiri and Xieng Khouang were determined by crop residue burning while in Central Highlands fertilizer and livestock were main emitters. High diversity farms obtained higher operating profits (10,379 USD y 1) than low diversity farms (4584 USD y 1). Crop-livestock integration, a combination of measures including introduction of improved forages grasses, manure recycling and residue feeding, and reduction of residue burning, resulted in larger ‘solution spaces’, thus providing farmers with more options to mitigate agro-environmental trade-offs. SIGNIFICANCE: These findings underline the potential of crop-livestock integration to support sustainable intensification pathways in the Greater Mekong region. Public and private investment in further research and extension is needed to develop and scale context-specific crop-livestock integration practices

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4) were female. Most patients (n = 3685 84.7%) were from low-and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 62.8%), followed by strabismus (n = 429 10.2%) and proptosis (n = 309 7.4%). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 95% CI, 12.94-24.80, and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 95% CI, 4.30-7.68). Conclusions and Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs. © 2020 American Medical Association. All rights reserved

Household-level drivers of dietary diversity in transitioning agricultural systems : Evidence from the Greater Mekong Subregion

Over the past four decades, agricultural systems in the Greater Mekong Subregion (GMS) have largely evolved from a subsistence orientation toward commercial production, but the multi-faceted changes behind this evolution vary in substance and degree. Despite connoting economic progress, effects of these changes on household welfare indicators such as dietary diversity have been unclear. By taking a comprehensive view of the farm household, this study discerns the drivers of household dietary diversity in this transitional context by linking the Household Dietary Diversity Score (HDDS), as an indicator of dietary diversity, to key household characteristics, livelihood strategies and indicators of farm performance in three study sites in Cambodia, Laos and Vietnam. The Rural Household Multi-Indicator Survey (RHoMIS) tool, a combined survey and analysis platform, was employed to collect data from over 1300 farm households. HDDS is found to increase among the sites in a way that is roughly associated with their state of agricultural transition, though differing combinations of market orientation, specialisation, and intensification traits that describe such a transition suggest that the pathway to commercialisation, and dietary diversity, is not a linear one. Drivers of dietary diversity vary markedly between the sites. In the Laos site, HDDS is most closely correlated to a set of variables closely linked with agricultural transition, while in the Cambodia site it is associated more with other farm and household characteristics. In the Vietnam site, dietary diversity is correlated to the overall value of crop production. Findings point to the need to contextualise site-specific knowledge of linkages between dietary diversity and ongoing agricultural transition in the GMS, as well as policy and interventions seeking to improve dietary diversity in the face of such transition.</p

Global Retinoblastoma Presentation and Analysis by National Income Level

This cross-sectional analysis reports the retinoblastoma stage at diagnosis across the world during a single year, investigates associations between clinical variables and national income level, and investigates risk factors for advanced disease at diagnosis. Key PointsQuestionIs the income level of a country of residence associated with the clinical stage of presentation of patients with retinoblastoma? FindingsIn this cross-sectional analysis that included 4351 patients with newly diagnosed retinoblastoma, approximately half of all new retinoblastoma cases worldwide in 2017, 49.1\% of patients from low-income countries had extraocular tumor at time of diagnosis compared with 1.5\% of patients from high-income countries. MeaningThe clinical stage of presentation of retinoblastoma, which has a major influence on survival, significantly differs among patients from low-income and high-income countries, which may warrant intervention on national and international levels. ImportanceEarly diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. ObjectivesTo report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and ParticipantsA total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and MeasuresAge at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. ResultsThe cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4\%) were female. Most patients (n=3685 {[}84.7\%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n=2638 {[}62.8\%]), followed by strabismus (n=429 {[}10.2\%]) and proptosis (n=309 {[}7.4\%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5\%) patients having intraocular retinoblastoma and 2 (0.3\%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1\%) having extraocular retinoblastoma and 94 of 498 (18.9\%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 {[}95\% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 {[}95\% CI, 4.30-7.68]). Conclusions and RelevanceThis study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs