Total organic area in EU-28 and some other European Countries in 2012 and 2017 [31].
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"2984",leadTitle:null,fullTitle:"The Species Problem - Ongoing Issues",title:"The Species Problem",subtitle:"Ongoing Issues",reviewType:"peer-reviewed",abstract:'The book includes collection of theoretical papers dealing with the species problem, which is among most fundamental issues in biology. 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\r\n\tOpen seas, enclosed basins as well as coastal areas are of utmost importance for human activities. Hence, since the last world war, scientists and engineers spent much effort in gaining insight on the main (and actually quite fascinating) physical phenomenon that occurs in such a kind of water body: surface waves. Long waves, wind waves, infragravity waves, earthquake-induced tsunamis, landslide-induced impulse waves are only a few examples of the wide range of water oscillations that engineers, with the help of scientists, need to face in order to guide the sustainable use of natural resources represented by water bodies. The new sensibility to climate change and integrated management are only two examples of new challenges to be faced.
\r\n\r\n\tMathematical modeling, either analytical or numerical, and experimental investigations are valuable tools that can be used to gain insight about wave generation, propagation, and interaction with the boundaries of water bodies, that are continuously and rapidly improving thanks to the technological advance.
\r\n\t
\r\n\tThis book is intended to provide the reader with a comprehensive overview of the current state-of-the-art about surface water waves, including forecasting and hindcasting of wind waves and storm surge, coastal risk analysis, and wave-structure-soil interaction.
The world today faces many challenges globally. It is characterized by extremely rapid technological progress, changes in political and economic relations, increasing income disparities, increasing global climate change, and, consequently, environmental burdens and changes in the natural environment. All this has implications for agriculture and the countryside, the society’s attitude to them, and views on food production, the methods and technologies used, and the safety and quality of produced food. Adequate habitat for humans, plants, and animals, the quality of natural resources (soil, water, air, and ecosystems), and safe food are the basic conditions for living on the planet. Global trends are causing a decline in the quality and availability of natural resources that are being consumed by today’s civilization. Trends and projections for population growth (10 billion people are expected to live on Earth by 2050 [1]) will also require increasing food needs. The current attitudes to agricultural production resources, social and climate changes, and increasing pollution of basic natural resources (soil, water, and air) require the strategic and economical management of these resources in order to enable the present and future generations to survive.
\nAgriculture faces many challenges as well as requirements related to natural resources, production technologies and methods, food safety, and quality. The society also has high expectations for rural areas. Agriculture is expected to be productive, competitive and economically attractive, resilient, and environmentally sustainable. The countryside, which is largely characterized by agriculture, is expected to be attractive to nonagricultural populations and to various economic activities. Food and the environment are becoming increasingly important areas of interest in modern society. Most countries are also increasing their emphasis, including in the light of their current experience, to ensure an adequate level of self-sufficiency in food products and to ensure food security. It should increasingly be based on locally produced food, with known and controlled origins, short retail chains, which also leaves a smaller environmental footprint while providing employment and adequate income for local growers.
\nModern consumers are giving more attention to nutrition and changing eating habits. It is important that the food is healthy and safe, the supply is undisturbed, and the way in which the food is produced or processed is supervised, so the ethical aspects of food production are also becoming important. Developed countries are also becoming more aware of the problem of large quantities of discarded food, which requires a different attitude toward food, reducing quantities of discarded food, better management of food surpluses, and greater awareness among consumers, traders, and producers.
\nAgriculture can also have negative impacts on the environment and climate, such as greenhouse gas emissions, negative impacts on water quality and water resources, and on natural ecosystems and biodiversity.
\nOrganic agriculture, on a global, European, and Slovenian scale, is gaining in importance. The number of organic farms, the share of organically cultivated agricultural land, the amount of organically produced food, and thus the market share of such food are increasing. In Slovenia, organic farming is one of the possibilities of producing safe and quality food, while fulfilling many other roles that agriculture plays beside the production of food.
\nOrganic farming largely meets the expectations and needs of the society in terms of protecting the environment in food production, the production of quality, healthy, and safe foods with high nutritional value, and the sustainable management of nonrenewable natural resources and the livestock of adequate breeding. Usually, organic farms have mixed production that combines crop production and animal husbandry. This allows for efficient resource management, nutrient cycling, biodiversity, environmental protection, and animal-friendly breeding. In both crop and livestock production, prevention of problems rather than their treatment is emphasized. The use of chemically synthesized fertilizers and pesticides, growth regulators, and hormones and the use of genetically modified organisms are not permitted in organic farming. Organic farming is based on rational use of natural resources, crop rotation, production of intermediate crops allowing the binding of nitrogen from the air, animal fertilizers, green fertilization and compost, biotic control of pests, and varieties more resistant to diseases and pests.
\nOrganic agriculture has a clear philosophical approach to farming, and the holistic approach focuses on working together with nature instead of against it [2].
\nOrganic farming contributes significantly to the provision of public goods, in particular to maintaining a sharp improvement in biodiversity, preserving drinking water resources, creating jobs due to the increased need for labor and increased unit labor value, preserving the agricultural cultural landscape, and protecting the environment in general.
\nOrganic and agro-ecological farming methods are based on four key principles: health, ecology, fairness, and care, enunciated by the International Federation of Organic Agriculture Movements (IFOAM) [3] and they guarantee healthy food production, assure environmental protection, and emphasize local resources and food systems [4]. Following these principles (included in various sets of standards, legislations, and production guidelines in different countries or for example on EU level) in practice enhances soil fertility and biodiversity, minimizing land degradation and erosion, chemical pollution, and other negative effects of industrialized agricultural activities.
\nAgriculture to be sustainable should be environmentally and socially sensitive, but also economically viable. We can talk about economic, environmental, and socio-cultural aspects of organic agriculture.
\nFrom an economic point of view, organic farming, as a more extension production method, has mostly higher production costs and lower yield that have to be covered with higher prices for consumers, price premiums, or subsidies [5, 6]. Organic farmers also sell their products through short distribution chains, mostly directly on farm, or on local street markets where they can achieve higher prices instead of supermarkets. They are able to achieve higher margins from the added-value if they processed their organic products at home or in cooperatives. Short food supply not only reduces negative environmental effects but, because of better efficiency, also brings down final prices for consumers and highlights the value of farmers’ work.
\nEnvironmental aspects are one of the most important characteristics and benefits of organic farming with very positive effects on soil, water, biodiversity, and climate change [5, 8, 9]. The main objectives of organic farming in relation to soil are the maintenance and enhancement of soil life and natural soil fertility, soil stability, and soil biodiversity, prevention of soil compaction and erosion, and the nourishment of plants with natural nutrient circuit. High organic matter in organic soil can be maintained and improved through crop rotation, with crops that fix nitrogen from the air, with green cover, or with manure from livestock production. Strict rules do not allow using external nonorganic inputs (synthetic fertilizers) [5, 7–9].
