Drought categories and related impact in the northern cape.
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These books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\\n\\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\\n\\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
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IntechOpen and Knowledge Unlatched formed a partnership to support researchers working in engineering sciences by enabling an easier approach to publishing Open Access content. Using the Knowledge Unlatched crowdfunding model to raise the publishing costs through libraries around the world, Open Access Publishing Fee (OAPF) was not required from the authors.
\n\nInitially, the partnership supported engineering research, but it soon grew to include physical and life sciences, attracting more researchers to the advantages of Open Access publishing.
\n\n\n\nThese books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\n\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\n\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
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\r\n\tSpinal cord injury represents a relatively frequent clinical scenario that emergency doctors, neuroradiologists, and spine surgeons have to deal with in their daily practice.
\r\n\r\n\tAlthough there are many publications on this topic, a consensus on the preferred management has not been reached yet. In fact, other than clearly surgical or non-surgical patients, there is a non-negligible number of cases where an interdisciplinary discussion is strictly needed, eventually determining a case-by-case treatment selection.
\r\n\r\n\tEmergency decompression surgery, often associated with fusion, represents an effective treatment for critical compressions of the spinal cord, while its role in subacute cases is still debated. Different medical managements have been proposed for the acute, subacute, and chronic phases, respectively. Since function preservation is the primary outcome to be pursued, the multidisciplinary case discussion is a fundamental step in the decision-making process. However, a practical guide on the state of the art on spinal cord injury management may result as useful to a large audience of practitioners.
",isbn:"978-1-80355-877-6",printIsbn:"978-1-80355-876-9",pdfIsbn:"978-1-80355-878-3",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,hash:"fc1ece21c6d20adecf2b9fe16489a07d",bookSignature:"Dr. Luca Ricciardi, Dr. Giorgio Lofrese, Dr. Andrea Perna and Ph.D. Sokol Trungu",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11285.jpg",keywords:"Concussion, Medullary Edema, Paraplegia, Neurotrauma, Functional Impairment, Neurorehabilitation, Physiotherapy, Steroids, Rhiluzole, Arthrodesis, Fusion, Instrumentation",numberOfDownloads:16,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 4th 2021",dateEndSecondStepPublish:"February 24th 2022",dateEndThirdStepPublish:"April 25th 2022",dateEndFourthStepPublish:"July 14th 2022",dateEndFifthStepPublish:"September 12th 2022",remainingDaysToSecondStep:"3 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"The clinical researcher focused on spine and spinal cord disorders. Dr. Ricciardi serves as a guest editor, editorial board member, and reviewer of many indexed journals such as the Journal of Neurosurgical Sciences and Frontiers in Neurooncology, Life, and Cell. He is a co-chairman for SPINE20, the World Congress on Spine Disorders at the G20 conference in Rome, Italy, and an individual delegate at the European Association of Neurosurgical Societies.",coeditorOneBiosketch:"A neurosurgeon specialized in craniocervical junction diseases and minimally invasive spine surgery. Dr. Lofrese was awarded the European Young Researcher Award (AOSpine) and the Young Neurosurgeon Award (WFNS). He is a member of EUROSPINE, SPINE20, and the European Association of Neurosurgical Societies.",coeditorTwoBiosketch:"Dr. Perna's main fields of study are the pathologies of the spine, with particular attention to spinal deformities, traumatological surgery, and infectious pathologies such as spondylodiscitis. His publications give particular attention to lateral surgery, while his other fields of interest are hand surgery and biomechanics applied to orthopedics.",coeditorThreeBiosketch:"Dr. Trungu completed his Ph.D. in Neuroscience and Neurosurgery at Sapienza University of Rome, Italy. His areas of special interest are Minimally Invasive Spine Surgery (MISS), complex spine surgery, spine trauma focusing on acute spinal cord injury, primary and secondary spinal tumors, and Neuro-oncology.",coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"421212",title:"Dr.",name:"Luca",middleName:null,surname:"Ricciardi",slug:"luca-ricciardi",fullName:"Luca Ricciardi",profilePictureURL:"https://mts.intechopen.com/storage/users/421212/images/system/421212.jpg",biography:"Dr. Ricciardi graduated in Medicine and Surgery in 2013 and finished his residency in Neurosurgery in 2019.\nIn 2017, he completed a fellowship in spinal deformities at the Catholic University of Rome - Italy, and in 2018 he completed a research fellowship at the Mayo Clinic, Jacksonville, Florida, US. He also completed the four-year training course of the European Association of Neurosurgical Societies and completed the European Board Exam part-1 for FEBNS.\nDr. Ricciardi has authored more than 60 papers published in peer-reviewed international journals. He has been serving as a reviewer for more than 15 scientific journals. He has been awarded as Publons Academy Mentor for training in peer-review, and he has conducted more than 80 certified peer reviews by the date. ( https://publons.com/researcher/1705851/luca-ricciardi/ ) \nIn 2021, Dr. Ricciardi was invited as Guest Editor for Systematic Reviews and Meta-analyses on the Journal of Neurosurgical Sciences, and as Invited Editor on Frontiers in Neurooncology, Life, and Cell. \nIn 2021, Dr. Ricciardi has been nominated co-Chairman and President of the Scientific Committee at SPINE20, the World Congress on Spine Disorders at the G20 conference in Rome, Italy.",institutionString:"Sapienza University of Rome",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Sapienza University of Rome",institutionURL:null,country:{name:"Italy"}}}],coeditorOne:{id:"436982",title:"Dr.",name:"Giorgio",middleName:null,surname:"Lofrese",slug:"giorgio-lofrese",fullName:"Giorgio Lofrese",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003FVMDgQAP/Profile_Picture_1633074659823",biography:"Dr. Lofrese is a neurosurgeon specialized in cranio-cervical junction diseases and minimally invasive spine surgery. As a former resident of the Catholic University in Rome, he completed his training in Milan, Bologna, and New York, concluding it in Curitiba with an AOSpine clinical fellowship. He is currently a permanent neurosurgeon at the Bufalini Hospital in Cesena, and a consultant neurosurgeon at the State Hospital of the Republic of San Marino. He was awarded with the European Young Researcher Award (AOSpine) and the Young Neurosurgeon Award (WFNS). 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Panico Hospital, Tricase, Italy. His areas of special interest are Minimally Invasive Spine Surgery (MISS), complex spine surgery, spine trauma focusing in acute spinal cord injury, primary and secondary spinal tumors, Neurovascular and Neuro-oncology. 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Batisani [1] stated that drought is a naturally occurring phenomenon that exists when precipitation is significantly below normal recorded levels, causing serious hydrological imbalances that adversely affect land resource production systems and its impacts may extend over a longer period even after a wet season. According to [2] prediction holds that drought will be a major concern for many African communities in the future due to climate change.
Drought vulnerability is associated with the risk and resilience of society to drought conditions and according to the study by Elsamian
According to a report by the National Department of Agriculture, Fisheries and Forestry [4], a national policy on the management of drought exists in South Africa and provinces are guided by the national policy framework [5]. The policy framework stipulates that provinces risk assessment basis for the development of disaster management planning must be in line with the national policy framework. In developing such a risk assessment, provinces must include contingency plans approved and accepted by all role players in the province. The contingency plan should be activated immediately after a drought disaster is declared and the long process of assessment and declaration impacts negatively on farmers.
Despite the existence of a national policy framework on drought in South Africa, Northern Cape Provincial small-scale farmers are still facing severe vulnerability with regard to prevention, adaptation, prediction, and early warning. Since 2015, 12 early warning reports have been generated for the Northern Cape Province and disseminated to farmers through extension services and communication as an integral component of the contingency plan. Awareness campaigns have been intensified with the objective of promoting a culture of risk avoidance among small farmers through integrated education, training, and public awareness programmes informed by scientific research. Drought aid schemes have been launched since the beginning of drought conditions in 2015 and the province declared a drought disaster zone on April 12, 2016 by the National Disaster Management Centre (NDMC).
