\r\n\tUnstoppable progress in the technologies of synthesis of diamond, graphene, and its compounds with stable parameters will provide materials for the industry of devices for integrated, radio, Opto- and quantum electronics and photonics. \r\n\tIn most electronic and optical properties, diamond and graphene are superior to traditional and perspective semiconductors. It is safe to say that silicon and gallium arsenide are materials for electronics and optoelectronics of the past, gallium nitride and silicon carbide are high-tech today, and diamond and graphene are the future of electronics and photonics.
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1. Introduction
1.1. Review of previous experience and accomplishments
As previously published (1) the Avera Health system launched its telemedicine program by offering consultation by video connectivity from the main tertiary hospital in the largest city of the multi-state North Central Region of the United States to some of its smallest partner clinics and hospitals. Between 1993 and 2004, medical providers and patients learned what it was like to practice medicine and receive care via a telemedicine connection. A major growth spurt in Avera’s rural telemedicine program came in 2004 after the initiation of a virtual ICU service staffed by intensivist physicians and critical care nurses; Avera eICU CARETM
Avera eICU CARE is a registered trademark of VISICU, Inc.
. Since 2004, Avera has initiated and rapidly expanded multiple other telemedicine programs to meet demand for additional services and coverage. These around-the-clock, always available services are unique as stand-alone programs, but combined provide one of the most robust telemedicine platforms on the planet.
In the previous report, the goals, expectations and consequences of the Avera eICU CARE program were described. Avera eICU CARE initially started with the system’s tertiary hospital, Avera McKennan Hospital & University Health Center, serving as the hub location for the provision of twenty-four hour per day remote patient care and monitoring of seriously ill patients in three medium-sized rural hospitals. Over time it evolved to include several more hospitals of that size called “Rural Regional Hospitals.” Additionally, remote Critical Access Hospitals (CAHs) began to request eICU coverage. Intensivist-led medical supervision and monitoring further expanded to hospitals outside of the Avera Health system, including those with different medical record or electronic record platforms. Finally, Avera eICU services expanded into multiple states.
Avera eCARETM has several years of experience in providing a broad expanse of telemedicine services. Each service has enjoyed similar growth and success. Avera’s programs have also experienced similar and unique challenges in implementation, growth, and cultural adaptation. The expansion of Avera’s telemedicine program was born in the success of Avera eICU CARE, and lead to the development and expansion of programs such as eEmergency and ePharmacy. Like the Avera eICU CARETM program, these services provide rural facilities access to additional health care services and providers. eEmergency and ePharmacy have expanded faster and are more widely distributed than Avera eICU CARETM. This could be the result of several factors, but one could postulate that perhaps these services have been more useful to rural sites of care. Today, a variety of services are being researched, designed and piloted to provide care to an amazing assortment of patients, medical providers, clinics, hospitals, and other health care facilities to be described later. Many of these pilots have been launched and have been well received. The goal of this chapter is to describe the status of the comprehensive Avera eCARETM system and to hypothesize the future of this very successful paradigm of care.
As time progresses and needs arise, unique applications of telemedicine supervision are developed. Many of these applications are in the pilot stages of development as part of Avera’s comprehensive program. Avera’s suite of telemedicine services are now largely sustained without any outside financial support. Avera’s telemedicine start-up costs have been off-set, in part, by grants and other funding opportunities. Avera’s growing breadth and scope of telemedicine service offerings lead to a decision to bring eCARE together as a “Virtual Hospital”. With this goal in mind, and generous financial support, Avera has developed a co-located telemedicine center that brings together all of Avera’s telemedicine services under one roof, offsite from any traditional hospital or clinic location. Side-by-side, the medical providers, nurses and support staff work toward multidisciplinary success in each patient encounter. This telemedicine center is unique in the practice of telemedicine and is called the Avera eHelmTM.
2. Current programs and their results
Figure 1 displays the geographic breadth of the Avera eCARETM program which is of one of the most comprehensive rural telemedicine programs in the world by geographic breadth, number of sites served, and number of unique telemedicine services operating from one location. It can be noted from the figure that the greatest concentration of activity is along the borders of five states of the North Central region of the United States: South Dakota, North Dakota, Minnesota, Iowa, and Nebraska. However, the greatest recent growth is westward including expansion into the states of Wyoming and Montana.
Figure 1.
shows the seven states of the North Central United States which receive Avera eCARETM services: Wyoming (WY), North Dakota (ND), South Dakota (SD), Nebraska (NE), Minnesota (MN), Montana (MT) and Iowa (IA).
Avera’s telemedicine experience initially shows the seven states of the North Central United States which receive Avera eCARETM services: Wyoming (WY), North Dakota (ND), South Dakota (SD), Nebraska (NE), Minnesota (MN), Montana (MT) and Iowa (IA).started by using video-conferencing equipment to facilitate medical consultations between primary care providers and patients in rural locations in South Dakota to specialists in a tertiary setting. It now is an active and robust program spanning seven states of the North Central region of the United States. Expansion of the type of programs and number of sites served has pushed Avera’s total service area to include more than one hundred sixty-five hospitals and clinics within and outside of the Avera Health system.
The six primary eCARE services are shown in Figure 2: eConsult, ePharmacy, eEmergency, eLong Term Care, and eUrgent Care in Correctional Facilities.
These telemedicine programs are shows the six telemedicine services offered by Avera eCARETM to date.designed to benefit rural patients and medical providers by improving the speed of care delivery and helping ensure the highest quality of care is provided locally where the patient resides. For the remote medical provider, Avera eCARE services offset a lack of specialists in rural areas affected by fewer resources and limited medical professional assistance and consultation. In addition, the facilities served may lack access to educational and career growth opportunities. These medical providers often have large patient loads and are required to be available to provide patient care many hours per week
Ormond, B., Wallin, S., Goldenson, S. (2000). Supporting the rural health care safety net. The Urban Institute, Occasional Paper 36.
,
2009. Rural practice, keeping physicians in. AAFP Position Paper. http://www.aafp.org/online.en/home/policy/policies/r/ruralpracticekeep.html
. Patients in remote, rural locations are often more elderly and are more likely to suffer from chronic disease than their urban counterparts
Joynt, K., Orav, J., and Jha (2013). Mortality rates for medicare beneficiaries admitted to critical access and non-critical access hospitals, 2002-2010.
. The cause of this startling statistic may be multifactorial but may include reasons such as greater distances to travel for specialty consultation, delays in seeking care due to higher rates of lacking primary health insurance or being underinsured, and in some cases inclement weather delaying access to care.
Figure 2.
shows the six telemedicine services offered by Avera eCARETM to date.
2.1. The Avera eCARETM programs
eConsult allows patients to access scheduled specialty consults at their local facility through two-way video technology. These consults are supported by special telephonic stethoscopes, otoscopes, and examination cameras. Avera first began providing virtual visits in 1993. eConsult benefits patients by saving time away from school or work and by saving the expenses of roundtrip travel. Figure 3 illustrates the utilization of this service by specialty over the past twelve months. As can be seen, primary specialties such as pediatrics or mental health are regularly requested. Many rare subspecialties are also utilized monthly. Infectious disease expertise is the single most frequently scheduled telemedicine consult provided to rural medical providers and their patients.
The status of this program is summarized as of May 30, 2013. eConsult is live in 109 sites; 76 patient sites and 33 specialty sites. Over a twelve month period, 5,900 eConsults were conducted by 88 unique specialist providers. eConsult services have saved an estimated 28,500 patient travel hours and more than 1.8 million patient travel miles. Additionally, access to specialist care via eConsult has resulted in a cost savings of more than $425,970 for rural patients
eConsult Database (2013). Avera eCARE Services.
.
Figure 3.
illustrates the utilization of telemedicine consultations by specialty over the past twelve months.