\nAnother problem of intensive conventional agriculture is water pollution. Organic farming, with strong restrictions in the use of chemically synthesized pesticides and mineral nitrogen fertilizers and lower animal stocking rates on farm, causes much less water pollution and helps to reduce leaching rates. With timing tillage properly, farmers can achieve further benefits in order to reduce nutrient leaking.
\nOrganic farming contributes to high degree of biodiversity in terms of domesticated species and floral and faunal diversity on the surface and in the soil. Traditional varieties and breeds, adopted on local conditions, and crop rotation make the whole system even more resilient, especially regarding pest and diseases. The maintenance of natural elements in the landscape, such as hedgerows, strips, and field margins can help to establish the ecological balance and make conditions for the predators of crop pests.
\nFarming, organic and conventional, has some positive and negative climate effects. The positive effect is that agriculture has a positive impact on carbon dioxide (CO2), acting as carbon sink. Plants use it for photosynthesis and store it in the soil’s organic matter. Due to the high organic matter content in the soil, organic farming as also conventional can contribute to CO2 reduction. Methane emissions from livestock production have negative effects. Due to the low stocking density, organic farming produces less methane on a hectare unit as conventional farming. There are still potentials to reduce methane emissions with improving manure management, ruminants’ diet, or increased productivity that can improve methane emissions on yield basis and reduce production costs [5, 7–9].
\nOrganic farming has positive effects also on human and animal health and animal welfare. Currently, the questions of food choice has become also an issue from the perspective of public health and motivation of the policy makers in developed economies to improve dietary patterns of the population [10]. Therefore, healthiness of the products in comparison to conventional food options is among the main reasons for organic food purchase. Food safety and well-balanced diet are important prerequisites for good health and well-being [5]. General rules on animal welfare are the same for organic and conventional farming. However, organic farming rules demand still higher level of animal welfare and an assurance of species-specific needs. On organic animal husbandry, animals must have free access to open air that can also interact among them. The number of animals must be adjusted to the available land and sticking density inside buildings and outside to ensure comfort and well-being of the different species. The use of antibiotics and hormones is strictly prohibited and good animal health can be achieved by the selection of appropriate breeds and building of immunological defenses of animals.
\nOrganic farming has the potential to assure also some social aspects, as a kind of positive externalities of its operating, like job opportunities and other contribution to local and regional economies.
\nOne of the characteristics of organic farming is also higher demand for labor in comparison with conventional agriculture [11], due to the need for more manual and mechanical work instead of chemical inputs. Some additional time is needed also to prepare products for market sale or for their distribution to consumers directly or for selling personally on local markets, for their processing at home, etc. On the other hand, this means a contribution to employment in rural areas and makes possible also to keep and operate small farms, which otherwise would not be competitive enough. Other social dimensions of organic farming, beside the influence on labor demand, are also connected with human health, democratic participation, resiliency, biological and cultural diversity, quality of life and human well-being, equity and ethics, and institutions (e.g., farmers’ cooperatives and associations) [12]. Benefits for farmers and other local people result from diversification of activities and income on farms (e.g., processing of products and tourism on farms) and through payments for ecosystem services that can have income and quality of life influence. Local residents gain human health benefits through access to fresh, traditional foods and access to landscape for leisure activities and have opportunities for direct relationships with producers. They can not only directly buy products but also help farmers with work as a kind of social gathering. Other wider social benefits can be in the field of democracy, gender perspective, resiliency, quality of rural life, and cultural conservation. Through the active engagement of producers, local residents, and visitors, democratic participation has improved. There are much more opportunities and need for cooperation between different stakeholders to build social capital, to preserve agricultural culture, knowledge, and traditions, to preserve some traditional production and processing techniques, etc.
\nSeveral studies in different countries tried to find out the factors that determine or have influence on farmer’s decision to convert to organic farming [13–20]. In general, the determinants can be divided into economic and noneconomic factors [17], and most studies that analyzed the adoption or conversion to organic farming confirmed the relevance of both types of factors.
\nFor the decision about farming system, farmers’ objectives are important. Objectives can be summarized as economic, environmental, or sociocultural [17].
\nFactors that influence the decision to convert from conventional to organic farming in the reviewed studies are as follows:
Farmers’ characteristics (age, gender, education, experiences, entrepreneurial spirit, etc.)
Farm structure (farm size, location, soil type, favorable or not favorable conditions for agriculture, available machinery, etc.)
Farm management (input use, crop rotation, crop diversification, specialization, etc.)
Exogenous factors (market prices, market size, available subsidies, information access, availability of advisors, support policies, etc.)
Attitudes, opinions, and preferences (about the environment, life style, health, risk, acceptance within the rural community, etc.)
More authors [14, 15, 21] concluded that the availability of information sources is an important factor in conversion process. Conversion is always connected with some risk. De Cock [22] in his study confirmed that conventional farmers are more risk averse than organic farmers; similar are the findings of Sera et al. [23] and Gardebroek [24] that organic farmers are less risk averse as conventional farmers.
\nKallas et al. [17] confirmed an expectation that for the adoption of organic farming location of farm can also play an important role. The location of farms in an unfavorable area for agriculture motivates adoption, and more likely to convert are also farmers who have second economic activity apart from agriculture and small family farms. Farm specialization also can have an influence; for example, farmers whose total farm income comes only from viticulture are less prone to convert. Conversion is more probable if the farm has diversified production or activities. Organic farms in general usually diversify their activities to reduce all kinds of risks (yield loss, decreasing prices, natural catastrophes, etc.).
\nOlder farmers are less willing to convert [15, 17, 20, 25], are mostly less educated, and are not so ambitious anymore. It is understandable that they are not so ready anymore for adjustments and changes, new learning, investments, new risks, etc. Their decisions are mainly based on economic variables, while the importance of the environmental over the economic considerations is a basic factor in the decision to convert to organic farming.