Since the declaration, the drought condition has been deteriorating, and DAFF has allocated R25 million to the Northern Cape Department of Agriculture for drought relief. The Department of Agriculture, Forestry and Fisheries procured 73,000 bags of drought pellets at a cost of R20.44 million for distribution to farmers in severely affected regions of the province in 2017 [6]. As the drought condition intensifies, the management strategies in the Northern Cape appear to be inadequate and the current study intended to examine factors enhancing small-scale farmers’ vulnerability to drought in the province so as to uncover new innovative management strategies to mitigate the condition. According to WSS NC [7], vulnerability embodies various factors which include environmental, physical, economic, and social factors. In order to address this problem, it is important to identify factors that cause the increased vulnerability of these farmers to drought despite the effort made by the government to mitigate the condition. Jordaan [8] argues that the situation is exacerbated by over-stocking in the Province which further complicate government efforts.
Wisner
In the Northern Cape Province of South Africa, there is an urgent need to reduce the vulnerability of small-scale farmers to climate variability and the threats posed by climate change [13]. Drought events and the magnitude of agricultural losses to drought in the Province indicate the continuing vulnerability of small-scale farmers to agriculture despite mitigation strategies in place. Farmers in the province face varying degrees of vulnerability to drought conditions within the agricultural sector depending on the size and nature of the farming operation and the drought has had a devastating effect on Northern Cape agricultural production and the impact on small-scale farmers is phenomenal.
Despite the differences in the definition of drought by different researchers and scholars, they all agree that drought is a prolonged absence of moisture in a specific environment that affects livestock and plants [3, 11, 14, 15, 16]. According to Miyan [17], droughts vary from region to region and the least developed countries have become the worst affected. According to
Natural grazing becoming depleted leading to the forced slaughtering of livestock, livestock deaths due to fodder unavailability.
Reduced plantings of summer cash crops.
Extremely high temperatures, which have a negative impact on pollination and thus lower yields.
The description of each type is short, simple, and brief for a better understanding of the nature of drought in the Northern Cape as shown inFigure 1.
Different categories of droughts and their development. Source: (derived from Peter, 53, Van loon, 54 Stahl 55).
The current study is modelled after the study by Wisner
Northern Cape economy relies mostly on farming and more people are employed in the agricultural sector, which depends entirely on precipitation for production. Drought has negative impacts on the welfare and employment of farmers, farmworkers, and their families. Farm income is dependent on the quality and quantity of livestock and crop produced at any given time and continued drought is hazardous to yields. Jordaan et al. [20] noted that socio-economic drought affects people’s lives in terms of their behaviour and options such as water rationing and increased water pricing. According to Wilhite socio-economic drought is dependent on the impact of meteorological, hydrological, and agricultural droughts on the supply and demand of agricultural goods and services.
Socio-economic drought occurs when demand for economic goods exceeds the supply caused by related shortfalls in the water supply. Socio-economic droughts differ markedly from the other types of droughts because it reflects the relationship between supply and demand commodities such as livestock forage, water, and hydroelectricity that is dependent on precipitation and supply varies as a function of precipitation or water availability [21]. Small-scale farmers are mostly affected by socio-economic drought because they are highly dependent on farming for their social being and economic livelihood.
Employment on farms depends on the profitability of farm businesses and farm labours both seasonal and permanent are influenced by farm margins. During drought there is a remarkable loss of expected return from all farming enterprises and this argument is supported by Eslamian
According to Van Zyl [16], there are alternatives and practical definitions for drought types usually experienced by farmers in the Province due to its unique geographical location. These include false drought where rainfall is below the long-term average, but due to overgrazing of the veld, fodder supply becomes prematurely depleted and giving the impression of prevailing drought; premature drought where a chronic drought situation is aggravated by overgrazing resulting in a premature declaration. In many instances, the adjoining farms may differ widely in intensity as a result of veldt management practices. There is also prolonged drought where for months, high intensity of livestock is maintained, and the result is more or less chronic food shortage even after good rains have fallen as plants become severely damaged. It is also possible that areas that have been declared as drought-stricken do not recover after good rains and a few months later the drought could even get worse.
Green drought occurs when excessive grazing pressures are maintained in semi-arid periods and this causes food shortages even though the vegetation is appearing green and soil moisture reserves are favourable. It can also occur where natural causes like rain showers during drought promote a short spell of green growth but not enough to break the drought. A green drought can also occur where the insect (locusts, Karoo, and commando caterpillars) severely attacks the plant and deplete the fodder to such a degree that it takes the appearance of a drought situation. There is thus a shortage of fodder in spite of favourable circumstances. Finally, financial drought in which farmers exert much pressure on the government to declare drought disaster to obtain financial assistance in order to improve their cash flow. Therefore, a region can be declared drought-stricken even though drought does not prevail as shown in Figure 2. The figure shows different droughts, causal factors, and the usual sequence of occurrence. Climatic factors like temperature, rainfall, evapotranspiration, and soil water deficiency are attributes that increase the vulnerability of small-scale farmers to drought in the Northern Cape Province.
Drought types, causal factors, and their usual sequence of occurrence.
The impacts of drought in relation to the different drought categories have also been determined. The table below indicates the impacts of droughts experienced by small-scale farmers in the Province who are economically, socially, and environmentally affected by drought. The table reveals various form of droughts has different impacts on small-scale farmers and Table 1 shows the drought category as well as an impact category in the Province.
Drought category | ||||
---|---|---|---|---|
Impact category | Meteorological drought | Soil moisture drought | Hydrological drought | |
Agriculture | Rainfed | X | x | |
Irrigated | x | X | ||
Ecosystems | Terrestrial | X | x | |
Aquatic | X | |||
Energy and industry | Hydropower | X | ||
Cooling water | X | |||
Navigation | X | |||
Drinking water | X | |||
Recreation |
Drought categories and related impact in the northern cape.
The preceding section presented the description of drought, forms, and type as well as the concept of drought. This section focuses on addressing the central questions and objectives which is based on the existing management framework to analyse the social, economic, and environmental factors enhancing small-scale farmers’ vulnerability to drought in the province. In this study, vulnerability is seen as a set of conditions and processes resulting from the physical, social, and economic challenges caused by persistent drought in the Northern Cape province of South Africa.
Varying degrees of vulnerability to drought conditions occur within the agricultural sector based on the size and nature of one’s farming operation. In the case of South Africa, small-scale and communal farmers have proven to be more vulnerable to droughts given their concentration in less favourable climatic zones, their lack of resources and reliance on their own production for house food security [22].
Khoshnodiffer,
Madzwamuse [25] argues that climate change also enhances small-scale farmers’ vulnerability to drought in the province and any vulnerability analysis must consider the social, economic, and institutional factors that favour large-scale commercial farmers to the neglect of small-scale farmers even though they operate under the same climatic conditions. Khoshnodiffer
Eslamian et al., [3] stated that factors governing drought vulnerability may be natural (meteorological, ecological, and hydrological) while anthropogenic factors include socio-economic and land use parameters. According to United Nations International Strategy for Disaster Reduction, there exist four groups of vulnerability factors that cause small-scale farmers’ vulnerability to drought. These are; physical factors that describe the exposure of vulnerable elements within a region; economic factors which describe the economic resources of individuals, populations groups, and communities; social factors, which describe non-economic factors that determine the well-being of individuals, population groups, and communities, such as the level of education, security, access to basic services, human rights, good governance, and environmental factors which describe the state of the environment within a region the small-scale farmer operate.
Jordaan
According to Yameogo [27], coping capacity can be defined as the means by which people or organisations use available resources and the ability to face adverse consequences that could lead to a disaster. In general, this involves managing resources, both in normal times as well as during crises or adverse conditions. The strength of coping capacities usually builds resilience to withstand the effects of natural and human-induced hazards. Farmers will sometimes resort to old age traditional and indigenous knowledge of coping with drought. Rainfall harvesting with cement tanks and catchment areas develop for water storage.
Farmers sometimes will move to areas where there is water and vegetation. Nomadic farmers are common in Northern Cape. They move along the Orange river where grazing and water are available. They sleep next to their flock and will move once grazing is depleted. During good rainy days, reservoirs are allowed to be filled with water and are closed with dexterity and art to be used during the drought period. Nobody is allowed to draw water from the well until the onset of drought. Maize, sorghum, and other drought-resistant crops are planted, harvested, stored, and preserved using old skills. During drought, this storage or silo (sefalana in Setswana) is opened and good food is obtained from this storage. This small silo is built by a specialist in making mud houses and the design is such that stored foodstuff does not get decomposed.