Avera eICU CareTM (eICU) began in 2004 and had accounted for the largest quantum of growth in the history of Avera’s telemedicine services until just recently. As stated earlier, Avera eICU CARE provides around-the-clock remote intensive care monitoring of seriously and critically ill patients in the thirty-three hospitals served. With the inception of this program, Avera was able to electronically quantitate the severity of illness for such patients by using an internationally known and validated severity adjustment methodology called the Acute Physiology and Chronic Health Evaluation (APACHE) scoring system. Patient data is automatically calculated from the data entered into the electronic medical record to generate APACHE predictions. The system also analyzes quality measures such as the frequency of ordering “best practice” national guidelines. Avera tracks outcomes such as severity-adjusted intensive care unit (ICU) length of stay, severity-adjusted ICU mortality, severity-adjusted hospital mortality, and severity adjusted hospital length of stay. Avera uses these analyses to design strategies to improve the care delivered to seriously and critically ill patients in the eICU CARE system. Avera eICU CARE has also provided education to medical providers across the region concerning this new high quality service by publishing results in the South Dakota Journal of Medicine (2).
From the initial forty beds, Avera eICU CARE has expanded to include smaller hospitals within the Avera system, hospitals out of the Avera system, and even hospitals out of the state. Avera was one of the first in the nation to offer the eICU service to patients in CAHs. Avera studied whether the Avera eICU program had an impact on patient outcomes. Data revealed that after the program was implemented there was reduction in severity-adjusted ICU mortality, reduction in severity-adjusted ICU length of stay, reduction of severity adjusted hospital mortality, and reduction of severity-adjusted hospital length of stay (3). In addition, Avera eICU CARE has improved compliance with best practice guidelines, and has achieved one hundred percent compliance with stress ulcer prophylaxis and DVT prophylaxis in eICU-monitored patients. APACHE data has shown that ICU mortality among eICU patients is an average of thirty to fifty percent below predicted in comparison to the APACHE database. Avera has also reduced ICU length of stay by an average of twenty-five percent. Using APACHE predictions, Avera has calculated the number of lives saved from the difference between observed to predicted mortality. Figure 4 shows those results from initial analysis to the current year.
Figure 4.
illustrates the number of lives saved quarterly from 2005 to the present.
The around-the illustrates the number of lives saved quarterly from 2005 to the present -clock, direct monitoring of critically ill and seriously ill patients by the intensivist-led team, supported by sophisticated technology that recognizes and alerts for negative trends in vital signs and abnormalities in laboratory tests is one of the primary reasons for such significant improvement in patient outcomes. The eICU team of intensivists and critical care nurses is alerted to negative trends in patient status and can immediately be present in a patient’s room by a two-way interactive televideo system to respond to emergencies. Additionally, Avera eICU CARE supports consistent application of evidenced-based medicine through active rounding on patients, with a focus on ensuring such evidence-based measures are implemented and documented in the medical record.
Avera eICU CARE currently provides coverage for one hundred thirty-two beds in thirty-three facilities across six states, spanning a geography from Wyoming to mid-Iowa and from North Dakota to Nebraska. The Avera eICU CARE team monitors an average of sixty to sixty-five patients at any time, and averages twenty-two admissions per a twenty-four hour period. eICU intensivist physicians write an average of 1,400 orders per month. This greatly exceeds the average number of interventions for other tele-intensivist programs (4), which attests to the welcome invitation by rural sites for continous coverage when primary providers cannot be available. There are no charges to patients for this service.
Although the number of ICU telemedicine programs in the United States has continued to grow rapidly, our program has been recognized for its coverage to the least densely populated geographic rural region (5) and to the largest number of critical access hospitals (those receiving federal pass-through payments for services but limited to 20 beds or less).
ePharmacy was developed shortly after the quantum expansion of the Avera eICU CARETM service. Many rural sites experienced long periods of time when a local pharmacist was not available, highlighting a need for this service. Avera’s virtual pharmacy service provides remote medication order review and approval before a first dose of medication is administered. ePharmacy uses automated dispensing equipment and remote provider order entry which has led to a reduction in serious safety events related to duplication of medication therapies, allergies, and drug-to-drug interactions. Currently ePharmacy service is provided to forty-six sites. Since its inception in 2009, more than 83,300 patients have been served by ePharmacy. To date more than 1,054,000 orders have been reviewed, and more than 14,200 serious safety events avoided. Each month, the ePharmacy team of pharmacists reviews more than 44,000 orders and documents 800 interventions to promote medication safety and efficacy.
Figure 5 illustrates the breakdown of adverse events noted in a single month.
Figure 5.
illustrates the types of errors which have been detected by the ePharmacy service line in a single month.
eEmergency (eED) illustrates the types of errors which have been detected by the ePharmacy service line in a single month.has had the greatest success with expansion and requests for service. As of June 1, 2013, seventy-six sites utilize eEmergency services. Figure 6 illustrates the pace of growth of this highly requested program to the rural communities of the North Central region of the United States. The eED provides immediate, two-way video access to a board-certified emergency physician and a core of experienced emergency nurses. They assist in the management of a multitude of medical emergencies such as trauma, acute myocardial infarction and stroke, to name a few.
Figure 6.
demonstrates the pace of growth of eEmergency services aided by the Helmsley grant to be described below.
eEmergency allows for the demonstrates the pace of growth of eEmergency services aided by the Helmsley grant to be described below.initiation of accurate diagnostic testing before local provider arrival, streamlines emergency transfer arrangements, and eliminates unnecessary transfers. Since inception in 2009 through May 30, 2013, more than 5,900 patients have been treated, over 10,800 transfers have been arranged, and over 980 transfers have been avoided, resulting in a savings of $7.85 million. Figure 7 breaks down the types of complaints routinely handled by the eED.
Figure 7.
illustrates the frequency of problems handled by the eEmergency program
The eEmergency program has illustrates the frequency of problems handled by the eEmergency program expanded to include the initiation of several quality improvement programs with major clinical effect on the region. One example includes what is called the “Chest Pain Initiative.” Because the eED is often involved in cases before the local provider has arrived, important diagnostic tests and critical therapies can be initiated that in the past may have been delayed. As an example the program has documented improvement in “door to ECG” times. After implementation of eED project, the median time to ECG has improved and now exceeds the Centers for Medicare and Medicaid Services (CMS) standard of ten minutes as shown in Figure 8.
Another component of the illustrates the improvement in median time to ECG for patients with chest pain presenting to emergency departments in the region due to assistance from eEmergency services.Chest Pain Initiative was improvement in aspirin administration. After the eED project was implemented, participating sites were noted to have 100 percent compliance with established guidelines for aspirin administration. Historically, these hospitals reported compliance as low as 67 percent
Avera Health Quality Department Data (2011).
. Other important outcomes impacted included significant decrease in the time to transfer and the increase in use of thrombolytics for care in the appropriately screened and eligible candidates. This number is at 100 percent.
Figure 8.
illustrates the improvement in median time to ECG for patients with chest pain presenting to emergency departments in the region due to assistance from eEmergency services.
eLong Term Care (eLTC) has developed as an outgrowth of eED, and uses telemedicine technologies to improve long term care staff and residents’ access to providers and specialty services in a manner that is high quality, convenient, and low cost. The goal of the program is to provide urgent care services to residents of long term care facilities in an effort to prevent emergency department visits and hospital admissions. This program was launched as a pilot project in January 2012 at four sites, and is currently available in six sites. In the first year of pilot, 120 residents were seen by the eLTC provider. Of these, 30 percent (36 encounters) resulted in an avoided a transfer to the emergency department or clinic. As an additional component of the service, specialist care via eConsult is available to residents in participating facilities. Grant support to be described below has assisted in innovating in this branch of telemedicine.
eAccess in Correctional Facilities has also developed as an outgrowth of eED. In this program, telemedicine technology is used to provide physician-directed urgent care services to inmates, resulting in a reduction of unnecessary and costly transfers. This pilot was launched in May 2012 at four sites. In the first twelve months of service, 372 patients have been served, with thirty-two percent of those encounters resulting in an avoided transfer. The distribution of complaints handled by the virtual physicians was similar to one shown above for the eEmergency program as a whole.