\nThe results of the Norwegian study [18] did not differ much. Organic farmers in Norway, compared with conventional farmers, mostly have larger farms, are mostly oriented to crop production, are more educated, and are located closer to urban centers. Farmers have different goals for their farms that can differ between conventional farmers, organic farmers, and farmers that are planning to convert. In Norway, main goals of conventional farmers were economic: to “achieve stable and reliable income,” to “maximize profit,” and to “improve the farm for next generation.” Organic farmers rank “sustainable and environmental-friendly farming” in the first place, while conventional farmers put this goal after economic goals. After environmental goals, organic farmers ranked “producing high quality food” and “reliable and stable income.” Suitable income was one of the three most important goals by all three groups of investigated farmers (conventional, organic, and farmers that are planning to convert), and it is also seen as a strategy for risk avoidance. All three groups of Norwegian farmers as least important goals ranked “higher private consumption,” “increasing equity,” and “social contacts.” Among the motives for the decision for organic farming, organic farmers choose as most important to “produce high quality food,” “higher soil fertility and less pollution problems” as second, and “professional challenges” as third. As least important motives, they defined “natural conditions” and “more stable income.” Farmers that are planning to convert to organic farming ranked motives little different; for them, financial motives (“profitability” and “organic farming payments”) are most important, while “production of high quality food” and “ideological and philosophic reasons” were less important for them as compared to certified organic farmers. Main goals and motives for organic farmers in Norway are therefore still traditional environment, food quality, and philosophical concerns. On the other hand, financial considerations (“profitability” and “income stability”) are important for conventional farmers as well as important motives for conversion for the potential converters.
\nStudies in other European countries found higher density of organic farms in regions less favorable to agricultural production (e.g., in Austria, Switzerland, and Germany). Results of a study in Germany [26] show that the number of organic farms and higher percentage of organically managed land are negatively correlated to soil quality and positively influenced by organic grassland payments.
\nDarnhofer et al. [27] studied the reasons and constraints of farmers for converting to organic farming in Austria. They identified five types of farmers: “committed conventional,” the “pragmatic conventional,” the “environment-conscious but not organic,” the “pragmatic organic,” and the “committed organic.” For “committed conventional” farmers, conventional approach to agriculture is the only sensible way. Their focus is maximizing outputs and profit per hectare, minimizing production costs, intensive use of external inputs, the introduction of the new technologies that make this possible, specialization of the farm, etc. Organic farming for them is not more environmentally friendly than conventional farming and they do not see organic farming as technically and/or economically feasible. They do not even think to convert to organic farming. “Pragmatic conventional” farmers can be seen as potential converters. They are generally not against organic farming, but a conversion is too risky for them, and without tangible benefit of the conversion, they will not implement it. Their main constraints are connected with the technical challenges and needed changes with farm organization, the uncertainty of price, and available market for their products. Some good examples of organic farmers’ conversion in the area and available market for organic products can make them to be more open for conversion. Most farmers see economic viability as a necessary condition for conversion, but not a sufficient one. These farmers are more inclined to solutions that do not require conversion, for example, farm diversification or additional off-farm income. The third type of farmers is “environment-conscious but not organic.” They are committed to environmentally friendly farming practices, but they do not receive any agri-environmental payments. Because they are not certified organic farmers, they are more flexibly and not subject to controls and are more independent of the regulations, although some of them follow organic standards very closely. The reasons are also bureaucratic demands and costs connected with certification, record-keeping, etc. Some of them are self-declared organic producers (without organic certificate) that have customers willing to pay premiums without organic certificate, because they trust them, as well as the quality of their products. There is no need for them to convert to organic methods. “Pragmatic organic” farmers were motivated to convert by good prospect for security income, mostly through the payments of agri-environmental programs. Financial motives were more important for their conversion as sustainability, health, or ethical aspects. Although financial motives are important for this group of farmers, income-maximization attitude for them is not necessary in the first place [15].
\nCompensatory payments enable them to “learn by doing.” They like to learn and make experiments with new ventures. Their challenges are the diversity of task in organic production, need for the craftsmanship, and always new skill requirements. Organic farming for them is an alternative to conventional farming but close to the “farming economically” thinking [28].
\nThe “committed organic” farmers follow a fundamental philosophy of organic farming: close nutrient cycles, no use of synthetic fertilizers and pesticides, crop rotation, and care for soil health. Organic farming for them is also a social movement and political statement and not only a production technique. Their first considerations are, beside the already mentioned basic principles, producer and/or customer health, ethical norms, and lifestyle; economic considerations are of secondary importance. These groups of farmers are really organic farming believers and mostly pioneers.
\nAt the end of 2017, nearly 70 million hectares of agricultural land were involved in organic farming on a global scale. Comparing to the end of 2016, there is a growth of 20% [29]. The largest organic agricultural area was recorded in Australia with 35.6 million hectares; the second in Argentina with 3.4 million hectares and the third in China with 3 million hectares. Europe together had the second largest area in 2017 (14.6 million hectares). Organic-managed agricultural area increased globally in all continents and in 2017 presented 1.4% of total global agricultural land. Shares of organic agricultural area compared to total agricultural area differ between the countries and were the highest in 2017 in Liechtenstein (37.9%), Samoa (37.6%), and Austria (24%). The global market for organic food in 2017 based on estimations reached around 97 billion US dollars (approximately 90 billion euros). The leading market with organic products were in the USA (40 billion euros), followed by Germany (10 billion euros), France (7.9 billion euros), and China (7.6 billion euros). Organic markets in 2017 showed a growth, in France for example by 18%. Country with the highest amount spent on organic food in 2017 was Switzerland (288 euros per capita), while Denmark had the highest organic market share (13.3% of the total food market). Countries differ also by numbers of organic producers. The total number of organic producers in 2017 has been estimated at 2.9 million. The highest number had India, followed by Uganda and Mexico. The number of producers between 2016 and 2017 increased by almost 5%. Organic land use structure in 2017 was the following: over two-thirds presented grassland or grazing areas (almost 48.2 million hectares), 17% (over 12 million hectares) arable land, and 7% permanent crops (nearly 4.9 million hectares). Arable land use had highest share for cereals and rice production (almost 38% of all), production of green fodder on arable land (over 23%), oilseed production (10%), and vegetables and dry pulses on the rest. Among permanent crops, the largest share belongs to coffee and olives (each with almost 20% of the organic permanent cropland), followed by nuts, grapes, and tropical and subtropical fruits.
\nAt the end of 2017, organic farming in the whole Europe was carried out on 14.6 million hectares of agricultural land (2.9% of the agricultural area). Compared to 2016, organic farmland has increased by over 1 million hectares. The largest organic agricultural areas were in Spain, Italy, and France. Retail sales of organic products increased by 10.5% compared with 2016 and reached 37.3 billion euros in 2017. Germany had the largest market for organic products (10 billion euros), followed by France (7.9 billion euros) and Italy (3.1 billion euros) [30, 31].
