Can guidelines improve referral to elective surgical specialties for adults? A systematic review

Aim To assess effectiveness of guidelines for referral for elective surgical assessment. Method Systematic review with descriptive synthesis. Data sources Medline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites. Selection of studies Studies evaluated guidelines for referral from primary to secondary care, for elective surgical assessment for adults. Outcome measures Appropriateness of referral (usually measured as guideline compliance) including clinical appropriateness, appropriateness of destination and of pre-referral management (eg, diagnostic investigations), general practitioner knowledge of referral appropriateness, referral rates, health outcomes and costs. Results 24 eligible studies (5 randomised control trials, 6 cohort, 13 case series) included guidelines from UK, Europe, Canada and the USA for referral for musculoskeletal, urological, ENT, gynaecology, general surgical and ophthalmological conditions. Interventions varied from complex (“one-stop shops”) to simple guidelines. Four randomized control trials reported increases in appropriateness of pre-referral care (diagnostic investigations and treatment). No evidence was found for effects on practitioner knowledge. Mixed evidence was reported on rates of referral and costs (rates and costs increased, decreased or stayed the same). Two studies reported on health outcomes finding no change. Conclusions Guidelines for elective surgical referral can improve appropriateness of care by improving prereferral investigation and treatment, but there is no strong evidence in favour of other beneficial effects

Rainfed Rice Farming Production Constrains and Prospects, the Kenyan Situation

Kenya experiences huge production-consumption deficit in relation to rice. This is due to changing eating habits that has adopted more rice in the menu and rapidly rising population. Rice production has remained low being unable to meet consumption. Rice ecosystems in Kenya include irrigated, rainfed lowland and rainfed upland. Irrigated ecosystem has over the years been given more emphasis despite rainfed rice farming having double the potential over irrigation system. Ecologically rice grows well in abundant water supply, warm to high temperatures and in Clay sandy to loamy soils with slightly acidic to neutral pH. Rice varieties grown in Kenya are mainly traditional, introduced improved, hybrids and landraces. Rainfed rice farming faces constraint’s key among them being; drought and erratic rainfall, weeds, pest and diseases, cheap imports, land ownership and poor infrastructure. Mitigating against drought and erratic rainfall, improving farm inputs and equipment, increasing germplasm production and distribution, credit support and marketing to farmers, improving farmers skills through technological transfers and infrastructural development are prospects that if adopted could increase rainfed rice productivity. More attention towards improvement of rainfed rice farming could greatly contribute to bridging the production-consumption deficit that is bridged through imports. It is with this, that this review updates our understanding of rain fed rice farming in Kenya in terms of ecological conditions, ecological systems, varieties, constraints and prospects

Body-wave tomographic imaging of the Turkana Depression: Implications for rift development and plume-lithosphere interactions

The Turkana Depression, a topographically-subdued, broadly-rifted zone between the elevated East African and Ethiopian plateaus, disrupts the N–S, fault-bounded rift basin morphology that characterizes most of the East African Rift. The unusual breadth of the Turkana Depression leaves unanswered questions about the initiation and evolution of rifting between the Main Ethiopian and Eastern rifts. Hypotheses explaining the unusually broad, low-lying area include superposed Mesozoic and Cenozoic rifting and a lack of mantle lithospheric thinning and dynamic support. To address these issues, we have carried out the first body-wave tomographic study of the Depression’s upper mantle. Seismically-derived temperatures at 100 km depth exceed petrological estimates, suggesting the presence of mantle melt, although not as voluminous as the Main Ethiopian Rift, contributes to velocity anomalies. A NW–SE-trending high wavespeed band in southern Ethiopia at urn:x-wiley:15252027:media:ggge22580:ggge22580-math-0001200 km depth is interpreted as refractory Proterozoic lithosphere which has likely influenced the localization of both Mesozoic and Cenozoic rifting. At urn:x-wiley:15252027:media:ggge22580:ggge22580-math-0002100 km depth below the central Depression, a single localized low wavespeed zone is lacking. Only in the northernmost Eastern Rift and southern Lake Turkana is there evidence for focused low wavespeeds resembling the Main Ethiopian Rift, that bifurcate below the Depression and broaden approaching southern Ethiopia further north. These low wavespeeds may be attributed to melt-intruded mantle lithosphere or ponded asthenospheric material below lithospheric thin-spots induced by the region's multiple rifting phases. Low wavespeeds persist to the mantle transition zone suggesting the Depression may not lack mantle dynamic support in comparison to the two plateaus

The development of multiple phases of superposed rifting in the Turkana Depression, East Africa: evidence from receiver functions