2.2. Major lessons learned and challenges
Credentialing and licensure for all these telemedicine services requires considerable amount of time and perseverance. Avera eCARETM medical providers are licensed in every state where eCARE services are provided. In addition, medical providers must apply for, and be granted, medical privileges in each hospital in which services are provided. Nursing licensure is no less challenging. Several states in which eCARE services are provided participate in the Nurse Licensure Compact. In these states, licensure in one participating state covers the nurse when he or she is working in other participating states. South Dakota, Iowa, Nebraska, and North Dakota are all compact members. Separate full, unrestricted nursing licenses are needed in Minnesota, Montana, and Wyoming. Nursing staff is not required to apply for any privileges in any of the hospitals currently served.
Two different processes are used for credentialing and privileging, the traditional process that has been in place for many years, and a newer telemedicine application process. Approximately fifty percent of hospitals receiving eCARE services have adopted the telemedicine credentialing/privileging process. The other fifty percent have chosen to continue with the traditional route for a variety of reasons including preference for the existing method and the unsure nature of state and federal survey teams’ reception of this new process.
The ePharmacy staff of hospital-trained pharmacists are licensed in each state where ePharmacy services are provided. Licensure is highly regulated by each state’s Board of Pharmacy. Most of these states require a separate written exam before granting a license. Credentialing and privileging is not required for pharmacists.
2.3. Funding Sources
Avera Health member hospitals and clinics have long been financially supportive of the telemedicine mission. Through the innovative thinking of Avera leaders, telemedicine has been considered a strategic part of Avera’s future and has been budgeted for accordingly. In addition to internal financial support, various granting agencies have provided funding for the implementation and growth of many eCARE programs. These agencies have ranged from the local, state and federal government, foundations of publicly traded companies, as well as private local and national foundations. Without this generous support, telemedicine expansion on such a broad scale would have been difficult, if not impossible. We will summarize some of eCARE’s past grant awards and funding opportunities below.
The United States Department of Agriculture (USDA) has funded seven grants exceeding $2.7 million to expand various Avera eCARETM programs. In addition, private foundations focused on rural healthcare have provided financial resources to operationalize some a variety of eCARE programs. One particular grant from a private foundation has allowed for greater collaboration between individual Avera eCARETM services. eCARE services that were once scattered across a large medical campus are now able to function as a fully integrated virtual hospital, housed in a state-of-the-art building miles from any traditional hospital walls. This new location allows Avera to provide telemedicine based care in a much more cohesive and supportive manner. This new super-hub is called the Avera eHelmTM. The eHelm serves as an incubator for new and innovative telemedicine programs and services by allowing and facilitating dialog and cross-fertilization of existing telemedicine experts.
In 2012, an Avera community hospital was awarded a grant from the Health Resources and Services Administration (HRSA) Office of Rural Health Policy to expand the eLong Term Care program to an additional sixteen centers.
2.4. Awards
Avera’s telemedicine efforts have been recognized by several national health organizations looking to reform and improve health care. In 2009, Avera was awarded the American Telemedicine Association’s President’s Institutional Award for leadership in telemedicine. Avera has received thirteen “HealthCare’s Most Wired” awards from a consortium that includes McKesson, AT&T, and Care Tech Solutions, in cooperation with the College of Healthcare Information Management Executives, the American Hospital Association, and Health and Health Network (H&HN) magazine. Avera also won one of three 2011 & 2012 “Most-Wired Innovator” awards and was recognized for this accomplishment at the 2011 and 2012 American Hospital Leadership Summits. Avera eCARE was recognized as a finalist for the Monroe E. Trout Premier Cares award in January, 2012, and was nominated for a Catholic Health Association of the United States award in 2013. eCARE has also been recognized internally for its impact on quality of care, and has received three Avera Quality Congress awards; one for ePharmacy, one for eEmergency and another for the eEmergency Chest Pain Initiative.
3. The future –A paradigm shift
The proliferation of different virtual health services in Avera’s comprehensive telemedicine program is illustrated in Figure 9. Telemedicine can be used to supplement each phase of the health care continuum. Telemedicine has evolved in the North Central Plains region as a program that supports the entire continuum from primary care, emergency care, critical care, multiple pharmaceutical interventions, and a nascent follow-up program in long term care facilities.
Figure 9.
illustrates the complete continuum of telemedicine services which now exist and are co-located in a single hub such as the Avera eHelm which coordinates and enhances patient care.
Figure 10 illustrates the illustrates the complete continuum of telemedicine services which now exist and are co-located in a single hub such as the Avera eHelm which coordinates and enhances patient care “air traffic control” model of telemedicine utilization, where telemedicine providers serve as back up for the other components of the continuum. While this may be the case in some urban settings, rural areas might utilize telemedicine in a formal role in direct patient care, leading a local medical team from a remote location. Remote telemedicine care may actually provide total first line diagnosis and therapies in the near future.
Figure 10.
illustrates the important “air traffic control” or back up capability of telemedicine for each phase in the health care continuum..
To this end, illustrates the important “air traffic control” or back up capability of telemedicine for each phase in the health care continuum.Avera eCARETM is planning for a major shift in healthcare delivery in the future.
A paradigm shift in health care delivery is being driven by the expansion of telemedicine services. The progression of innovation in telemedicine, especially in remote areas (rural parts of the United States, Third World Countries, Emerging Nations), which cannot develop a full medical infrastructure on their own, will turn to “The Virtual Hospital, The New Doctor’s Office, and the New Continuity Service”, all expansions of mature telemedicine centers.
Instead of increased numbers of brick and mortar tertiary centers to which patients travel, now there is the possibility of a virtual electronic hub to provide tertiary hospital services to remote sites as they currently exist. In effect, telemedicine brings the tertiary care hospital to the patient. Reduced costs of transfer of patients, improved patient and family satisfaction, increased access to specialists and especially rare sub-specialist consultation are all the byproducts of a robust and integrated telemedicine program. Implementation of improved wireless (cellular) technology to allow remotely controlled medical machines such as mechanical ventilators, dialysis equipment, and robotic care is likely imminent as an augmentation of such a tertiary care eHospital. In addition, the challenges of local staffing, supply, and power all need to be addressed as unique challenges.
Another trademark of a highly integrated telemedicine program lies in the doctor’s office. In a specialist’s office there would be a synthesis of activity which allows more active inclusion of telemedicine into practice. A patient might be seen physically in an exam room next to a telemedicine patient in the next exam room. This seamless integration of telemedicine work stations into the flow of patient care would allow the doctor to see any patients regardless of their location. Physician time could be, and in some cases is, divided equally and seamlessly between time spent with physically present patients and virtual patients. In the future, the physician may also be located remotely seeing patients at all locations via telemedicine.
Electronic continuity services could include nontraditional settings such as long term care facilities, correctional facilities, and expanded telemedicine home-based services. In these new and dynamic locations the goal of telemedicine is to continue to monitor compliance with discharge instructions, meticulously supervise proper medication intake at home or in the facility in which the patient resides, and to ensure timely follow up with the primary medical provider and any needed specialists. This system would be designed to prevent errors, relapses, or delays in follow up which might lead to unnecessary emergency visits, hospitalizations, and premature relapses in medical problems.