\nOrganic farming in European Union in 2017, by Eurostat data, was carried out on 12.6 million hectares of agricultural land in use in 28 member states, representing 7% of the total utilized agricultural area. The differences between member states are considerable. The largest shares of agricultural land in use for organic farming in 2017 had Austria (23.4%), Estonia (19.6%), and Sweden (19.6%). Since 2013, the number of fully organic agricultural holdings in the EU-28 increased by 30% and represented around 2% of total EU-28 agricultural holdings, while increase in organic area between 2012 and 2017 was 25% [30, 31]. Some member states increased their total organic area between 2012 and 2017 significantly (i.e., Croatia and Bulgaria for over 100%), and some decreased in smaller amount (Poland for 24.5%, the UK for 15.6%, Greece for 11.3%, etc.). Countries with the highest total1 organic areas in terms of hectares are Spain, Italy, and France. These countries together with Germany in 2017 presented around 55% of the total EU-28 organic areas (Table 1).
\n\n | Organic area (ha) | \nChange 2012–2017 (%) | \n|
---|---|---|---|
\n | 2012 | \n2017 | \n|
EU-28 | \n10,047,896 | \n12,560,191 | \n25.0 | \n
Belgium | \n59,718 | \n83,508 | \n39.8 | \n
Bulgaria | \n39,138 | \n136,618 | \n249.1 | \n
Czech Republic | \n468,670 | \n496,277 | \n5.9 | \n
Denmark | \n194,706 | \n226,307 | \n16.2 | \n
Germany | \n959,832 | \n1,138,272 | \n18.6 | \n
Estonia | \n142,065 | \n196,441 | \n38.3 | \n
Ireland | \n52,793 | \n74,336 | \n40.8 | \n
Greece | \n462,618 | \n410,140 | \n−11.3 | \n
Spain | \n1,756,548 | \n2,082,173 | \n18.5 | \n
France | \n1,030,881 | \n1,744,420 | \n69.2 | \n
Croatia | \n31,904 | \n96,618 | \n202.8 | \n
Italy | \n1,167,362 | \n1,908,570 | \n63.5 | \n
Cyprus | \n3923 | \n5616 | \n43.2 | \n
Latvia | \n195,658 | \n268,870 | \n37.4 | \n
Lithuania | \n156,539 | \n234,134 | \n49.6 | \n
Luxembourg | \n4130 | \n5444 | \n31.8 | \n
Hungary | \n130,607 | \n199,683 | \n52.9 | \n
Malta | \n37 | \n41 | \n10.8 | \n
Netherlands | \n48,038 | \n56,203 | \n17.0 | \n
Austria | \n533,230 | \n620,656 | \n16.4 | \n
Poland | \n655,499 | \n494,978 | \n−24.5 | \n
Portugal | \n200,833 | \n253,786 | \n26.4 | \n
Romania | \n288,261 | \n258,471 | \n−10.3 | \n
Slovenia | \n35,101 | \n46,222 | \n31.7 | \n
Slovakia | \n164,360 | \n189,148 | \n15.1 | \n
Finland | \n197,751 | \n258,672 | \n30.8 | \n
Sweden | \n477,684 | \n576,845 | \n20.8 | \n
The United Kingdom | \n590,011 | \n497,742 | \n−15.6 | \n
Norway | \n55,260 | \n47,042 | \n−14.9 | \n
Switzerland | \n121,013 | \n150,491 | \n24.4 | \n
Total organic area can be used as arable land (production of cereals, root crops, fresh vegetables, green fodder, industrial crops, etc.) or as permanent grassland (pastures and meadows as food for animals) or as permanent crops production (fruit trees, olives, and vineyards). In 2017, in EU-28, arable land represented 44.5% of the total organic crop area, permanent grassland 44.4%, and permanent crops 11%. There are significant differences between EU member states also in this structure: in 13 member states, permanent grassland covered more than 50% of the organic area (i.e., Ireland (95%), Czech Republic (85.5%), and Slovenia (81.4%)), while arable land represented more than 50% of the organic area in 11 EU member states (highly predominant in Finland (99.2%), Denmark (81%), and Sweden (77.9%)). Permanent crops were less presented in the total organic area, the highest shares in 2017 had Malta (48.8%) and Cyprus (46.7%) with predominated olive trees, and the share was more as 20% in Italy, Spain, Portugal, and Bulgaria and between 10 and 20% in Croatia and Greece. In the rest of the 16 EU member states, permanent crops accounted less than 5% of the total organic areas (Figure 1).
\nThe structure of organic agricultural land in use by country in 2017 (% of total organic area—fully converted and under conversion). Data source: Eurostat (online data code: org_cropar [
The most popular species in organic livestock in EU member states in 2017 were bovines and sheep. The number of organic bovine animals was more than 4 million heads (around 5% of all bovines reported in 2017). The highest shares of organic bovines, dairy cows, and sheep and goats had Latvia (34.1% of total sheep and goat and 23.6% of bovines), Austria (21.7% of total bovines), and Sweden (21.2% of total bovines). The highest share of organic dairy cows in 2017 had Austria (21.2% of all dairy cows), followed by Sweden (16.4%) and Latvia (12.7%). Organically reared pigs had small share of the total reared pigs, and the highest share had Denmark with 3% [31].
\nIn 2018, 3741 agricultural holdings were included in the organic farming control system (2.9% more than in 2017), of which 3320 were already organic agricultural holdings, with obtained ecological certificate, while the remaining 421 were still in conversion (Figure 2) [32]. In 2018, all agricultural holdings in the organic farming control system accounted for 5.4% of all agricultural holdings in Slovenia, and those that already reached the status of organic producers represented 4.8% of all agricultural holdings in Slovenia [32, 33].
\nDynamic of growth of organic farms in Slovenia between 2000 and 2018. Data source: SiSTAT [
In 2018, the area of ecological agricultural land in use increased by 1320 ha or 7% compared to 2017 (between 2016 and 2017, increased by 3996 ha or 11%). Organic production in 2018 was carried out on 47,848 ha of utilized agricultural area (on about 10% of all agricultural land in use). Permanent meadows and pastures occupied the largest share in the structure of organic agricultural land in use, over 81% (Figure 3). Compared to 2017, in 2018, the area of organic permanent meadows and pastures decreased by 1%, the area of organic vineyards increased the most (by 37% or 124 ha), orchards by 14%, and olive trees by 13%, while the area of organically produced vegetables increased by 11%.
\nIn 2018, fruit production was significantly higher than in 2017, almost by 6 times. Due to adverse climatic conditions (frost and hail), fruit production in 2017 was namely very low or even without any products, and also other plant production in 2017 was lower. Better production conditions in 2018 have made it possible to increase the total organic production in arable land and gardens by 27% and in vegetable production by 21%, while the output of organic vineyards’ production was 15% higher and in olive groves by 31%.