According to Roos
Small scale farmers are vulnerable to economic, social, and environmental effects of drought and their adaptability or coping capacity differ according to their experience of drought and mitigation ability. There is a correlation between strong financial position and coping ability among small-scale farmers. Farmers who have more money in the bank can buy more feeds or production inputs and lessen the burden of relying on state assistance. The other factor is drought preparedness and pre-disaster planning. If the farmer did his homework way in advance he can cope well when drought has occurred. Farmers normally stockpile feeds during years of bumper production, fill the storage with unused fodder and ensure that fodder banks are up and running. Their products fetch lower prices at markets due to low quality and quantity during droughts. Prices are high for production inputs like fertilisers, feeds, medications, fuel, and replacement stock. Farmers must be available for training and capacity building on drought and its vulnerability.
In order to cope well with drought vulnerability, farmers must be candid enough to do self-introspection, own lifestyle audits; reduction in the expenditure of non-essentials like clothes and eating out in big restaurants, hotels, guesthouses. Coping capacity for drought is determined by analysing the capacity of farmers, farmworkers, and rural towns to cope with droughts. Factors considered for equating coping capacity include (i) land ownership, ii) on-farm diversification to provide own feed and fodder during drought, (iii) government support during drought, (iv) institutions support during drought, (v) alternative source of income, and non-agricultural entrepreneurship opportunities [8]. According to Shiferaw
Drought also affects farming towns and different municipalities in Northern Cape very severely; integrated development plans (IDP) which include drought management plans to large extent increase the coping ability of farmers against drought. During drought, farmers are assisted with fodder supply and their intergovernmental cooperation. For example, the department of social service will help with clothes, food, counselling, while the department of health with coping capacity by the provision of medicine and the department of water affairs will provide water with tanks [30]. Typically, main water sensitive urban design (WSUD) activities and strategies include the following, stormwater/drainage management, re-use of water, demand reduction techniques, and greenroom installation, with each main activity having its own set of sub-activities. Water demand management (WDM) or portable water demand reduction techniques ensures that water is reduced through leaks, reduced wastewater flows, and better awareness of consumers of the environmental and financial value of water [31].
The Disaster Management Act and National Disaster Management Framework [32] provide the legislative and policy frameworks for national and provincial drought management, mitigation practices, and strategies. Other legislative mandates are the strategic plan, Conservation of Agricultural Resources Act (CARA), and National Disaster Management Act Framework (NDMF). Drought management in Northern Cape is everyone’s responsibility. Drought can only be effectively control the implementation of the mitigation strategies is approached from an integrated strategic position taking cognisance of location specifics. Research is required in view of the vulnerability of small-scale vegetable farmers to drought in the Northern Cape as the existing policies and risk management plans adapted from the Department of Agriculture, forestry and fisheries [4] frameworks appear inadequate.
The preceding subheadings discuss the vulnerability of small-scale farmers to drought disasters in the Northern Cape. Vulnerability factors like unemployment, low income, poverty, population migration, change of food and eating pattern and loss of dignity were discussed. Surely, socio-economic drought vulnerability will be with farmers until precipitation fall and other mitigation strategies and policies are fully implemented. Northern Cape is affected by climate change which is characterised by global warming resulting in high atmospheric moisture losses. Evaporation and transpiration result in extreme water losses and this affects fauna and flora on a big scale. Climate change refers to a change of climate that is attributed directly or indirectly to human activity that alters the global atmosphere and that is in addition to natural climate variability observed over comparable periods of time [33].
Climate change according to the National Climate Change Response, White Paper is the trend in change of the earth’s general weather conditions as a result of an average rise in the temperature of the earth’s surface often referred to as global warming. (The Government of the Republic of South Africa, 2011). Significant changes in extreme weather events such as heatwaves, very hot days, high fire danger days, and dry spells are likely to increase. Climate change is expected to increase the frequency and magnitude of many types of extreme events including floods, droughts, tropical cyclones, and wildfires [34]. The consequences of increased temperature change in rainfall patterns, extreme weather events, sea-level rise, and changes in biodiversity will have a significant influence on national economies, rural livelihoods, and development in general. According to Madzwamuse [25], Africa is said to be the most vulnerable continent to the impact of climate change as a result of national economies depending on natural resources.
Agricultural production is projected to fall by 50% due to a reduction in precipitation and an increase in temperature while most African states will be faced with water scarcity and stress by 2050. Madzwamuse [25] and Hassan [35] stated that the impact of climate change in the South African agricultural sector will differ in different farming systems. Dry land smallholder producers will be affected mostly compared to irrigation and large-scale/commercial producers.
Northern Cape is one of the driest Province in the Republic of South Africa and it is also vulnerable to other disasters like veldt fires during the winter season when vegetation is extremely dry. Unsustainable use of land and other resources increase the vulnerability of farmers of the Northern Cape. Land degradation often stems from the nexus between poverty and lack of capacity to invest in more sustainable agricultural practices and improve land use patterns. The vulnerability to agricultural drought means that the extent of agriculture potential sensibility to the drought threat. Agricultural research on the vulnerability to agricultural drought is of great significance to mitigate drought losses and guarantee Provincial food security [31].
The economic, social, and environmental impacts of drought are huge in Northern Cape and the national costs and losses incurred threaten to undermine the wider economic and development gains made in the last few decades in the region. There is an urgent need to reduce the vulnerability of countries to climate variability and the threats posed by climate change [13]. Drought events and the magnitude of agricultural drought losses indicate the continuing vulnerability of the country to agricultural drought. Drought is among the most multifaceted and least understood of all natural hazards. Climatic variability adversely affects food production in two ways—it leads to low production, which translates into limited access, both physical and economic food. The exposure of agriculture to drought and heavy precipitation threatens food security and exacerbates poverty among smallholder farmers [36].
The impact of the drought on livestock production (beef and sheep) in the Northern Cape can be felt by the small scale at markers. Feedlots are under pressure due to shortages of maize products and high input prices and more costs will push up the price of A-grade beef prices. With good rainfall in the near future, Northern Cape producers can begin to rebuild their herds. An increase in milk prices can also cause the slaughter of cattle from this sector to decrease, putting further pressure on the factory meat prices (Agri growing greatness.co.za). In the livestock industry, below normal rainfall has almost depleted natural grazing veld, placing feed supplies for the upcoming winter season in a precarious position [18].
Southern African countries experience a dry season in winter, limiting forage. This means that any delays in the rains obviously prolong the winter period, which thus increases food shortages for livestock. Such a scenario results in high mortality of livestock, especially cattle. Losing livestock could increase poverty and negatively affect rural people’s livelihoods and food security [37]. According to Nkomo [38], the impact of drought on small-scale farmers is devastating as water allocation for irrigation to farmers has been cut back in the region. The cutbacks have had a direct impact on the incomes of those farmers. Small-scale farmers are more vulnerable compared to large-scale commercial farmers because they have no insurance and savings which may serve as a mitigation strategy.
The following vulnerabilities are used to measure or assess the degree of vulnerabilities to drought disasters of small-scale farmers in Northern Cape, South Africa. Economic, social, and environmental drought vulnerabilities assessment for Northern Cape small-scale farmers. This model was proposed by Jordaan
The identification of drought vulnerability indicators of small-scale farmers in the Northern Cape is an essential step for planning drought mitigation management. The disaster risk assessment methodology as stipulated in the Disaster Management Act (Act 57 0f 2002) was used as the framework for drought risk assessment in the NC. Stage one consisted of the framework for main risk factors, the factor components and examples of indicators considered for drought risk assessment in this research. Various frameworks, models, approaches, and equations are used to assess different drought vulnerabilities; emerging farmers are exposed to in Northern Cape.