The Turkana Depression in Eastern Africa separates the elevated plateaus of East Africa to the south and Ethiopia-Yemen to the north. It remains unclear whether the Depression lacks dynamic mantle support, or if the entire East Africa region is dynamically supported and the Depression compensated isostatically by thinned crust. Also poorly understood is how Miocene-Recent extension has developed across the Depression, connecting spatially separated magmatic rift zones in Ethiopia and Kenya. Receiver function analysis is used to constrain Moho depth and bulk-crustal V P /V S ratio below new seismograph networks in the Depression, and on the northern Tanzania craton. Crustal thickness is ∼40 km below northern Uganda and 30–35 km below southern Ethiopia, but 20–30 km below most of the Depression, where mass-balance calculations reveal low elevations can be explained adequately by crustal thinning alone. Despite the fact that magmatism has occurred for 45 Ma across the Depression, more than 15 Ma before East African Rift (EAR) extension initiated, bulk crustal V P /V S across southern Ethiopia and the Turkana Depression (∼1.74) is similar to that observed in areas unaffected by Cenozoic rifting and magmatism. Evidence for voluminous lower crustal intrusions and/or melt, widespread below the Ethiopian rift and Ethiopian plateau to the north, is therefore lacking. These observations, when reviewed in light of high stretching factors (β ≤ 2.11), suggest Cenozoic extension has been dominated until recently by faulting and plate stretching, rather than magma intrusion, which is likely an incipient process, operating directly below seismically-active Lake Turkana. Early-stage EAR basins to the west of Lake Turkana, with associated stretching factors of β ≈ 2, formed in crust only moderately thinned during earlier rifting episodes. Conversely, ∼23 km-thick crust beneath the Kino Sogo Fault Belt (KSFB) has small offset faults and thin sedimentary strata, suggesting almost all of the observed stretching occurred in Mesozoic times. Despite the KSFB marking the shortest path between focused extensional zones to the north and south, seismicity and GPS data show that modern extension is localized below Lake Turkana to the west. Failed Mesozoic rift zones, now characterized by thinned crust and relatively refractory mantle lithosphere, are being circumnavigated, not exploited by EAR rifting

Comparative studies on the structure of an upland African stream ecosystem

Upland stream systems have been extensively investigated in Europe, North America and Australasia and many of the central ideas concerning their function are based on these systems. One central paradigm, the river continuum concept is ultimately derived from those North American streams whose catchments remain forested with native vegetation. Streams of the tropics may or may not fit the model. They have been little studied. The Amani Nature Reserve in the East Usambara Mountains of north-eastern Tanzania offers an opportunity to bring these naturally forested systems to the attention of the ecological community. This article describes a comparison made between two lengths of the River Dodwe in this area. The work was carried out by a group of postgraduate students from eighteen European and African countries with advice from five staff members, as part of a course organised by the Tropical Biology Association. Rigorous efforts were made to standardise techniques, in a situation where equipment and laboratory facilities were very basic, through a management structure and deliberate allocation of work to specialists in each area.The article offers a summary of invertebrate communities found in the stream and its biomass. Crabs seem to be the key organism in both sections of the streams

Comparison of alternative evidence summary and presentation formats in clinical guideline development: a mixed-method study.

BACKGROUND: Best formats for summarising and presenting evidence for use in clinical guideline development remain less well defined. We aimed to assess the effectiveness of different evidence summary formats to address this gap. METHODS: Healthcare professionals attending a one-week Kenyan, national guideline development workshop were randomly allocated to receive evidence packaged in three different formats: systematic reviews (SRs) alone, systematic reviews with summary-of-findings tables, and 'graded-entry' formats (a 'front-end' summary and a contextually framed narrative report plus the SR). The influence of format on the proportion of correct responses to key clinical questions, the primary outcome, was assessed using a written test. The secondary outcome was a composite endpoint, measured on a 5-point scale, of the clarity of presentation and ease of locating the quality of evidence for critical neonatal outcomes. Interviews conducted within two months following completion of trial data collection explored panel members' views on the evidence summary formats and experiences with appraisal and use of research information. RESULTS: 65 (93%) of 70 participants completed questions on the prespecified outcome measures. There were no differences between groups in the odds of correct responses to key clinical questions. 'Graded-entry' formats were associated with a higher mean composite score for clarity and accessibility of information about the quality of evidence for critical neonatal outcomes compared to systematic reviews alone (adjusted mean difference 0.52, 95% CI 0.06 to 0.99). There was no difference in the mean composite score between SR with SoF tables and SR alone. Findings from interviews with 16 panelists indicated that short narrative evidence reports were preferred for the improved clarity of information presentation and ease of use. CONCLUSIONS: Our findings suggest that 'graded-entry' evidence summary formats may improve clarity and accessibility of research evidence in clinical guideline development. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN05154264

Genomics for public health and international surveillance of antimicrobial resistance.

Historically, epidemiological investigation and surveillance for bacterial antimicrobial resistance (AMR) has relied on low-resolution isolate-based phenotypic analyses undertaken at local and national reference laboratories. Genomic sequencing has the potential to provide a far more high-resolution picture of AMR evolution and transmission, and is already beginning to revolutionise how public health surveillance networks monitor and tackle bacterial AMR. However, the routine integration of genomics in surveillance pipelines still has considerable barriers to overcome. In 2022, a workshop series and online consultation brought together international experts in AMR and pathogen genomics to assess the status of genomic applications for AMR surveillance in a range of settings. Here we focus on discussions around the use of genomics for public health and international AMR surveillance, noting the potential advantages of, and barriers to, implementation, and proposing recommendations from the working group to help to drive the adoption of genomics in public health AMR surveillance. These recommendations include the need to build capacity for genome sequencing and analysis, harmonising and standardising surveillance systems, developing equitable data sharing and governance frameworks, and strengthening interactions and relationships among stakeholders at multiple levels