\nThe structure of organic agricultural land use in Slovenia in 2018. Data source: SiSTAT [
The number of animals on organic farms in Slovenia in 2017 and 2018. Data source: SiSTAT [
Due to the large share of grassland, as well as the need for organic fertilizers for organic farming, organic farms usually also keep cattle. The number of individual species kept by organic farms varies, while poultry, cattle, and sheep dominated the number of animals. Between 2016 and 2017, the number of animals on organic farms increased by around 4%. The number of organic honeybees increased by as much as 20%, while the number of rabbits decreased by 11%. In 2018, the number of animals on organic farms decreased by 9%, probably because of worst climatic conditions for the production of animal feed. The only increase compared to 2017 was in the number of beehives by 31% (Figure 4). In 2018, the amount of organic products from animal production increased: the total weight of meat by 26% (cattle meat increased by 27%, pig meat by 19%, sheep meat decreased by 41%, and goat meat by 57%). The increase was significant also in the weight of poultry meat by 29% and in the weight of other animals’ meat (i.e., games) by 238%. The increase compared with 2017 was evident also in the production of cow’s organic milk by 20%, while sheep’s and goat’s milk decreased (by 2 and 13%). Honey production in 2018 was 41% higher than in 2017 and egg production 26% higher [32].
\nDespite the growth in number of organic farms in Slovenia, the current development of organic farming is not in line with the expectations and goals set in the Action Plan for the Development of Organic Agriculture in Slovenia by 2015. Problems in the field of organizing and linking producers have been identified as the most problematic [34]. There is still insufficient volume and supply of organic foods, there are not enough qualified organic crop advisers and poor knowledge transfer, in animal products from organic farming it still happens that organic products go into conventional processing, etc.
\nThe Ministry of Agriculture of the Republic of Slovenia will strive to achieve these goals in the future, since organic farming will be an important part of the agricultural development strategy in Slovenia after 2020. “The society expects quality food and smart management of natural resources. Consumers are increasingly putting in front their health and the healthy environment in which they live. Organic farming present also a good entrepreneurial opportunity for farmers, and the ministry intends to continue to raise awareness among consumers of healthy food and the environment, and to encourage the demand for local, organic foods, and, on the other hand, promote the integration and participation in the food production chain” said the Minister of Agriculture of the Republic of Slovenia Dr. Aleksandra Pivec [35].
\nOrganic farming, due to its production characteristics, can be a good choice for farming in areas such as “areas facing natural or other specific constraints” (ANCs), before in the EU called “less favored areas” (LFAs), protected areas (national, regional, or landscape parks), Natura 2000 areas, and water protection areas. Such areas are precisely spatially defined, based on criteria defined by the European or Slovenian legislation.
\nMany farmers in Europe are located in areas that are less favored for agriculture. They are facing natural constraints such as difficult climatic conditions, steep slopes, worst soil quality, and other natural handicaps. Farmers in such areas face many difficulties and have higher production costs but are very important from the viewpoint of sustainability. Most developed countries are paying them to mitigate the risks of land abandonment and thus a possibility of desertification, loss of biodiversity, valuable rural landscape, and other multifunctional roles that farmers play in such areas. ANCs are designated by member states based on EU Regulation 1303/2013 where objective biophysical criteria for the designation are declared. EU Member States have possibility to designate three different categories of ANCs: (1) mountain areas; (2) areas, other than mountain areas, facing natural constraints; and (3) areas affected by specific constraints [36]. In Slovenia, 86.9% of the country area is declared as ANCs or 76.2% of all agricultural land (Figure 5) [37]. Farmers with agricultural land in ANCs are eligible to receive compensation payments that are calculated on the basis of differences in costs or income as resulting from natural constraints and in comparison to areas not suffering from those natural or specific constraints.
\nAreas facing natural or other specific constraints in Slovenia.
In Slovenia, 269,475 ha or 13.3% of the national territory of Slovenia is defined as a protected area characterized by a rich and heterogeneous natural and cultural heritage. Such areas have not only economic but also environmental and social potential; thus, all aspects and prerequisites should ensure sustainable development. Protected areas in Slovenia are represented by one national park (Triglav National Park), three regional parks, 44 landscape parks, and several smaller protected areas such as nature reserves (57) and natural monuments (1164) [38].
\nIn the Nature Conservation Act [39], protected areas are defined as areas of nature with a great abiotic, biotic, and landscape diversity and high density and diversity of natural values.
\nThe main objective of the Natura 2000 network in the European Union is to conserve valuable biodiversity for future generations [40]. Slovenia is one of the EU Member States with well-preserved environment and with very rich biodiversity. Great biodiversity is not only the result of different geo-morphological and climatic conditions but also a result of human activities in space. Natura 2000 areas in Slovenia in total encompass 7684 km2 or approximately 37% of the country territory [41], one of the highest among EU member states. Two thirds of Natura 2000 sites in Slovenia are forested, a substantial part consists of areas with little vegetation above the tree line in the mountains (rock walls), and there are notable grassland areas. A quarter of the total Natura 2000 sites in Slovenia are protected areas (Triglav National Park, regional and landscape parks, nature reserves, or natural monuments).
\nImplementing of appropriate farming practices in Natura 2000 sites is a prerequisite for the conservation of certain plant and animal species and habitats. The use of agricultural land within Natura sites is regulated by EU regulations and allows farmers to obtain direct payments for farming. There are also certain restrictions, such as prohibiting the plowing of rich grasslands and need for maintaining landscape features (e.g., preserving vegetation zones along watercourses, smaller basins, dry walls, terraces, and tree groups). An instrument for directing the agricultural use of such areas is the agri-environment-climate payments under the CAP (i.e., KOPOP measures in Slovenia), which represent one of the most important ways of directing agricultural activity to a more sustainable way in Slovenia and in the EU. Farmers decide for such measures voluntarily, but they have to implement it on the area covered for at least 5 years. In addition to these measures, some other payments (e.g., ANCs, support for organic farming) that contribute to land cultivation and, in particular, the prevention of grassland overgrowth in Natura 2000 sites can contribute to the achievement of sustainability objectives in Natura 2000 sites. Other CAP Measures such as Cooperation, CLLD, Knowledge Transfer, and Counseling also contribute to the achievement of the conservation objectives of the sites [42].