Diarrhea is one of the most common symptoms in the gastroenterologist clinical practice. It is defined as an increase in the average number of bowel movements, stool output and/or weight, or a reduced stool consistency, and according to duration, can be acute if it lasts less than 7 days, persistent acute (>7 days and < 14 days), sub-acute (>14 days and < 28 days), or chronic (>4 weeks) [1, 2, 3, 4, 5, 6]. Most episodes of acute diarrhea occur as a result of infectious agents or dietary transgression. Acute persistent and subacute diarrhea may be caused by unidentified microorganisms or might be secondary to medications [1]. Chronic diarrhea is one of those conditions with the broadest differential diagnosis, that includes anatomical and/or physiologic abnormalities of the gastrointestinal (GI) tract, inflammatory or neoplastic conditions, malabsorptive disorders, drug side effects, dysbiosis, functional as well as post-infectious syndromes such as small intestine bowel overgrowth (SIBO), functional diarrhea or post-infectious irritable bowel syndrome (Pi-IBS) [2, 3, 4, 5, 6]. One of the most common, albeit rarely unconsidered causes, is drug-side effect [7, 8]. A large number of at least 700 drugs have been implicated as cause of chronic diarrhea through a number of different, and sometimes overlapped pathophysiologic mechanisms [9]. Although initial therapy is drug withdrawal, in several cases treatment directed at pathophysiologic mechanism is needed to revert damage and improve symptoms.
Enteral damage and consequent symptoms such as diarrhea, bloating, flatulence and pain may be mediated through different mechanisms falling into two main categories: (1) Functional damage: it can be caused by abnormalities in any of the mechanisms involving digestion (maldigestion) and/or absorption (malabsorption), GI motility disturbances, alterations in the water and electrolyte absorption and/or secretion mechanisms, and altered microbiota and/or microbiome (dysbiosis), and (2) Microscopic or overt mucosal damage: this can be caused by direct contact of the drug, ischemic-related damage, systemic inflammatory or autoimmune mechanisms, and may affect different portions of the small intestine, colon, or both (Figure 1, [9]). According to the involved mechanism, main symptoms may predominate diarrhea, malabsorptive complaints such as steatorrhea, weight loss and anemia, or abdominal pain, and in severe cases, occult or overt bleeding.
Pathophysiologic mechanisms of enteropathy according to drug type.
Small intestine is involved in both digestive and absorptive processes of all major nutrients, fatty acids and multiple ions, occurring across the entire intestinal wall at different levels. Normal functional anatomy includes a full bowel length, normal intestinal villi and absorptive capacity, conserved neuroendocrine regulatory systems, and a normal motility activity, particularly the major motor complex (MMC) [10]. Several drugs may interfere with one or multiple mechanisms associated with either digestion processes or mechanisms associated with intestinal absorption. Alpha-glucosidase inhibitors such as acarbose decrease carbohydrate digestion, lipase-inhibitors such as orlistat and cetilistat affect fat absorption, bile acid binding resins such as cholestyramine or colestipol affects not only bile acid absorption but also that of vitamin B12 and lipid-soluble vitamins, but as they are used in bile-acid diarrhea as main therapeutic indication, they can be associated with constipation instead of diarrhea. Different drugs may induce calcium precipitation, such as aluminum or tetracycline, with further changes in bowel habit. Structural damage leading to villous inflammation and/or atrophy is described in the mucosal damage section [11].
A number of drugs used to treat metabolic conditions such as diabetes mellitus and obesity have intrinsic malabsorptive mechanisms as their main mode of action, and may lead to diarrhea and other related symptoms due to those mechanisms.
Acarbose is a pseudo-tetrasaccharide that selectively inhibits alpha-glucosidase activity in the brush border membrane of the small intestine, an essential enzyme for digestion of starch, maltose and sucrose, delaying glucose absorption from carbohydrate food and thus improving glycemic control among patients with either glucose intolerance or diabetes mellitus [12]. Among common side effects, mainly intrinsic to its mode of action, include flatulence, bloating and diarrhea [13].
Orlistat is a reversible inhibitor of gastric and pancreatic lipoprotein lipases, resulting in inhibition of up to 30% of dietary fat absorption, decreasing fat mass, as well as levels of the regulatory hormone leptin as patients lose weight [14]. Most common adverse events, also intrinsic to its mechanism of action, are diarrhea, steatorrhea, flatulence, bloating and abdominal pain [15]. Recently a second lipase inhibitor, cetilistat, has shown similar efficacy with fewer side effects when compared to orlistat, however prevalence of diarrhea may be as high as 25% of users [16].
Metformin, a dimethyl-biguanide, is an oral glucose-lowering agent absorbed in the small intestine, that has several modes of action: it reduces hepatic glucose production by inhibition of hepatic gluconeogenesis, it increases insulin sensitization by increasing plasma glucagon-like-protein (GLP) type 1 concentrations, with a smaller effect on dipeptidyl-peptidase 4 (DPP-4), resulting in increased glucose uptake in the small intestine [17]. It may also induce alterations in enteral microbiome, particularly increased abundance of
As previously mentioned, small intestine is both an absorptive and secretory organ, and most of the water and electrolyte handling in the GI tract is regulated at this level by autonomic nerve system as well as by neuromuscular signal pathways [10]. A number of drugs may alter one or several of the mechanisms associated with normal GI motility and/or water and electrolyte secretion including laxatives, motilin analog antibiotics, enterokinetic drugs, secretagogues, colchicine, and prostaglandin analogs.
Several antibiotics, particularly the macrolides (e.g., azithromycin, clarithromycin, erythromycin), act as motilin analogues. Motilin is a hormone that induces MMC activity though four distinct phases: first one is a period of near quiescence, second is characterized by irregular small-amplitude waves, phase III induces high-amplitude propulsive contractions all along the small intestine, and during phase IV, motor activity declines to basal values [20]. Although macrolides have a predominant gastroduodenal site-of-action, they may also induce diarrhea by similar MMC-related mechanisms in the small bowel, and are fully reversible after stopping the drug [21].
Laxatives are drugs used to treat different types of constipation, and may cause diarrhea through a number of mechanisms according to pharmacologic type. Osmotic agents extract through osmosis fluid into the intestinal lumen to soften stools an accelerate colon transit time, examples are non-absorbable carbohydrates (e.g., lactulose), polyethylene glycol, as well as citrate, sodium or phosphate-based products. Stimulant agents induce high-amplitude propagated contractions (HAPC) and alter intestinal and colonic absorption as well as secretion mechanisms, examples include the anthraquinones senna and cascara sagrada, bisacodyl and sodium picosulfate. Newer enterokinetic drugs such as tegaserod and prucalopride are agonists of serotonin 5-HT4 receptors throughout the GI tract, they also induce increased MMC and HAPC activity and accelerate enteric transit time. Secretagogue agents such as linaclotide, plecanatide, lubiprostone and tenapanor increase intestinal secretion by one of three different mechanisms: activation of intestinal guanylate cyclase C receptors, increasing intraluminal fluid secretion (e.g., linaclotide, plecanatide), type 2 chloride channel activation in the apical membrane of epithelial cells resulting in increased fluid and chloride secretion (e.g., lubiprostone), and inhibition of gastrointestinal sodium-hydrogen exchanger-3 (e.g., tenapanor). All these drugs are used for treating chronic constipation, and IBS with predominant constipation, and diarrhea is the most common side effect. Colchicine is a cytotoxin used to treat acute attacks of gout, and is frequently associated with diarrhea as enhances intestinal water secretion. Misoprostol, a prostaglandin analogue used in the past for drug-associated peptic ulcer disease or in the obstetric practice, is associated frequently with diarrhea induced by an increased smooth-muscle GI activity [22].
Dysbiosis is a term used to describe any quantitative and/or qualitative imbalance, dysfunction or disturbance of the gut microbiota and microbiome as an indicator of disease or poor health status [23], and may be caused by a number of risk factors, including medications. Drugs and microbiota have a two-way relationship: drugs exert a significant impact on organs and tissues through their effect on gut microbiota, but in the other hand, microbiota metabolic capacity may affect stability, metabolite production, availability, absorption and thus, increase or decrease efficacy and/or toxicity of different medications [24, 25, 26]. A number of drugs have been described to alter the composition of the gut microbiota, including antibiotics, proton-pump inhibitors (PPI), nonsteroidal anti-inflammatory drugs (NSAID), opioids, metformin, statins, psychotropics, particularly atypical anti-psychotics, levothyroxine, anticoagulants, antiarrhythmics, and several oncologic medications including chemotherapeutic agents, and targeted therapy [18, 27, 28, 29, 30, 31, 32, 33]. A recent study evaluated more than 1000 marketed drugs and found that 24% of them induced significant microbiota composition [30].