Finally,\n\t\t\t\t\tFigure 11 illustrates how such complete telemedicine services may expand beyond health systems and rural neighbors. It could even result in global extension of successful telemedicine systems of medical care. A telemedicine program with multiple services could be located together in a core such as the Avera eHelmTM. These hubs could just as easily and efficiently provide telemedicine care to the ends of the earth and beyond as they could in the same city or building. Home care, concierge care, doctor’s office care, medical home care, urgent care, emergency department care, behavioral health care, general hospital care, specialty hospital care (behavioral health, cardiac, orthopedic), intensive care, long term hospital care (LTHC), and others could be connected to a core like the Avera eHelmTM providing telemedicine care and coordination with its multiple primary care and specialty allied health members, nurses, and physicians.
Figure 11.
illustrates a model of global care coordinated by multiple electronic telemedicine programs coordinated by a core of expert telemedicine caregivers located in a core such as the Avera eHelmTM.
In summary, to illustrates a model of global care coordinated by multiple electronic telemedicine programs coordinated by a core of expert telemedicine caregivers located in a core such as the Avera eHelmTM.date more than 153,000 patients have been touched by at least one Avera eCARETM service. More than 165 hospitals and clinics across a 495,000 square mile service use at least one Avera eCARETM service. At the present 650 providers are served by Avera eCARETM. The total financial impact has been greater than 55 million dollars.
The future goals of Avera eCARETM includes a plan to create virtual support for hospitals, clinics, long term care facilities and other nontraditional care locations to provide access to care at the same level of quality available in urban settings. In addition, Avera is exploring a robust home monitoring and coaching system of care that enables providers to interact with chronically ill patients in their home environments. These steps will create a virtual support for patient centered medical homes.
In conclusion, the success of these multiple diverse telemedicine programs in the rural region of the North Central United States has been a result of trying to meet the needs for health care in this area. Telemedicine has been well received due to many factors, including the remoteness of many communities, the frequently inclement weather which impairs urgent face-to-face health care, the lack of health care resources in the agricultural economy, and the extremely low number of specialty and subspecialty providers located these states. The success of Avera eCARE has not gone unnoticed. Many have asked to learn how to duplicate some or all of Avera models of comprehensive telemedicine.
Today and in the future, Avera will continue to leverage technology to connect with our North Central USA population, to engage the people of this rural region in prevention and in provision of care and services on the go and where they live. Finally, Avera will partner with stakeholders who will join in the advancement of innovation, research and policy for telemedicine practice and reimbursement.
The Avera eCareTM Research Group also includes: Jay Weems, Srivedi Gangineni MD, Scott Deppe MD, David Kovaleski, MD, Sarah Kappel CCRN, Tami Schnetter CCRN, Andrea Darr Pharm.D., Deanna Larson RN, David Erickson MD.
Acknowledgments
The authors wish to thank the Avera eCareTM Research Group which also includes: Jay Weems, Srivedi Gangineni, Scott Deppe, David Kovaleski, Sara Kappel, Tami Schnetter, Andrea Darr, Deanna Larson, David Erickson
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Avera Health Intensivists/eICU, USA
Department of Internal Medicine, University of South Dakota Sanford School of Medicine, South Dakota, USA
Department of Internal Medicine, University of South Dakota Sanford School of Medicine, South Dakota, USA
Avera eICU, South Dakota, USA
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1. Introduction
Agave sisalana Perr. ex. Engelm is a monocotyledonous, xerophytic, succulent plant that belongs in the Asparagaceae family. The genus Agave has more than 200 species, and Mexico is their centre of origin and dispersion, where they have high economic importance and several industrial applications [1, 2]. This genus is able to grow in different conditions, as well as to show excellent adaptation to environments with warm climate, high luminosity and prolonged droughts [3, 4]. Tolerance to abiotic stresses is a striking feature of A. sisalana, which confers good performances to this species under conditions that limit the development of most plants [4]. This tolerance is related to morphological and physiological characteristics, such as the CAM metabolism (crassulacean acid). This type of metabolism allows for greater efficiency in water use, higher carbon uptake during the night and low nutritional demand when compared to C3 and C4 plants [1, 5, 6, 7].
Sisal is a monocarpic plant, and the emission of an inflorescence characterises the end of its vegetative cycle, which can occur between 8 and 30 years. The plant multiplies vegetatively through bulbils produced on the inflorescence pole or by stolons that emerge from the rhizome (subterraneous stem) of adult plants. The use of bulbils is the most common form of propagation, but stolons can also be used. The production of seeds is rare, and induction techniques are necessary when this is the objective [8, 9, 10]. Most species of Agave are highly endemic and have high levels of genetic variation within populations and low differentiation between populations [11]. This limited diversity hinders the establishment of germplasm banks and the search for genes that confer desirable characteristics to these plants.
Agave sisalana is a good producer of hard natural fibres [1]. The fibre extracted from this plant occupies the sixth position of importance and represents 2% of the world production of plant fibres [12]. This product is extracted from the leaves of the plant and is traditionally used in the manufacture of cords and ropes [9]. In addition, it is widely used in various industrial sectors. Amongst several applications, sisal fibre has been increasingly used in the reinforcement of building materials, furniture, panels and automobile upholstery [1, 12, 13]. In addition to the various applications and industrial uses, sisal fibre has advantages over synthetic fibres for having lower density (lighter) and lower production cost and is biodegradable and recyclable. Therefore, the use of sisal fibre fits in the growing world tendency that favours the use of sustainable natural resources with less environmental impact [14, 15].
There has been a growing interest in the use of waste or by-products from Agave species in biotechnological processes [16, 17]. After fibre extraction the residue is usually discarded [18]. This residue accounts for 98% of the total biomass of the plant and has potential to be used as raw material for biofuels, especially because it is not directly used as food [6, 12, 19]. In order to exploit the economic value of this material, a joint initiative between the Common Fund for Commodities, the United Nations Industrial Development Organization (UNIDO) and the Tanzanian sisal industry financed the first commercial plant for the production of biogas [12]. In addition to some medicinal properties reported [20, 21], A. sisalana also produces compounds that have different biological properties [18] of great interest in the pharmaceutical industry such as hecogenin [12, 21, 22, 23]. All of the above features place sisal as a strategic species to be exploited in tropical semiarid regions and in temperate latitudes with drought resulting from global climate change [16, 19, 24].
The main world producers of sisal fibre are Brazil, Tanzania, China, Kenya and Madagascar [25]. Other countries, such as Mexico, South Africa, Mozambique, Angola, Indonesia, Thailand, Haiti and Cuba, also produce but in smaller quantities. According to FAO reports, in 2011 Brazil alone produced more than 111 thousand tons of sisal fibre [12].
In Brazil, the semiarid region of Bahia province (northeastern Brazil) is responsible for more than 95% of the country’s sisal production [26]. Other provinces that produce smaller amounts of sisal in Brazil are Paraiba, Rio Grande do Norte and Ceará [27]. It is estimated that more than 150,000 families are directly linked to the producing chain of this crop, totalling more than 700,000 small farmers, and more than half a million direct and indirect jobs are involved in activities related to the maintenance, harvesting, extraction and processing of fibre [28, 29, 30]. In this sense, sisal has an important economic and social role of the semiarid region of Brazil.
Sisal management is simple because this plant exhibits tolerance to various abiotic stresses. Even under minimal management conditions, the plant presents good development and consequently good fibre production, with low nutritional requirements [12]. However, although it presents all these adaptive advantages to stress conditions, the main problem is of phytosanitary origin. Sisal bole rot, the main disease of sisal, has caused considerable damage to the crop [31]. This disease causes the death of infected plants, and despite the economic and social importance of sisal, there are few government efforts to control the disease.
In this chapter we introduce the sisal bole rot disease, a neglected disease that represents the main challenge for sisal production in Brazil and other countries of the world. In addition, we discuss some aspects involved in its symptomatology, aetiology, epidemiology and management. The majority of the results that will be shown were obtained in Brazil, where most of the research on sisal bole rot was done.