\nWater protection areas in Slovenia cover about 17% of the country’s territory [43]. They are located mainly in the plains, where agriculture is the most intensive. The burden on water and its quality comes not only from agriculture but also from disorderly sewage, wild waste landfills, transport, industry, etc. In Slovenia, groundwater accounts for as much as 98% of all drinking water supply for residents, making efficient protection of groundwater quality of great importance for the health of the population [44]. Most water protection areas in Slovenia are covered by forest (61.1%), followed by grassland (13.6%) and fields (10.9%) [43]. Despite the fact that ecological farming is the most suitable due to the protective objectives on these areas, the share of ecological areas in water protection areas is less than 2%. The reason is likely that these areas are in plains where intensive farming is dominant. In addition, the farm cannot farm organically on water protection areas and conventionally in the remaining ones at the same time. By regulation, only the whole farm can be converted into organic. Due to restrictions on farming, farmers are achieving lower yields on such land. Environmental legislation in the fields of water protection areas and agriculture are consistently implemented and controlled, but on the other hand, the state does not pay farmers yet for a loss of income at the expenses of the restrictions it imposes on the legislation. There is much dissatisfaction among farmers and therefore probably less readiness for organic farming on water protection areas.
\nThe data in Table 2 show the organic farms by type of area with restrictions/limitations or natural obstacles for agriculture (situation in 2011).
\n\n | Utilized agricultural area (UAA) (ha) | \nShare of utilized agricultural area (%) | \nArea in organic control (ha) | \nShare of area in organic control (%) | \nNo. of organic farms | \nShare of organic farms (%) | \n
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ANCs (LFA) | \n449,000 | \n72.4 | \n28,198 | \n94.5 | \n1922 | \n93.0 | \n
Natura 2000 areas | \n142,067 | \n22.9 | \n6820 | \n22.9 | \n369 | \n17.9 | \n
Protected areas | \n66,293 | \n10.7 | \n1487 | \n5.0 | \n124 | \n6.0 | \n
Water protection areas | \n95,768 | \n15.4 | \n4913 | \n16.5 | \n263 | \n12.7 | \n
The majority of Slovenian organic farms (93% of all) were in 2011 in areas facing natural or other specific constraints. This is not particularly surprising since such areas make up as much as 85% of the country’s territory. Farms in such areas have less favorable conditions for agriculture, so the conversion to organic farming is one of the strategies to survive and improve the economic situation. Due to the high proportion of permanent grassland in ANCs, high share of organic farms in such areas specializes in livestock husbandry [46]. Such a distribution of organic farms indicates that organic farming is more interesting for farms with poor conditions for cultivation and with already extensive farming practices that do not need some special adjustments. Subsidies contribute to their farm efficiency. In 2011, approximately 23% of total area in organic control in Slovenia and 18% of total number of organic farms were located in Natura 2000 areas. This indicates that more incentives to increase a share of organic farming in areas with high biodiversity are needed. Only 13% of organic farms were located in 2011 in water protection areas, and only 16% of the farmlands were organically cultivated.
\nOrganic producers depend on the demand for organically produced products. The proportion of consumers purchasing organic food on a regular basis remains low, although consumers have mostly positive attitudes toward organic food as proved in many studies. Decisions about organic food consumption are influenced by different factors. Aertsens et al. [47] made an overview of different studies and exposed the following determinants:
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One of the strongest motives for purchasing organic food is connected with food safety and healthiness (values). Organic consumers believe that organic food tastes better than conventional and also curiosity often stimulates purchase. From universalism point of view, organic farming is mostly perceived by consumers to be more environmental friendly as conventional farming. Some people may consume organic foods that make them different from others and feel some positive self-image and identity. Beliefs about health, taste, and environmental aspects have strong influences on attitude toward buying organic food. Consumer response and behavior are often emotionally conditioned (e.g., fear of contaminated meat determines purchasing behavior of organic meat). All kind of norms (social, personal, and moral) influence purchasing organic products as well and there are some barriers too such as high prices, availability of products, lack of trust in organic certificates, and financial abilities. People with low income have limited or no possibility to buy organic products despite the fact that they want and believe in such products. Socio-demographic characteristics of consumers have less influence on organic food purchases as values [47]. From a gender perspective, more women than men have positive attitudes toward organic food; women generally also concern more about health and healthy food. The age was not recognized as a very significant factor; some studies found the differences between age groups, but more of them did not. The differences are probably influenced by other factors (e.g., macrolevel factors). Families with children are more likely to buy organic food products, while education seems not to play an important role in organic food consumption.
\nSlovenian consumers purchase mostly in supermarkets or discount stores. One of the latest studies [48, 49] on purchasing habits of Slovenian consumers showed that 28% of interviewed customers often buy organic products, 34% of them occasionally, and 34% very rare or never. There are no significant differences between the groups of customers buying conventional or organic products, except that among customers of organic products share of women is higher. Buyers of organic food are not different by region and type of settlement, but they have higher income. Regular organic food buyers are more likely to buy organic food directly from the farmer, on farm, or on local street market, and to a lesser extent from supermarkets and discount stores. Customers see the supply of organic products in supermarkets as too narrow and mostly not Slovenian origin. One of the strongest motives for purchasing organic food is customers believe that such food is fresh, healthier, of higher quality, and of better taste. Over 40% of organic food buyers believe that such food is completely free of pesticide residues.
\nThe main obstacle for those who do not buy organic food and products is too high price; they also do not trust that organic food is of better quality, healthier, or tastier as conventionally produced food. They even do not trust in their origin and food labels.
\nThe origin of the product is very important for Slovenian buyers in general, so they expect it to be clearly marked on the product, with a clearly defined country of origin (e.g., Slovenia, Austria, etc. and not only as EU origin). Over 80% of customers most trusted in organic products from Slovenia, followed by organic products of Austrian and German origin. Slovenian organic food buyers least trust organic products from Israel and Turkey. They believe that by buying Slovenian food they support Slovenian farmers and contribute to the development of the local food market, to protect the environment, and to the maintenance of cultural landscape and vital countryside.
\nBuyers of organic food are most attracted to the Slovenian origin, the label “Chosen quality of Slovenia” and the specific indication of the farm where the food comes from. Attractive are also some special offers and lower prices. The highest share of the purchase decision explains the product origin (63%) and the price is slightly more important than the production method. Interesting finding of survey is that Slovenian consumers are ready to pay also 80% higher price for food of Slovenian origin as for comparable foods from abroad. They are even ready to pay more for conventional food with Slovenian origin as for certified organic food from Austria or Italy [48, 49].
\nIn terms of the preservation of agricultural production in the entire territory of Slovenia, the preservation of rural settlements and biodiversity, to which the appropriate farming method contributes, areas with limited factors for farming are very important, not just flatlands with the best conditions for agricultural production. In these areas, the promotion of sustainable ways of farming, such as organic farming, is very important and should be supported by appropriate agricultural policy measures and support payments in the future. Data on the volume of organic farming show that the number of farms and the volume of agricultural land in organic production are growing too slowly, especially the share of arable land and permanent crops. The target set by the 2015 organic farming action plan was not achieved. Several farms have also withdrawn from organic farming due to some reductions in payments.