Between 5 and 49% of antibiotic users develop diarrhea during or after treatment. Prevalence is highly variable and can be influenced by reporting country, age, and hospital setting. For instance, antibiotic-associated diarrhea (AAD) represent between 3.2–29% of all causes of diarrhea, with a mean prevalence of 9.6%, in the emergency department this figure raises to 18.6%, and in the intensive care units range from 13.9 to 21.5% [34, 35, 36]. Risk factors for AAD are: increasing age, therapy with more than 1 antibiotic, clindamycin use, long-term antibiotic use, and concomitant PPI use. In most cases, withdrawal of antibiotic may stop diarrhea. However, longer use may predispose to enteral and colonic damage, dysbiosis, and increases risk of developing infections by patobionts (microorganisms that usually interact with host in a symbiotic way, but have the potential of acting as pathogens under certain circumstances). Most common microorganisms associated with DAA are
Proton pump inhibitors (PPI) inhibit gastric acid secretion through irreversible blockage of the hydrogen-potassium pump in the parietal cell, and are used for a number of conditions associated with acid exposure such as gastroesophageal reflux disease, peptic-ulcer disease and associated bleeding, and certain types of dyspepsia, and are one of the most common used drugs worldwide [43]. Chronic associated hypochloridria may induce significant changes in microbiota composition throughout the whole gastrointestinal tract. At small intestine long-term PPI use is associated with increasing abundance of
A number of different drugs such as atypical anti-psychotics, antidepressants and other mood stabilizers, statins, antiarrhythmics, and anticoagulants are associated with changes in microbiome composition, but its role as a cause of diarrhea is unclear [30, 47, 48]. In several cases, in statins for instance, microbiome changes may be associated with improved outcomes, such as better lipid control [47], in others, as with psychotropics, resulting dysbiosis is associated with anti-commensal activity and drug metabolism alterations, resulting in minor GI symptomatology [30, 48]. Finally, NSAID and immunotherapy are drugs involved in enteropathy by different mechanisms, including dysbiosis, but as mucosal damage is their main pathophysiologic mechanism, are discussed below.
Drug-associated gastrointestinal damage may affect any part of the GI tract, and small intestine and colon enteropathy accounts for 20–40% of all GI side effects [10]. Mechanisms include direct cytotoxic damage on the intestinal mucosa resulting in several degrees of inflammation, including mucositis, erosions and/or ulcers, hemorrhagic enteritis, alterations in permeability, protein-loss associated enteropathy, and ischemic damage, either caused by long-standing vasoconstriction and/or thrombosis [11]. In some cases, as with chemotherapeutic agents, bone marrow damage and neutropenia may lead to intestinal bacterial translocation, secondary infections with pathogens such as
Non-steroidal anti-inflammatory drugs (NSAID) are prescribed for a variety of pain and inflammation-associated conditions such as rheumatologic and orthopedic disorders, migraine as well as post-surgical states, and exert their effects through cyclooxygenase (COX) inhibition with resultant decrease of prostaglandin synthesis. NSAID are associated both with upper and lower GI symptoms, as well as mucosal injury at any part of the GI tract, and symptoms vary widely from dyspepsia and heartburn to diarrhea, bloating and overt GI bleeding [7, 8, 11, 52, 53, 54, 55]. Despite gastroduodenal damage is the most common clinical presentation in most NSAID long-term users, up to 70% may develop different degrees of mucosal breaks, including erosions, ulcerations, mucosal hemorrhage or even stenosis in distal portions of the small intestine such as jejunum or ileum, as determined by studies using video capsule endoscopy [56, 57]. Pathophysiology of NSAID-induced enteropathy is a complex one, and includes different mechanisms such as COX inhibition and topical effect, interactions with bacteria and bile acids, as well as overexpression of pro-inflammatory cytokines. Inhibition of COX-1 is associated with decreased mucosal blood flow, mucus production, and intestinal motility, which are predominant, but not critical factors for damage. Topical effect, a COX-independent action requiring mucosal contact of the drug from the luminal side, is considered the triggering event in most cases [53, 54]. Once NSAID is absorbed into the cell, induces mitochondrial injury by producing vacuolation and swelling, and alters oxidative phosphorylation and electron transport, considered one of the earliest intracellular changes after NSAID administration. As a result, intestinal permeability is increased, allowing luminal factors to disrupt the intestinal barrier function [54]. A second mechanism is associated with interactions between microbiota, bile acids and further activation of innate immunity after being exposed to NSAID. Animal models have shown that germ-free rats treated with NSAID do not develop intestinal ulcers unless bacteria are introduced. NSAID induce an increase in Gram-negative bacterial abundance,
In addition to NSAID, several drugs may induce small intestine mucosal disease secondary to vasoconstriction and ischemia, including potassium supplements, oral contraceptive pills, and a number of cytotoxic drugs such as methotrexate and chemotherapeutic agents that are associated with different degrees of mucositis [11], and are discussed below.
Among patients receiving oncologic therapy, those treated with cytotoxic drugs, radiotherapy, targeted therapy, and immunotherapy, particularly with the so-called check-point inhibitors have increased risk of developing various degrees of enteropathy and diarrhea. Between 40 and 100% of cancer patients treated with chemotherapeutic agents develop gut toxicity at some point during their treatment, a term called “chemotherapy-induced intestinal mucositis” (CIM). Prevalence and severity depend on drug and dosing regimen, intensity, route of delivery, and patient predisposing conditions. CIM pathophysiology involves mainly mechanisms related to cell growth inhibition, immunological reactions, and dysbiosis [61]. Cytotoxic agents such as methotrexate, doxorubicin, 5-fluorouracil, capecitabin and irinotecan target enteral tissue by interrupting DNA synthesis by direct injury or by generation of reactive oxygen species, leading to release of active signaling factors (i.e., caspases, β-catenin, and NF-κβ), and eventually to mucosal damage and apoptosis, most of which wipe out the intestinal crypt stem cell pool [61, 62]. A five-stage model for CIM has been proposed, that includes: 1) initiation, 2) signal activation and primary damage response, 3) pathway amplification, 4) tissue inflammation (e.g., erosions, ulcerations, apoptosis), and 5) healing. Clinical picture varies widely, and ranges from short periods of diarrhea and abdominal pain, to severe degrees of enterocolitis. When bone marrow-targeted chemotherapeutic agents are also given, increased risk of neutropenic enterocolitis, abdominal sepsis, and even death may occur. Treatment options, beside adjusting dose or even withdrawal of the drug may include antibiotics and probiotics in order to restore normal gut microbiota and reduce pathogenic intestinal bacteria, octreotide to decrease peptide-associated intestinal secretions, antioxidants such as amifostine, a drug that detoxifies reactive metabolites and scavenges free radicals, steroid anti-inflammatory agents to reduce inflammatory response, and possibly incretins and anti-apoptotic agents, most of which are under investigation [11, 61, 62].
Radiation therapy plays an important role as sole curative therapy for 25% of all cancers, and as adjuvant with chemotherapy in many other cases. During radiotherapy of abdominal and/or pelvic tumors, either the small intestine, colon or both are included in the treatment field and may be prone to toxicity. Risk factors for gut damage include those related to therapy itself such as radiation dose, time-dose-fractionation parameters, volume, and concomitant chemotherapy, and patient-related factors such as advanced age, previous abdominal surgeries, as well as vascular and metabolic comorbidities. Radiation enteropathy is classified as early or delayed when occurs prior or after 3 months after treatment. Early symptoms are nausea and abdominal pain, while diarrhea occurs usually after 2 or 3 weeks of treatment onset, and may persist for longer periods of time. Mechanisms of damage are multifactorial and include increased production of reactive oxygen species, mitotic cell death, mucosal atrophy, endothelitis, microvascular sclerosis, as well as fibrosis of the entire bowel wall. As radiation affects predominantly rapidly proliferating intestinal cells, villus epithelium turnover is insufficient to keep normal absorptive mechanisms. Long-term side-effects may include nutrient malabsorption, anemia, stenosis, and in most severe cases, intestinal obstruction. Management is largely symptomatic, with anti-diarrheal agents. As one of the early mechanisms of damage is production of reactive oxygen species, free radical scavengers such as amifostine can be used for reduction of radiotherapy side effects, but it has a narrow therapeutic time window and potential life-threathening side effects. Several candidate mitigator drugs are under investigation [63].