2. Bole rot disease: symptoms and epidemiology
The disease was first reported in production areas of Tanzania and Brazil [31, 32]. In Brazil, since the 1990s, the commercial production of sisal has been declining due to economical crises and the occurrence of this disease [33]. Diseased plants produce leaves that are not suitable for fibre extraction as they lose their turgescence, and although these diseased plants survive for some time, they die with the progress of the disease (Figure 1) [35]. Plants at advanced stages of the disease are easily identified by the symptoms, which include wilting and yellowing of the aerial part (Figure 1A). The main internal symptom of the disease is rotting of the stem with reddening of the tissues, a response of the plant to fungal colonisation. It is thought that there is no relationship between the phenological stage of the plant and the establishment of the disease, since the fungus is capable of infecting both plantlets (Figure 2E) and adult plants (Figures 1 and 2).
Figure 1.
Adult sisal plants under field conditions. (A) Healthy adult plant (white arrow) after leaf harvest for fibre extraction next to an adult plant showing the external symptoms of sisal bole rot (red arrow). The diseased plant has wilted and yellowish leaves that cannot be used for fibre extraction and therefore was not harvested. (B) and (C) Plants killed by the pathogen.
Figure 2.
Sisal plantlets with symptoms of sisal bole rot under greenhouse conditions. (A) Healthy sisal plantlets and (B) diseased plantlet with symptoms of sisal bole rot. (C) Stem of healthy plant. (D, F and G) Intermediate symptoms of sisal bole rot, characterised by rotting of the stem. (E and H) Dead plants. The white arrow indicates the production of conidia after colonisation of plant tissues.
It was reported that the pathogen depends on mechanical injuries and natural openings, mainly on physiologically stressed plants, to start the infection process [32]. In this sense, it is possible that wounds made by insects or by tools used in crop management, such as harvest of the leaves and cultural practices, are ways of pathogen penetration [32, 35, 36]. The histopathology of diseased plants showed that the pathogen penetrates the tissues of the host from the outside, that is, from the epidermis to the parenchyma and later to the central cylinder of the plant [37].
Abreu [36] studied the spatiotemporal distribution of sisal bole rot in producing areas of Bahia Province, Brazil, and found that the disease was present in all the studied farms (prevalence of 100%) and, on average, 35% of the plants were infected by the pathogen. This study also showed that the distribution of the disease occurs randomly in the cultivated areas [36]. In the case of sisal bole rot, incidence evaluations are more important than severity, as there are no measures that slow down the progress of the disease.
The lack of more studies on epidemiological aspects of sisal bole rot in different areas where the disease occurs directly impacts the establishment of phytosanitary management practices. More information on these aspects could contribute to the development of strategies to reduce the incidence of the disease. For the moment, what is known is that preventive measures should be employed to avoid the establishment of the pathogen in the area.
3. Causal agents
The disease was first observed in areas of sisal production in Tanzania in the 1930s but was only reported in the 1950s [32]. The causal agent was isolated from diseased plant parts and identified as Aspergillus niger. In this study, the authors reported fruiting bodies of A. niger in exposed plant tissues and also pointed out that the occurrence of the disease was linked to environmental conditions and the nutritional status of the plant [32]. The first report of this disease in Brazil also occurred in the 1950s, when Machado [38] described a rot of the base of sisal stem in the province of Paraíba, Brazil [39]. In Bahia, the largest sisal-producing province in Brazil, the disease was first noticed in a commercial plantation by researchers from the Agency for Agricultural Development of Bahia (EBDA) and Embrapa Semiárido (Brazilian Agricultural Research Institute) in the municipality of Santaluz [33].
In Tanzania and in Brazil, the disease was initially associated with the species A. niger. The aetiology of the disease was determined by Koch’s postulates from tissue fragments of diseased sisal plants [40]. Species of the genus Aspergillus are filamentous fungi belonging in the phylum Ascomycota [41]. Aspergillus niger and other closely related species form a cluster of morphologically similar species, collectively known as the section Nigri (Figure 3). The Nigri section is comprised of 27 valid species that contain the A. niger complex (Figure 3). All these species have as main characteristic the formation of black-coloured conidia, uniseriate or biseriate conidiophores and dark colonies (Figure 4) [42]. The taxonomy of the section Nigri is very complex because many species of this group are difficult to distinguish morphologically [41]. The morphological criteria were the only ones used to identify these species for a long time, and for this reason, many species were misidentified [43, 44].
Figure 3.
Phylogenetic tree of the 27 valid species belonging in the Nigri section of Aspergillus. The red circles indicate species shown to cause sisal bole rot in the A. niger complex. The tree was constructed with sequences of the calmodulin gene, with 456 nucleotides aligned using the maximum likelihood (ML) method and the K2 + G + I substitution model. The bootstrap analysis was performed with 1000 resamplings. The scale represents the number of substitutions per site.
Figure 4.
Macro- and micromorphology of Aspergillus welwitschiae isolated from diseased sisal plants. (A) Obverse and reverse of a plate containing mycelial growth of colony on Blakeslee’s malt extract (MEAbl), growing at 25oC for 7 days. (B) Conidiophores of A. welwitschiae and (C) conidia. Scale bars =10 μm.
The polyphasic taxonomy integrates molecular, physiological, metabolite production and morphological data for the identification and description of new species of the section Nigri [45, 46, 47, 48]. The regions recommended for the identification and description of species in the genus Aspergillus are fragments of the ITS region of the ribosomal DNA, calmodulin (caM), beta-tubulin (benA) and the beta subunit of the RNA polymerase (rpb2). However, caM sequences were proposed as the most informative markers for the section Nigri [49]. The gene benA is very informative for the uniseriate/aculeatus clade; however, care must be taken not to use the wrong set of primers (Bt2a/Bt2b) that can also amplify tubC, a paralog of benA, resulting in misidentification. The alternative primer pair ben2f/Bt2b should be used instead [50]. The other methods used in the polyphasic approach include growth on different media and temperatures, production of secondary metabolites and measurement of all fungal structures [44, 45].
The initial studies implicated only A. niger as the cause of bole rot disease because the authors only took the morphological features of the pathogen into account [32, 40]. Further studies including sequences of the ITS region of the ribosomal DNA and a fragment of the transcription and elongation factor of the RNA polymerase (tef1-alpha) also identified A. brasiliensis and A. tubingensis in addition to A. niger as agents of the disease [31]. Recently, Duarte et al. [37] identified molecular phylogeny strains of Aspergillus sp. of the section Nigri obtained from diseased plants using a fragment of the calmodulin gene and proposed that A. welwitschiae and not A. niger is the causal agent of sisal bole rot disease. However, these authors did not include A. niger in their study, and therefore, further investigations are still needed to evaluate the ability of other species in the section Nigri to cause the disease, including A. niger.
4. Disease management
There are no effective control methods available for bole rot disease [51]. Mechanical lesions are used by the pathogen as penetration sites, and this has direct implications for crop management since leaf harvest causes wounds in the plant [32, 36]. Additionally, the pathogen may be spread through the use of tools contaminated in diseased plants.
Most farmers use plantlets from stolons to establish new plantations, and infected plant material contributes to the spread of the disease to new areas. Therefore, the establishment of new areas using healthy plant material is thought to be one of the most effective ways to prevent the introduction of the pathogen. Removal and destruction of diseased plants from the plantations, balanced fertilisation to prevent stresses and disinfestation of the tools used in diseased plants are other measures recommended to decrease the incidence and avoid the spread of the disease to new areas [52].