\nData on available quantities of Slovenian organic food and consumer needs indicate that demand for this type of food is much higher than supply. Slovenian organic producers can provide only about 20% of the demanded quantities for organic products. The market supply of organic products from Slovenia can, therefore, and should be increased. Direct support to organic producers, support for adaptation and investment for organic farms, farm modernization, greater integration of producers for joint market entry, and more research and knowledge transfer, can contribute to increase the supply of organic products.
\nThe resolution “Our Food, Rural Areas and Natural Resources after 2021” [50], which represents a strategic framework for the development of Slovenian agriculture, food processing, and rural areas, gives organic farming and areas with natural handicaps for agriculture notable attention, which should be followed by agricultural policy measures in the new programming period beyond 2020.
\nTo increase the share of organic farms in Slovenia, as well as in other countries, it is important to know the reasons, objectives, and motives that influence the decision to convert to organic farming. When preparing some effective support policies, it is important to take into account the findings of different studies. General findings are that financial motives are very important to attract potential converters. However, many other factors as well influence farmers’ decisions. However, if farmers are only economically motivated for conversion, short-term benefits through policy payments may go out of the scheme as soon as economic conditions are not so favorable anymore. That has happened in Slovenia as well.
\nNatural conditions for agriculture, farm and farmer’s characteristics, demand for organic products among consumers, yield loss, price premiums, market prices, consumers’ purchasing power, and other factors that influence the decision about farming system must be well understood. As conversion is a strategic decision of farmer and his/her family, it is necessary that support policies are long-term oriented and provide the conditions for the success of the farm business. Adoption of organic farming is not only economically motivated but also different noneconomic factors were found as important. The probability of conversion to organic farming is influenced also by the farmers’ attitudes to the environment, food quality and health, lifestyle, and other ideals. This should also be taken into account when promoting organic farming and encouraging farmers to convert.
\nDecision for organic farming in areas with natural handicaps or restrictions seems appropriate, especially on farms where grassland predominates. The readiness for conversion increases if the level of payments for organic farming also increases and there are already successful organic farms in the area [51]. Farms can improve the economics of farming through higher direct and rural development payments for organic farming and the implementation of agri-environment-climate measures. Another possibility is linking organic farming with tourism or processing of products on the farm and sold them direct on the farm or in the local environment to local people, visitors of tourist farms, and local institutions (schools, kindergartens, hospitals, etc.). Indeed, ensuring the environmental and social role of organic farming is only possible if farming is economic at the same time. We can agree with Meemken and Qaim [8] that “organic farming is not paradigm for sustainable agriculture and food security, but smart combinations of organic (especially in less favored, water protection, and protected areas) and improved conventional methods could contribute toward sustainable productivity increases in global agriculture”.
\nTraumatic brain injury (TBI) is frequently associated with depressed level of consciousness, compromised protective airway reflexes or apnea, which can increase the risk of aspiration or result in hypoxemia and worsen the secondary brain damage. Therefore, patients with TBI and Glasgow Coma Scale (GCS) ≤ 8 have been traditionally managed by prehospital or emergency room (ER) intubation. This practice is also reflected by the current guidelines: the American College of Surgeons Committee on Trauma Advanced Trauma Life Support (ATLS) recommends intubation for patients with a GCS of 8 or lower for airway protection [1]. Also, the practice management guidelines of the Eastern Association for the Surgery of Trauma give a level 1 recommendation for endotracheal intubation of patients with severe cognitive impairment (GCS ≤ 8) [2].
However, the potential benefit of an intubation in TBI, is also associated with risks: Difficult or failed endotracheal intubation may cause hypoxemia, aspiration, and hypotension and requires admission to the intensive care unit (ICU). In fact, there is no direct evidence supporting routine intubation of all patients with a GCS ≤ 8. Consequently, recent evidence challenged the practice of a strict GCS threshold for intubation and even suggested that routine endotracheal intubation for GCS ≤ 8 in TBI may be harmful [3].
The primary goal in the prehospital care of the trauma patient is to secure adequate ventilation until transfer to hospital care. To achieve this goal, various techniques for airway establishment and subsequent ventilation can be performed: endotracheal intubation has been considered as the gold standard. However, ventilation may also be achieved by less invasive and time consuming procedures such bag-valve mask (BVM) ventilation with the optional use of oropharyngeal (OPA) or nasopharyngeal (NPA) adjuncts. More advanced techniques include supraglottic airway (SGA) devices. There is a wide range of medications available to facilitate intubation prehospital or in the ER.
To date, there are no evidence-based guidelines for TBI patients regarding standardized airway management in the prehospital setting or in the ER. This explains also why indications and techniques for airway establishment vary in different systems and countries around the world. In the United States of America (USA) prehospital care is usually provided by emergency medical technicians or trained paramedics, whereas prehospital care in most European countries is provided by physicians [4]. Following these differences of American and European Emergency Medical Service (EMS) systems, the US prehospital care strategy follows more “scoop and run approach” with prioritizing rapid patient transport to trauma centers. In Europe the priority lies more on field triage, on scene assessment and initiation of procedures such as intubation “stay and play approach” [5].
This chapter will address the question what airway management strategy best meet the patients need and is associated with most favorable outcomes in TBI. Indications and optimal method of securing the airway prehospital and in the ER will be discussed. In addition, technical aspects including medication for pretreatment, induction, paralysis and sedation for endotracheal Intubation in the presence of TBI will be outlined.
Advanced prehospital care has been practiced for several decades in Western countries. In TBI particularly, prehospital airway management is one of the most critical aspects that determine patient outcomes. The importance of the airway management is reflected by the Advanced Trauma Life Support (ATLS) algorithm [1], in which the airway takes priority over any other therapeutic interventions.
General prehospital TBI guidelines [6] are emphasizing avoidance and treatment of hypoxia, prevention and correction of hyperventilation, and avoidance and treatment of hypotension. The implementation of these prehospital guidelines showed that adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission [7]. These findings support the widespread implementation of the prehospital TBI treatment guidelines. However, specific evidence-based guidelines are needed to establish the optimal airway management in the prehospital setting.