The immune system has an important role in recognizing and eliminating some tumors. Activation of T cells require a signal between T-cell receptors and the major histocompatibility complex along with a stimulatory checkpoint expressed on T cells called CD-28, and the antigen-presenting cells [64]. Tumors may use immune-checkpoint pathways as a mechanism of immune resistance. Two well-known immune-checkpoint receptors are CTLA-4 (CD152), a negative regulator of T-cell-mediated anti-tumor response, and the programmed cell death protein 1 (PD-1 or CD279), expressed on the surface of activated T cells that interacts with programmed death ligand (PD-L1 and L2), leading to T-cell inactivation [64, 65]. The immune check-point inhibitors (ICI) are monoclonal antibodies that block these pathways, including inhibitors of PD-1, PD-L1, and CTLA-4. Immunomodulating therapy, or immunotherapy act to enhance anti-tumor immune responses by blocking negative regulators of immunity, and has revolutionized cancer therapy by improving survival outcomes and is now the standard treatment of different types of cancer, including several metastatic tumors. Currently approved ICI are the anti-PD-1 pembrolizumab and nivolumab, used for treating melanoma and metastatic non-small-cell lung cancer, the anti-CTLA-4 ipilimumab, a fully humanized monoclonal antibody approved for metastatic melanoma, as well as the anti-PDL-L1 atezolizumab and durvalumab, also for non-small cell lung cancer. Ipilimumab, for instance, competitively binds to CTLA-4, blocking tolerance to self-antigens, without blocking CD28 (a stimulatory checkpoint), increasing T-cell proliferation and activation leading to autoimmune damage to a number of organs, including the entire GI tract. In a similar way, anti-PD1/PDL-1 agents such as nivolumab and pembrolizumab increase T-cell response while reducing self-tolerance, and the result is similar to that seen with ipiliumumab [64, 65, 66, 67]. This kind of damage behaves similarly to that seen on inflammatory bowel diseases (IBD) such as Crohn’s disease and ulcerative colitis, as well as their clinical presentation, with various degrees of enteral and/or colonic damage ranging from erosions and ulcerations to obstruction, and wall necrosis, and presenting as chronic diarrhea, abdominal pain, GI bleeding and progressive anemia [68]. Histologic findings range from combined acute (e.g., neutrophils) and chronic (i.e., lymphocytes and plasma cells) inflammatory infiltrates, eosinophilia, atrophy, granulomatous reaction, crypt abscesses, and bullous pemphigoid, and in most severe cases an increased apoptotic activity within the crypt epithelium may be seen, affecting small intestine, colon or both [69, 70].Treatment is similar to that given for IBD and may include mesalazine, systemic corticosteroids, and in refractory cases, biologic therapy with infliximab [71, 72].
Another category of oncologic treatment is the called targeted therapy, which acts by identifying and attacking certain types of cancer cells, and by inhibiting oncogenes driving aberrant growth, and may include monoclonal antibodies and small molecule inhibitors. A number of targeted therapies are approved for different types of cancer. Many of them may be associated with different degrees of oral and GI mucositis, particularly cetuximab, erlotinib, gefitinib, lapatinib, sorafenib, and sunitinib, with odds ratio for diarrhea and enteritis ranging from 1.5 to 4.5 [73]. More recently, the HER-2-targeted monoclonal antibody trastuzumab, used for HER-2-overexpressing breast cancer, has been associated with a number of GI manifestations associated to toxicity, including diarrhea, abdominal pain, and ulcerative enterocolitis similar to that seen with ICI. Mechanism underlying GI toxicity remains under investigation, but it seems to be associated with HER-2 receptors in gut epithelial cells [74]. Treatment is empiric, following the same principles as for ICI.
A number of drugs are associated with an increased risk of microscopic enteritis and/or colitis, in some cases eosinophilic enteritis, or even may resemble microscopic enteral damage of other diseases, such as celiac disease. Microscopic enteritis encompasses a group of disorders characterized by microscopic mucosal and/or mucosal inflammatory infiltrates by a number of different inflammatory cells, including lymphocytes (i.e., lymphocytic enteritis/colitis), eosinophils (e.g., eosinophilic enteritis/colitis), and lymphocytes along with collagen deposits (i.e., collagenous sprue/collagenous colitis), in absence of significant macroscopic mucosal damage, leading to watery diarrhea [50, 75, 76, 77]. In the small bowel, microscopic enteritis may also be associated with mucosal atrophy in some cases, and the clinical picture may be that of malabsorptive diarrhea, with foul-smelling feces, steatorrhea, and anemia [76]. In most cases an autoimmune predisposition has been proposed, but when disease develops during or shortly after a specific drug use, causality for drug-induced disease can be proposed according to a World Health Organization system based on temporal sequence, prior information of the drug, dose–response relationship, exclusion of other etiologies, and re-challenge [78]. Pathophysiology mechanisms are not clear, and may involve activation of the immune system in response to exposure to luminal antigenic factors, including drug-itself, metabolites, bile-acids, or may be associated with changes in microbiota linked to long-term drug use, such as in PPI.
A number of drugs have been linked to microscopic colitis, including aspirin, NSAID, PPI, SSRI, particularly sertraline, clozapine, ticlopidine, flavonoids and acarbose [51]. A recent case–control study found a significant increased risk for microscopic colitis with current use of NSAID, PPI, and SSRI with adjusted odd ratios of 1.86, 3.37 and 2.03 respectively. Current PPI use was associated also with increased risk of both lymphocytic (OR 2.06) and collagenous colitis (OR 5.3), whereas current NSAID use was associated with increased risk of collagenous colitis (OR 2.32), and current SSRI use increased risk of lymphocytic colitis (OR 2.28). Long-term PPI and/or NSAID use had the highest odds ratio (4.6 and 4.8 respectively) for developing microscopic colitis [79]. As previously mentioned, NSAID may affect any part of the GI tract, by a number of different pathophysiologic mechanisms. In the small intestine NSAID-associated damage ranges from microscopic enteritis to severe mucosal affection with erosions and/or ulcers. Histologic manifestations of NSAID may resemble those of celiac disease, with villous blunting and intraepithelial lymphocytosis, and can be found in any part of the small intestine [80].
Eosinophilic enteritis and colitis are included in the group of eosinophilic gastrointestinal disorders, and are characterized by a high eosinophilic infiltrate in the gut wall, without evidence of other causes. Pathophysiology involves a combination of genetic predisposition, dysbiosis, and a triggering factor, usually an allergen, that may include drugs, followed by recruitment and activation of eosinophils to sites of inflammation regulated by pro-inflammatory cytokines [81]. Drugs such as clozapine, naproxen, carbamazepine, and rifampicin have been associated with increased eosinophilic infiltrate in the distal ileum and colon [77]. More recently the anti-CTLA-4 check-point inhibitor ipilimumab and the anti-PD1 nivolumab have been link to eosinophilic enteritis [70]. Other immunosuppressant drugs such as mycophenolate mofetil, a drug used to prevent acute allograft rejection may affect both small bowel and colon, causing an eosinophilic-associated damage, with features similar to those of acute graft-versus-host disease [82].
Angiotensin II receptor inhibitors (AT-II RI) are one of the most common drugs for treating high blood pressure, with a generally safe side-effect profile. In 2012 a case series of 22 patients developing chronic diarrhea and weight loss while taking olmesartan was published. None had positive celiac serology, and a combination of villous atrophy and variable degrees of inflammation including collagen deposits was observed in small intestine biopsies, with clinical and histologic recovery after discontinuation of the drug [83]. More recently, other AT-II RI have been also associated with different degrees of enteropathy. A systematic review included 248 cases, most of which were associated with olmesartan (94%), however telmisartan, irbesartan, valsartan, losartan and eprosartan also were reported to be associated with various degrees of enteropathy. Interestingly, despite negative serology in most cases, 71% had a positive HLA-DQ2 or DQ-8, haplotypes associated with celiac disease [84].
Drugs are a common cause of chronic diarrhea and enteropathy by a number of mechanisms including intrinsic mode of action, malabsorption, dysbiosis, increased GI motility, alterations in water and electrolyte absorption and secretion mechanisms, autoimmune macroscopic or microscopic damage, and cytotoxic effect. Site of damage may include either part of the small intestine, colon, or both, and can be manifested by malabsorptive, inflammatory or watery diarrhea. In most cases diarrhea subsides after drug withdrawal, but in some cases a number of inflammatory conditions requiring other forms of therapy may be needed.