Another method investigated to manage the disease is the use of antagonistic microorganisms [53, 34]. Chemical control was never investigated probably because the causal agents are soilborne fungi and farmers have little financial resources. Biological control is an environmentally friendly and viable method to control plant pathogens [54, 45]. Antagonistic bacteria were shown to have potential to control the bole rot disease [53, 34]. Several strains of an undescribed species of Burkholderia and strains of Bacillus decreased the incidence and severity of the disease under field conditions (Figures 5 and 6) [53, 34]. Therefore, it is possible to establish programmes aimed at the development of biological products to manage the disease in the field.
Figure 5.
Management of sisal bole rot disease with antagonistic bacteria. (A) and (B) Plantlets treated with Burkholderia sp. and inoculated with the pathogen A. welwitschiae in the field. (C) and (D) Sisal plants inoculated with A. welwitschiae only under field conditions (positive control).
Figure 6.
Incidence of sisal bole rot disease by the application of Burkholderia and Bacillus strains under field conditions. The means represent 25 replicates per treatment. The negative control was treated with water only (CT-) and positive control with A. welwitschiae (CT+). Error bars represent the standard error of the means.
5. Outlook
Little is known about the mechanisms used by the pathogen to infect the plant, although Aspergillus shows a typical necrotrophic behaviour [37]. More information on the pathogenicity mechanisms could be obtained by the use of omics tools, such as RNAseq, to identify genes expressed by the pathogen during infection. Other microorganisms can influence the establishment and progress of the disease, and in this sense it will be interesting to study the comparative microbiome of diseased and healthy plants. This information may be used to engineer the microbiome to keep the plants healthy, as it has been attempted for other agricultural crops [55].
Sisal bole rot cannot be controlled by any single method, and therefore, the integration of control measures must be adopted. Resistant cultivars are not available for this crop, and unfortunately there are no breeding programmes focusing on sisal bole rot [9]. Breeding programmes are limited by the low genetic diversity of natural populations out of Mexico.
Preventive measures are thought to be the most effective ways to control bole rot, and these include (i) the use of healthy planting material, (ii) balanced fertilisation to avoid nutritional stresses and (iii) maintaining adequate soil humidity levels to avoid physiological imbalances [52]. When these measures are not able to contain the pathogen, removal of diseased plants is recommended to decrease the source of inoculum of the pathogen [52]. One challenge in this regard is the development strategies to identify diseased plants before the dispersal of pathogen propagules.
Sisal residues are commonly used to fertilise plants in the field [52], but only the fermented residue is suitable for this purpose as fresh residues stimulate the spread of the pathogen [56]. Information such as these could be disseminated to farmers to contribute to the management of the disease. Sisal farmers in many parts of the world do not have access to information on the technical aspects of sisal, depend on familiar labour and have little financial resources to invest in the crop. The information generated so far on the management of the disease through the use of antagonistic bacteria are promising, but it is still necessary to develop it into products that can be used by the farmers. New studies aiming at formulating and distributing biological products should be encouraged to contribute to the sustainability of this crop in the long run. The general lack of research on bole rot classifies it as a neglected disease that deserves more attention from research institutes and the government.
Acknowledgments
The authors thank the Brazilian agencies CNPq and CAPES for the financial support.
\n',keywords:"Aspergillus welwitschiae, Agave sisalana, biological control, disease management, semiarid regions",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/68015.pdf",chapterXML:"https://mts.intechopen.com/source/xml/68015.xml",downloadPdfUrl:"/chapter/pdf-download/68015",previewPdfUrl:"/chapter/pdf-preview/68015",totalDownloads:922,totalViews:0,totalCrossrefCites:0,dateSubmitted:"January 30th 2019",dateReviewed:"May 21st 2019",datePrePublished:"July 9th 2019",datePublished:"April 15th 2020",dateFinished:"July 9th 2019",readingETA:"0",abstract:"Sisal (Agave sisalana) is one of the main sources of hard natural fibre and raw materials for the industry, medicine and handicrafts. Sisal yields a coarse and strong fibre that is increasingly being used in composite materials for automobiles, furniture, construction and plastic and paper products. Extracts of sisal contain substances with anti-inflammatory, antimicrobial and anthelmintic activities. Sisal is adapted to warm environments with low rainfall and is an excellent option for cultivation in semiarid conditions, where other crops cannot be grown. The world’s largest sisal producers are Brazil, Tanzania, China, Kenya and Madagascar. Sisal is a labour-intensive crop with great socio-economical importance as it is cultivated in poor areas employing familiar labour. Sisal bole rot is the main disease of sisal, responsible for substantial losses in producing countries. The disease is caused by certain species of the genus Aspergillus, especially the ones belonging in the section Nigri. The main symptoms are yellowing of the aerial parts and the red-coloured rot of the bole, which causes the plant to die. In this review we are going to address the taxonomy of the causal agents, disease diagnosis and epidemiology and disease management, with emphasis on biological control.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/68015",risUrl:"/chapter/ris/68015",signatures:"Valter Cruz-Magalhães, Jackeline Pereira Andrade, Yasmim Freitas Figueiredo, Phellippe Arthur Santos Marbach and Jorge Teodoro de Souza",book:{id:"8814",type:"book",title:"Plant Diseases",subtitle:"Current Threats and Management Trends",fullTitle:"Plant Diseases - Current Threats and Management Trends",slug:"plant-diseases-current-threats-and-management-trends",publishedDate:"April 15th 2020",bookSignature:"Snježana Topolovec-Pintarić",coverURL:"https://cdn.intechopen.com/books/images_new/8814.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-78985-116-8",printIsbn:"978-1-78985-115-1",pdfIsbn:"978-1-78984-698-0",isAvailableForWebshopOrdering:!0,editors:[{id:"66211",title:"Prof.",name:"Snježana",middleName:null,surname:"Topolovec-Pintaric",slug:"snjezana-topolovec-pintaric",fullName:"Snježana Topolovec-Pintaric"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Bole rot disease: symptoms and epidemiology",level:"1"},{id:"sec_3",title:"3. Causal agents",level:"1"},{id:"sec_4",title:"4. Disease management",level:"1"},{id:"sec_5",title:"5. Outlook",level:"1"},{id:"sec_6",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",body:'Nava-Cruz NY, Medina-Morales MA, Martinez JL, Rodriguez R, Aguilar CN. Agave biotechnology: An overview. Critical Reviews in Biotechnology. 2015, 2015;35:546-559. DOI: 10.3109/07388551.2014.923813'},{id:"B2",body:'Trejo-Torres JC, Gann GD, Christenhusz MJ. The Yucatan Peninsula is the place of origin of sisal (Agave sisalana, Asparagaceae): Historical accounts, phytogeography and current populations. Botanical Sciences. 2018;96:366-379. DOI: 10.17129/botsci.1928'},{id:"B3",body:'Pinos-Rodríguez JM, Zamudio M, González SS, Mendoza GD, Bárcena R, Ortega ME, et al. Effects of maturity and ensiling of Agave salmiana on nutritional quality for lambs. 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DOI: 10.1007/978-0-387-92207-2'},{id:"B44",body:'Samson RA, Houbraken JAMP, Kuijpers AFA, Frank MJ, Frisvad JC. New ochratoxin A or sclerotium producing species in Aspergillus section Nigri. Studies in Mycology. 2004;50:45-61'},{id:"B45",body:'Varga J, Kocsubé S, Tóth B, Frisvad JC, Perrone G, Susca A, et al. Aspergillus brasiliensis sp. nov., a biseriate black Aspergillus species with world-wide distribuition. International Journal of Systematic and Evolutionary Microbiology. 2007;57:1925-1932. DOI: 10.1099/ijs.0.65021-0'},{id:"B46",body:'Noonim P, Mahakarnchanakul W, Varga J, Frisvad JC, Samson RA. Two novel species of Aspergillus section Nigri from Thai coffee beans. International Journal of Systematic and Evolutionary Microbiology. 2008;58:1727-1734. DOI: 10.1099/ijs.0.65694-0'},{id:"B47",body:'Oliveri C, Torta L, Catara VA. Polyphasic approach to the identification of ochratoxin A-producing black Aspergillus isolates from vineyards in Sicily. 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Available from http://sistemasdeproducao.cnptia.embrapa.br/FontesHTML/Sisal/CultivodoSisal/doencas.html [Accessed: 25 May 2010]'},{id:"B52",body:'Suinaga FA, Silva ORRF, Coutinho WM. Cultivo de sisal na região Semi-árida do Nordeste Brasileiro. Campina Grande, Brazil; 2006. p. 44'},{id:"B53",body:'Magalhães VC, Barbosa LO, Andrade JP, Soares ACF, de Souza JT, Marbach PAS. Burkholderia isolates from a sand dune leaf litter display biocontrol activity against the bole rot disease of Agave sisalana. Biological Control. 2017;112:41-48. DOI: 10.1016/j.biocontrol.2017.06.005'},{id:"B54",body:'Baker KF. Evolving concepts of biological control of plant pathogens. Annual Review of Phytopathology. 1987;25:67-85'},{id:"B55",body:'Mueller UG, Sachs JL. Engineering microbiomes to improve plant and animal health. Trends in Microbiology. 2015;23:606-617. DOI: 10.1016/j.tim.2015.07.009'},{id:"B56",body:'do Carmo CO, Tavares PF, da Silva RM, Damasceno CL, Sá JO, Soares ACF. Fatores que afetam a sobrevivência de Aspergillus niger e sua relação com a podridão vermelha do caule do sisal. Magistra. 2018;29:144-153'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Valter Cruz-Magalhães",address:null,affiliation:'