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However, the current system evaluation toolkit does not recommend specific areas required for further improvement. The objective of this chapter was to identify those constructs and their attributes that were the most suitable candidates for managerial intervention by applying partial least squares structural equation modeling. In doing so, the quantitative survey was adopted from the past studies together with new items creation representing system quality, records quality, service quality, and knowledge quality as the predictors while effective use and user performance as the outcomes. When extending the findings in importance‐performance map analysis, two‐system quality attributes (workflows fit and work styles fit) and all‐knowledge quality attributes exhibited higher importance rank for managerial actions. The chapter also provides a valuable recommendation for the policy and decision‐makers at the managerial level on how to apply the proposed system evaluation method in producing more efficient strategic‐planning strategies for further system upgrades and new implementation at health facilities.",book:{id:"5808",slug:"advances-in-health-management",title:"Advances in Health Management",fullTitle:"Advances in Health Management"},signatures:"Mohd Idzwan Mohd Salleh, Rosni Abdullah and Nasriah Zakaria",authors:[{id:"198049",title:"Mr.",name:"Mohd Idzwan",middleName:null,surname:"Mohd Salleh",slug:"mohd-idzwan-mohd-salleh",fullName:"Mohd Idzwan Mohd Salleh"},{id:"205599",title:"Prof.",name:"Rosni",middleName:null,surname:"Abdullah",slug:"rosni-abdullah",fullName:"Rosni Abdullah"},{id:"205600",title:"Dr.",name:"Nasriah",middleName:null,surname:"Zakaria",slug:"nasriah-zakaria",fullName:"Nasriah Zakaria"}]},{id:"54483",doi:"10.5772/67818",title:"Assessment of Avoidable Mortality Concepts in the European Union Countries, Their Benefits and Limitations",slug:"assessment-of-avoidable-mortality-concepts-in-the-european-union-countries-their-benefits-and-limita",totalDownloads:1357,totalCrossrefCites:2,totalDimensionsCites:5,abstract:"The concept of avoidable mortality is intended to assessing health care system performance. It is defined as premature deaths from selected disease groups that are considered either treatable through the timely and effective health care (amenable mortality), or preventable by public health interventions (preventable mortality). The purpose of study is to analyse the impact of four lists of causes of death created by researchers on amenable mortality by country, sex and cause of death. Data on deaths were obtained from the WHO database for 20 European Union countries in 2014. We applied the method of direct standardisation using the European Standard Population, Spearman rank‐order correlation with statistical significance tests and confidence intervals. We found that the selection of diseases considered as amenable has not significantly impact on the cross‐country comparison, but the weight of selected list of causes of death is significant at the national level. The concept has several limitations relating to selection of diseases and setting age threshold over time, availability of health care resources, prevalence of diseases or variation of causes of death coding among countries. However, indicator of avoidable mortality offers a way of the evaluating effectiveness of health systems in maintaining and improving population health.",book:{id:"5808",slug:"advances-in-health-management",title:"Advances in Health Management",fullTitle:"Advances in Health Management"},signatures:"Beata Gavurova and Tatiana Vagasova",authors:[{id:"197261",title:"Prof.",name:"Beata",middleName:null,surname:"Gavurova",slug:"beata-gavurova",fullName:"Beata Gavurova"},{id:"201172",title:"Dr.",name:"Tatiana",middleName:null,surname:"Vagasova",slug:"tatiana-vagasova",fullName:"Tatiana Vagasova"}]},{id:"54609",doi:"10.5772/67817",title:"The Efficiency of Post‐Communist Countries’ Health Systems",slug:"the-efficiency-of-post-communist-countries-health-systems",totalDownloads:1236,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"Health‐care costs are a major financial burden for the transition economies, which have experienced rapidly increasing demand for health‐care services. The former communist countries of the Central and Eastern Europe and Central Asia needed to reform the financing of their health‐care systems and make efforts to strengthen the role of primary care while limiting the role of hospital care. The growing health needs and, consequently, costs resulted in the increased attention paid to the performance of health systems. The aim of this chapter is to determine the efficiency of health systems in post‐communist countries. The data envelopment analysis method was used. The effective health systems were identified and recommendations for the inefficient countries were formulated.",book:{id:"5808",slug:"advances-in-health-management",title:"Advances in Health Management",fullTitle:"Advances in Health Management"},signatures:"Justyna Kujawska",authors:[{id:"198853",title:"Dr.",name:"Justyna",middleName:null,surname:"Kujawska",slug:"justyna-kujawska",fullName:"Justyna Kujawska"}]},{id:"56415",doi:"10.5772/intechopen.69954",title:"Low-Cost Health/Medical Tourism of Italians",slug:"low-cost-health-medical-tourism-of-italians",totalDownloads:1145,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"In recent years, becoming a form of spatial mobility of people is mainly called “medical tourism or health tourism”. In Italy the adoption of the expression “turismo sanitario” is often used as an international expression synonymous with “medical tourism or health tourism”: this situation raises a number of conceptual problems. In fact, the Italian public health service is one of the most developed in the world and is distinguished by many nations to the fact to offer its citizens free of charge and many health care services. In this situation, the Italian citizen in need of medical care is not convenient to travel to other places and is not obliged to do so. In fact, the Italian citizen tends to move for medical and health care that the Italian public health service does not deliver at no charge: such as dental care, we will deal with this case illustrating some examples of dental tourism low cost of the Italians. However, from our point of view, tourism period may be coupled to the trips to the health or well-being only in cases where the journey is “voluntary.” All this will be discussed in this paper.",book:{id:"5808",slug:"advances-in-health-management",title:"Advances in Health Management",fullTitle:"Advances in Health Management"},signatures:"Tullio Romita and Antonella Perri",authors:[{id:"204991",title:"Dr.",name:"Tullio",middleName:null,surname:"Romita",slug:"tullio-romita",fullName:"Tullio Romita"},{id:"213614",title:"Dr.",name:"Antonella",middleName:null,surname:"Perri",slug:"antonella-perri",fullName:"Antonella Perri"}]},{id:"73241",doi:"10.5772/intechopen.93604",title:"Epidemiology of Obesity in Children and Adolescents",slug:"epidemiology-of-obesity-in-children-and-adolescents",totalDownloads:680,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"The childhood overweight and obesity epidemic has become a global emergency in public health and a crucial challenge of the twenty-first century. Nowadays, childhood and adolescent obesity represent a significant public health problem both in developing and developed countries. Globally, above 340 million children and adolescents aged 5–19 years were overweight or obese in 2016. Childhood obesity is a critical burden because it can be associated with a higher possibility of obesity, premature death, and disability in adults, as well as early markers of cardiovascular disease. In Europe, childhood obesity remains a significant health challenge and is distributed disparately across and between countries and population groups. In 2019, over 398,000 children aged 6–9 years were severely obese in Europe. Particularly, Southern European countries such as Greece, Italy, Malta, San Marino, and Spain had one in five children obese in 2018. In Europe, different initiatives and actions have been launched in recent years to fight childhood obesity. However, the progress on combating obesity in children has been slow and inconsistent across the region. In this chapter, we have discussed the prevalence of obesity in children and existing policies to combat childhood obesity in the World Health Organization (WHO) European Region.",book:{id:"9559",slug:"teamwork-in-healthcare",title:"Teamwork in Healthcare",fullTitle:"Teamwork in Healthcare"},signatures:"Giulio Nittari, Stefania Scuri, Getu Gamo Sagaro, Fabio Petrelli and Iolanda Grappasonni",authors:[{id:"322429",title:"Dr.",name:"Giulio",middleName:null,surname:"Nittari",slug:"giulio-nittari",fullName:"Giulio Nittari"},{id:"322447",title:"Prof.",name:"Iolanda",middleName:null,surname:"Grappasonni",slug:"iolanda-grappasonni",fullName:"Iolanda Grappasonni"},{id:"322448",title:"Dr.",name:"Stefania",middleName:null,surname:"Scuri",slug:"stefania-scuri",fullName:"Stefania Scuri"},{id:"323556",title:"Prof.",name:"Fabio",middleName:null,surname:"Petrelli",slug:"fabio-petrelli",fullName:"Fabio Petrelli"},{id:"323558",title:"Dr.",name:"Getu Gamo",middleName:null,surname:"Sagaro",slug:"getu-gamo-sagaro",fullName:"Getu