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In recent years, the application of chemistry to biological molecules has gained significant interest in medicinal and pharmacological studies. This topic will be devoted to understanding the interplay between biomolecules and chemical compounds, their structure and function, and their potential applications in related fields. Being a part of the biochemistry discipline, the ideas and concepts that have emerged from Chemical Biology have affected other related areas. 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Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. Dr. Beydemir is also Rector of Bilecik Şeyh Edebali University, Turkey.",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",slug:"deniz-ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",biography:"Dr. Deniz Ekinci obtained a BSc in Chemistry in 2004, MSc in Biochemistry in 2006, and PhD in Biochemistry in 2009 from Atatürk University, Turkey. 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\r\n\tTransforming our World: the 2030 Agenda for Sustainable Development endorsed by United Nations and 193 Member States, came into effect on Jan 1, 2016, to guide decision making and actions to the year 2030 and beyond. Central to this Agenda are 17 Goals, 169 associated targets and over 230 indicators that are reviewed annually. The vision envisaged in the implementation of the SDGs is centered on the five Ps: People, Planet, Prosperity, Peace and Partnership. This call for renewed focused efforts ensure we have a safe and healthy planet for current and future generations.
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\r\n\t
\r\n
\r\n\tThis Series focuses on covering research and applied research involving the five Ps through the following topics:
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\r\n\t
\r\n
\r\n\t1. Sustainable Economy and Fair Society that relates to SDG 1 on No Poverty, SDG 2 on Zero Hunger, SDG 8 on Decent Work and Economic Growth, SDG 10 on Reduced Inequalities, SDG 12 on Responsible Consumption and Production, and SDG 17 Partnership for the Goals
\r\n
\r\n\t
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\r\n\t2. Health and Wellbeing focusing on SDG 3 on Good Health and Wellbeing and SDG 6 on Clean Water and Sanitation
\r\n
\r\n\t
\r\n
\r\n\t3. Inclusivity and Social Equality involving SDG 4 on Quality Education, SDG 5 on Gender Equality, and SDG 16 on Peace, Justice and Strong Institutions
\r\n
\r\n\t
\r\n
\r\n\t4. Climate Change and Environmental Sustainability comprising SDG 13 on Climate Action, SDG 14 on Life Below Water, and SDG 15 on Life on Land
\r\n
\r\n\t
\r\n
\r\n\t5. Urban Planning and Environmental Management embracing SDG 7 on Affordable Clean Energy, SDG 9 on Industry, Innovation and Infrastructure, and SDG 11 on Sustainable Cities and Communities.
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\r\n\t
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\r\n\tThe series also seeks to support the use of cross cutting SDGs, as many of the goals listed above, targets and indicators are all interconnected to impact our lives and the decisions we make on a daily basis, making them impossible to tie to a single topic.
",coverUrl:"https://cdn.intechopen.com/series/covers/24.jpg",latestPublicationDate:"May 26th, 2022",hasOnlineFirst:!0,numberOfOpenTopics:4,numberOfPublishedChapters:12,numberOfPublishedBooks:0,editor:{id:"262440",title:"Prof.",name:"Usha",middleName:null,surname:"Iyer-Raniga",fullName:"Usha Iyer-Raniga",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRYSXQA4/Profile_Picture_2022-02-28T13:55:36.jpeg",biography:"Usha Iyer-Raniga is a professor in the School of Property and Construction Management at RMIT University. Usha co-leads the One Planet Network’s Sustainable Buildings and Construction Programme (SBC), a United Nations 10 Year Framework of Programmes on Sustainable Consumption and Production (UN 10FYP SCP) aligned with Sustainable Development Goal 12. The work also directly impacts SDG 11 on Sustainable Cities and Communities. She completed her undergraduate degree as an architect before obtaining her Masters degree from Canada and her Doctorate in Australia. Usha has been a keynote speaker as well as an invited speaker at national and international conferences, seminars and workshops. Her teaching experience includes teaching in Asian countries. She has advised Austrade, APEC, national, state and local governments. She serves as a reviewer and a member of the scientific committee for national and international refereed journals and refereed conferences. She is on the editorial board for refereed journals and has worked on Special Issues. Usha has served and continues to serve on the Boards of several not-for-profit organisations and she has also served as panel judge for a number of awards including the Premiers Sustainability Award in Victoria and the International Green Gown Awards. Usha has published over 100 publications, including research and consulting reports. Her publications cover a wide range of scientific and technical research publications that include edited books, book chapters, refereed journals, refereed conference papers and reports for local, state and federal government clients. She has also produced podcasts for various organisations and participated in media interviews. She has received state, national and international funding worth over USD $25 million. Usha has been awarded the Quarterly Franklin Membership by London Journals Press (UK). Her biography has been included in the Marquis Who's Who in the World® 2018, 2016 (33rd Edition), along with approximately 55,000 of the most accomplished men and women from around the world, including luminaries as U.N. Secretary-General Ban Ki-moon. In 2017, Usha was awarded the Marquis Who’s Who Lifetime Achiever Award.",institutionString:null,institution:{name:"RMIT University",institutionURL:null,country:{name:"Australia"}}},subseries:[{id:"91",title:"Sustainable Economy and Fair Society",keywords:"Sustainable, Society, Economy, Digitalization, KPIs, Decision Making, Business, Digital Footprint",scope:"
\r\n\tGlobally, the ecological footprint is growing at a faster rate than GDP. This phenomenon has been studied by scientists for many years. However, clear strategies and actions are needed now more than ever. Every day, humanity, from individuals to businesses (public and private) and governments, are called to change their mindset in order to pursue a virtuous combination for sustainable development. Reasoning in a sustainable way entails, first and foremost, managing the available resources efficiently and strategically, whether they are natural, financial, human or relational. In this way, value is generated by contributing to the growth, improvement and socio-economic development of the communities and of all the players that make up its value chain. In the coming decades, we will need to be able to transition from a society in which economic well-being and health are measured by the growth of production and material consumption, to a society in which we live better while consuming less. In this context, digitization has the potential to disrupt processes, with significant implications for the environment and sustainable development. There are numerous challenges associated with sustainability and digitization, the need to consider new business models capable of extracting value, data ownership and sharing and integration, as well as collaboration across the entire supply chain of a product. In order to generate value, effectively developing a complex system based on sustainability principles is a challenge that requires a deep commitment to both technological factors, such as data and platforms, and human dimensions, such as trust and collaboration. Regular study, research and implementation must be part of the road to sustainable solutions. Consequently, this topic will analyze growth models and techniques aimed at achieving intergenerational equity in terms of economic, social and environmental well-being. It will also cover various subjects, including risk assessment in the context of sustainable economy and a just society.