Gamo Sagaro"}]}],mostDownloadedChaptersLast30Days:[{id:"73280",title:"Teamwork in a Surgical Department",slug:"teamwork-in-a-surgical-department",totalDownloads:1096,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Teamwork is essential in surgery. A surgeon alone cannot fulfill his daily tasks. Surgical departments are divided into surgical teams: the surgical team in the operating theater, the surgical ward team, and the surgical emergency team. The common task of those teams is adequate patient care. The characteristics of team members describe necessary abilities such as: open communication, effective coordination skills, collaboration willingness, interdependency, mutual performance monitoring, backup behavior, adaptability, team orientation, and personality type. Team processes are recurring and ongoing short-term courses that occur in the team. The team developmental model separates the development of a team in four stages over a longer period of time. In the last stage, the team reaches the highest level of teamwork performance. Each team must be assessed for their nontechnical skills with team measurement tools. Surgical teams are insufficiently measured. There are possible disadvantages in teamwork, which must be considered and discussed versus the obvious benefits. Leadership is a process where the leading team member sets the direction for the others. There are different styles of leadership, whereby the dominant role of the leader is more or less pronounced. Leadership and teamwork are not contradicting characteristics of teams in the surgical department.",book:{id:"9559",slug:"teamwork-in-healthcare",title:"Teamwork in Healthcare",fullTitle:"Teamwork in Healthcare"},signatures:"Nikolai Ramadanov",authors:[{id:"322676",title:"Dr.",name:"Nikolai",middleName:null,surname:"Ramadanov",slug:"nikolai-ramadanov",fullName:"Nikolai Ramadanov"}]},{id:"54844",title:"Extending Health Information System Evaluation with an Importance‐Performance Map Analysis",slug:"extending-health-information-system-evaluation-with-an-importance-performance-map-analysis",totalDownloads:1443,totalCrossrefCites:3,totalDimensionsCites:6,abstract:"Evaluation of a health information system is necessary for determining effective use and for enhancing the productivity of medical practitioners. However, the current system evaluation toolkit does not recommend specific areas required for further improvement. The objective of this chapter was to identify those constructs and their attributes that were the most suitable candidates for managerial intervention by applying partial least squares structural equation modeling. In doing so, the quantitative survey was adopted from the past studies together with new items creation representing system quality, records quality, service quality, and knowledge quality as the predictors while effective use and user performance as the outcomes. When extending the findings in importance‐performance map analysis, two‐system quality attributes (workflows fit and work styles fit) and all‐knowledge quality attributes exhibited higher importance rank for managerial actions. The chapter also provides a valuable recommendation for the policy and decision‐makers at the managerial level on how to apply the proposed system evaluation method in producing more efficient strategic‐planning strategies for further system upgrades and new implementation at health facilities.",book:{id:"5808",slug:"advances-in-health-management",title:"Advances in Health Management",fullTitle:"Advances in Health Management"},signatures:"Mohd Idzwan Mohd Salleh, Rosni Abdullah and Nasriah Zakaria",authors:[{id:"198049",title:"Mr.",name:"Mohd Idzwan",middleName:null,surname:"Mohd Salleh",slug:"mohd-idzwan-mohd-salleh",fullName:"Mohd Idzwan Mohd Salleh"},{id:"205599",title:"Prof.",name:"Rosni",middleName:null,surname:"Abdullah",slug:"rosni-abdullah",fullName:"Rosni Abdullah"},{id:"205600",title:"Dr.",name:"Nasriah",middleName:null,surname:"Zakaria",slug:"nasriah-zakaria",fullName:"Nasriah Zakaria"}]},{id:"73241",title:"Epidemiology of Obesity in Children and Adolescents",slug:"epidemiology-of-obesity-in-children-and-adolescents",totalDownloads:680,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"The childhood overweight and obesity epidemic has become a global emergency in public health and a crucial challenge of the twenty-first century. Nowadays, childhood and adolescent obesity represent a significant public health problem both in developing and developed countries. Globally, above 340 million children and adolescents aged 5–19 years were overweight or obese in 2016. Childhood obesity is a critical burden because it can be associated with a higher possibility of obesity, premature death, and disability in adults, as well as early markers of cardiovascular disease. In Europe, childhood obesity remains a significant health challenge and is distributed disparately across and between countries and population groups. In 2019, over 398,000 children aged 6–9 years were severely obese in Europe. Particularly, Southern European countries such as Greece, Italy, Malta, San Marino, and Spain had one in five children obese in 2018. In Europe, different initiatives and actions have been launched in recent years to fight childhood obesity. However, the progress on combating obesity in children has been slow and inconsistent across the region. In this chapter, we have discussed the prevalence of obesity in children and existing policies to combat childhood obesity in the World Health Organization (WHO) European Region.",book:{id:"9559",slug:"teamwork-in-healthcare",title:"Teamwork in Healthcare",fullTitle:"Teamwork in Healthcare"},signatures:"Giulio Nittari, Stefania Scuri, Getu Gamo Sagaro, Fabio Petrelli and Iolanda Grappasonni",authors:[{id:"322429",title:"Dr.",name:"Giulio",middleName:null,surname:"Nittari",slug:"giulio-nittari",fullName:"Giulio Nittari"},{id:"322447",title:"Prof.",name:"Iolanda",middleName:null,surname:"Grappasonni",slug:"iolanda-grappasonni",fullName:"Iolanda Grappasonni"},{id:"322448",title:"Dr.",name:"Stefania",middleName:null,surname:"Scuri",slug:"stefania-scuri",fullName:"Stefania Scuri"},{id:"323556",title:"Prof.",name:"Fabio",middleName:null,surname:"Petrelli",slug:"fabio-petrelli",fullName:"Fabio Petrelli"},{id:"323558",title:"Dr.",name:"Getu Gamo",middleName:null,surname:"Sagaro",slug:"getu-gamo-sagaro",fullName:"Getu Gamo Sagaro"}]},{id:"73609",title:"Spiritual Environment Management Tool",slug:"spiritual-environment-management-tool",totalDownloads:535,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"This chapter is about the spiritual environment management tool, which includes spirituality at work and spiritual practices. This management tool is divided into two steps: diagnostic of the worker’s perceptions about spirituality at work (first step) and spiritual practices design (second step). By meaning, spirituality at work can help healthcare managers to build effective teamwork in medicine. Spirituality at work has a multidimensional and measurable nature and is aligned with the three principles of the World Health Organization, based on two arguments: the new approach should be preventive and should promote partnership. This fact allows the managers as well the human resource department to classify the organizational environment on the next spiritual issues in the first step: meaningful work; opportunities for inner life; the sense of community; alignment with the organization’s value; emotional balance and inner peace. The reduction of medical errors to improve patient safety require the performance of multistep tasks of the great complexity of healthcare professionals, and this chapter pretends to show how the spiritual environment management tool can contribute with the “all working together” goal through a multi-disciplinary care team.",book:{id:"9559",slug:"teamwork-in-healthcare",title:"Teamwork in Healthcare",fullTitle:"Teamwork in Healthcare"},signatures:"Maria Joelle",authors:[{id:"230270",title:"Dr.",name:"Maria",middleName:null,surname:"Joelle",slug:"maria-joelle",fullName:"Maria Joelle"}]},{id:"54168",title:"European Health System Typologies: Last 30 Years Under Review",slug:"european-health-system-typologies-last-30-years-under-review",totalDownloads:1652,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The quest of the researcher to classify national health systems into homogeneous groups has a long history. In this paper, the last 30 years are divided in two periods (1985–2000 and 2000–2015) in order to present and briefly describe the most influential national health system typologies.",book:{id:"5808",slug:"advances-in-health-management",title:"Advances in Health Management",fullTitle:"Advances in Health Management"},signatures:"Aida Isabel Pereira Tavares",authors:[{id:"196819",title:"Prof.",name:"Aida Isabel",middleName:null,surname:"Tavares",slug:"aida-isabel-tavares",fullName:"Aida Isabel Tavares"}]}],onlineFirstChaptersFilter:{topicId:"461",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:8,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:286,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:9,numberOfPublishedChapters:101,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:11,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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