",annualVolume:11975,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/91.jpg",editor:{id:"181603",title:"Dr.",name:"Antonella",middleName:null,surname:"Petrillo",fullName:"Antonella Petrillo",profilePictureURL:"https://mts.intechopen.com/storage/users/181603/images/system/181603.jpg",institutionString:null,institution:{name:"Parthenope University of Naples",institutionURL:null,country:{name:"Italy"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"179628",title:"Prof.",name:"Dima",middleName:null,surname:"Jamali",fullName:"Dima Jamali",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSAIlQAO/Profile_Picture_2022-03-07T08:52:23.jpg",institutionString:null,institution:{name:"University of Sharjah",institutionURL:null,country:{name:"United Arab Emirates"}}},{id:"170206",title:"Prof.",name:"Dr. Orhan",middleName:null,surname:"Özçatalbaş",fullName:"Dr. Orhan Özçatalbaş",profilePictureURL:"https://mts.intechopen.com/storage/users/170206/images/system/170206.png",institutionString:null,institution:{name:"Akdeniz University",institutionURL:null,country:{name:"Turkey"}}},{id:"250347",title:"Associate Prof.",name:"Isaac",middleName:null,surname:"Oluwatayo",fullName:"Isaac Oluwatayo",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRVIVQA4/Profile_Picture_2022-03-17T13:25:32.jpg",institutionString:null,institution:{name:"University of Venda",institutionURL:null,country:{name:"South Africa"}}},{id:"141386",title:"Prof.",name:"Jesús",middleName:null,surname:"López-Rodríguez",fullName:"Jesús López-Rodríguez",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRBNIQA4/Profile_Picture_2022-03-21T08:24:16.jpg",institutionString:null,institution:{name:"University of A Coruña",institutionURL:null,country:{name:"Spain"}}},{id:"208657",title:"Dr.",name:"Mara",middleName:null,surname:"Del Baldo",fullName:"Mara Del Baldo",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRLMUQA4/Profile_Picture_2022-05-18T08:19:24.png",institutionString:"University of Urbino Carlo Bo",institution:null}]},{id:"92",title:"Health and Wellbeing",keywords:"Ecology, Ecological, Nature, Health, Wellbeing, Health production",scope:"
\r\n\tSustainable approaches to health and wellbeing in our COVID 19 recovery needs to focus on ecological approaches that prioritize our relationships with each other, and include engagement with nature, the arts and our heritage. This will ensure that we discover ways to live in our world that allows us and other beings to flourish. We can no longer rely on medicalized approaches to health that wait for people to become ill before attempting to treat them. We need to live in harmony with nature and rediscover the beauty and balance in our everyday lives and surroundings, which contribute to our well-being and that of all other creatures on the planet. This topic will provide insights and knowledge into how to achieve this change in health care that is based on ecologically sustainable practices.
",annualVolume:11976,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/92.jpg",editor:{id:"348225",title:"Prof.",name:"Ann",middleName:null,surname:"Hemingway",fullName:"Ann Hemingway",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035LZFoQAO/Profile_Picture_2022-04-11T14:55:40.jpg",institutionString:null,institution:{name:"Bournemouth University",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"169536",title:"Dr.",name:"David",middleName:null,surname:"Claborn",fullName:"David Claborn",profilePictureURL:"https://mts.intechopen.com/storage/users/169536/images/system/169536.jpeg",institutionString:null,institution:{name:"Missouri State University",institutionURL:null,country:{name:"United States of America"}}},{id:"248594",title:"Ph.D.",name:"Jasneth",middleName:null,surname:"Mullings",fullName:"Jasneth Mullings",profilePictureURL:"https://mts.intechopen.com/storage/users/248594/images/system/248594.jpeg",institutionString:"The University Of The West Indies - Mona Campus, Jamaica",institution:null},{id:"331299",title:"Prof.",name:"Pei-Shan",middleName:null,surname:"Liao",fullName:"Pei-Shan Liao",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000032Fh2FQAS/Profile_Picture_2022-03-18T09:39:41.jpg",institutionString:"Research Center for Humanities and Social Sciences, Academia Sinica, Taiwan",institution:null}]},{id:"93",title:"Inclusivity and Social Equity",keywords:"Social contract, SDG, Human rights, Inclusiveness, Equity, Democracy, Personal learning, Collaboration, Glocalization",scope:"
\r\n\tThis topic is dedicated to the efforts and promotion of UNESCO SDG4, the UNESCO initiative on the future of education, and the need for a new social contract for education. It aims to disseminate knowledge on policies, strategies, methods, and technologies that increase the resilience and sustainability of the development of the future of education and the new social contract for education. It will also consider the global challenges such as globalization, demographic change, digital transformation, climate change, environment and the social pillars of sustainable development.
\r\n
\r\n\tResponses to the pandemic and the widespread discontent that preceded it must be based on a new social contract and a New Global Deal for education that ensures equal opportunities for all and respects all people’s rights and freedoms (UNESCO; 2021). Such a new social contract, as proposed by UNESCO, must be based on the general principles underlying human rights - inclusion and equality, cooperation and solidarity, and collective responsibility and interconnectedness - and be guided by the following fundamental principle: Ensure that everyone has access to quality education throughout their lives.
\r\n
\r\n\tWe face the dual challenge of delivering on the unfulfilled promise of ensuring the right to quality education for every child, youth, and adult, as well as fully realizing the transformative potential of education as a pathway to a more sustainable collective future. To achieve this, we need a new social contract for education that eliminates inequities while transforming the future. This new social contract must be based on human rights and the principles of non-discrimination, social justice, respect for life, human dignity, and cultural diversity. It must include an ethic of care, reciprocity and solidarity. The new social contract builds on inclusiveness, equity, lifelong learning, SDG, collaboration and personal learning in a global context for democracy.
\r\n
\r\n\tAt an international level, the adoption of the Open Educational Resources recommendation and the Open Science recommendation represents an important step towards building more open and inclusive knowledge societies as well as the achievement of the UN 2030 Agenda. Indeed, implementing the recommendations will help to achieve at least five more Sustainable Development Goals (SDGs) that are intertwined with the topic of this book series, namely SDG 5 (Gender equality), SDG 9 (Industry, innovation and infrastructure), SDG 10 (Reduced inequalities within and across countries), SDG 16 (Peace, justice and strong institutions) and SDG 17 (Partnerships for the goals).
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\r\n\tIf we aim to prosper as a society and as a species, there is no alternative to sustainability-oriented development and growth. Sustainable development is no longer a choice but a necessity for us all. Ecosystems and preserving ecosystem services and inclusive urban development present promising solutions to environmental problems. Contextually, the emphasis on studying these fields will enable us to identify and define the critical factors for territorial success in the upcoming decades to be considered by the main-actors, decision and policy makers, technicians, and public in general.
\r\n
\r\n\tHolistic urban planning and environmental management are therefore crucial spheres that will define sustainable trajectories for our urbanizing planet. This urban and environmental planning topic aims to attract contributions that address sustainable urban development challenges and solutions, including integrated urban water management, planning for the urban circular economy, monitoring of risks, contingency planning and response to disasters, among several other challenges and solutions.
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