Patients require an advanced airway under two sets of circumstances: failure to maintain a patent airway and the inability to oxygenate and ventilate the patient adequately [8]. While endotracheal intubation in the OR is a very safe and straightforward procedure with very low complication rate, emergency intubation of an unstable patient in the field is linked to a high rate of complication with up to 25% mortality in some studies. Emergency intubation remains a hazardous maneuver even under the best conditions. And no matter how skilled the prehospital team is, best conditions are seldom encountered in the field. This is why endotracheal intubation should ideally performed by skilled providers in patients who are likely to benefit from this technique. In a prehospital setting the indication to establish an airway is not always that obvious and depends on multiple factors (Figure 1
Severity of patients’ condition and the presence of hypoxia: Traumatic brain injury (TBI) is frequently associated with depressed level of consciousness, compromised protective airway reflexes or apnea, which can increase the risk of aspiration or result in hypoxemia and worsen the secondary brain damage. During the past 45 years, the quantitative GCS as a simple and practical numeric method for assessing impairment of the level of conscious has become the universal criterion for mental status assessment [10]. Consequently, the GCS is also a frequently used score to decide whether an intubation should be performed or not. According to the ATLS [1] and the practice management guidelines of the Eastern Association for the Surgery of Trauma [2] intubation is recommended for GCS ≤8. However, there is no scientific evidence supporting this practice. The dogma that patients with a GCS ≤ 8 are at higher risk for aspiration or hypoxic injury has now been challenged. A prospective study from Hong Kong, in 2012, showed that of 33 patients with a GCS ≤ 8 36.4% had intact airway reflexes and potentially capable of maintaining their own airway, whilst many patients with a GCS > 8 have impaired airway reflexes and potentially be at risk for aspiration [11].
The need for immediate establishment of an obstructed or impaired airway or hypoxia is unquestionably associated with better outcomes. However, performing an intubation in a suboptimal environment in the field, especially if performed by paramedics, may be challenging and require multiple attempts and in some cases may result in the loss of airway with catastrophic consequences. A difficult intubation may result in hypoxemia, aspiration, and hypotension, factors that may contribute to worse outcomes. Also, prehospital intubation and hand ventilation is often associated with hyperventilation and hypocapnia, which could worsen brain edema and secondary brain damage. Finally, prolonging the prehospital time and delaying definitive care, may have adverse effects on the patient, especially in the presence imminent herniation due to increased intracranial pressure (ICP) or an ongoing hemorrhage.
In conclusion, it is important to identify those patients who might benefit from prehospital endotracheal intubation and those who can potentially be harmed by the procedure. At this moment there is no class I evidence supporting any specific approach. It might be appropriate to attempt prehospital intubation in a small number of selected patients with imminent airway obstruction or hypoxia not responding to oxygen administration.
Training and skills of the EMS personnel and the available equipment: In the United States of America (USA) prehospital care is usually provided by emergency medical technicians for basic life support (BLS) or trained paramedics for advanced life support (ALS), whereas prehospital care in most European countries is provide by physicians. Basic providers are restricted to splinting, bandaging, alignment of displaced limbs, the administration of oxygen including BVM ventilation, chest compression and the use of an automated external defibrillator (AED) in case of cardiac arrest. However, especially in the USA many of BLS providers have obtained an intermediate level (EMT-I); these individuals can obtain a more definitive airway such as using a SGA device or even perform endotracheal intubation. Paramedics are trained and performed endotracheal intubation. However, very often many paramedics, especially in areas with no large trauma volumes may not use this skill very often and may become less competent with the procedure. On the other hand, especially an experienced physician proficient with endotracheal intubation, is more likely to perform an intubation more liberally, often unnecessarily. In the United States, prehospital care strategy follows the principle of “scoop and run” with prioritizing rapid patient transport to trauma centers and minimal interventions on scene. In Europe there is a strong element on field triage and initiation of more advanced therapeutic interventions, such as intubation. This prehospital strategy is also known as “stay and play”. A matched cohort study compared patients with isolated severe TBI in Switzerland and the United States [12]. In line with the described differences in prehospital strategies, patients in Switzerland had significantly longer scene times (23 vs. 9 minutes, p < 0.001) and prehospital endotracheal intubation was more frequently performed (31% vs. 18.7%, p = 0.034). However, no significant differences in outcomes were observed between the two cohorts. The results what prehospital strategy should be prioritized and if an endotracheal intubation should be performed remain controversial, although there is evidence that a “scoop and run” approach is preferable for penetrating trauma. In these scenarios the number of meaningful interventions that can be made by prehospital providers is limited and rapid transportation to the hospital is the most important aspect, because in-hospital surgery is typically needed for hemorrhage control.
Safety and environment on scene: The safety aspect on scene, as well as the transportation mode and the expected time to reach the next hospital are important for considering airway interventions on scene. Especially for longer transports, the time-saving aspect of the scoop and run approach without airway interventions becomes less important and early establishment of an airway may improve patient outcomes.
Prehospital airway-management. The indication to establish an airway in a prehospital setting depends on: the severity of patients’ condition and the presence of hypoxia; the training and skills of the EMS personnel including the available equipment; and the safety and environment on scene. Figure provided by Clerc EMS Monthey, Switzerland.
Considering all factors above, complexity of the decision to perform a prehospital intubation becomes obvious, and it is not surprising that the literature on this topic remains contradictory. A retrospective multicenter study including 13,625 patients with moderate to severe TBI showed that prehospital intubation was independently associated with a decrease in survival [13]. Several other studies implicated out-of-hospital intubation as a factor associated with negative outcomes [14, 15]. In a recently published study prehospital airway management in severe TBI patients did not have a significant impact on mortality or long-term neurological outcomes [16]. Other investigations have also demonstrated no difference or even improved outcomes with field intubation [17, 18].
Besides intubation, different other options for airway management are available in a prehospital setting. The simplest approaches such as the jaw thrust or chin lift maneuver are included in the first aid. Oropharyngeal (OPA) or nasopharyngeal (NPA) adjuncts may be inserted orally or nasally to secure an open airway. More advanced airway techniques include the establishment of an airway using an SGA device and finally the performance of endotracheal intubation. In particular cases, a surgical airway must also be considered. A major challenge in prehospital airway management is to determine the appropriate approach for the individual patient in the present environment and setting. Table 1 shows various airway management techniques and summarizes advantages and disadvantages in prehospital use.
Airway management techniques | Skills | Training needed | Time needed | Possible complications | Level of sedation/unconsciousness needed | Equipment needed | Protection against aspiration and airway shutdown | Ventilation possible without face mask |
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Trauma jaw thrust, trauma chin lift | ||||||||
Oropharyngeal airway, Nasopharyngeal airway | ||||||||
Laryngeal mask, laryngeal tube | ||||||||
Endotracheal intubation, surgical airway |
Overview of different airway management techniques—advantages and disadvantages in prehospital use.
A recently published systematic review [19] was assessing comparative benefits and harms across three different airway management approaches (BVM, SGA, and endotracheal intubation) for patients with trauma, cardiac arrest, or medical emergencies requiring prehospital ventilatory support or airway protection. Overall, 99 studies involving 630,397 patients from 1990 to September 2020 were considered for analysis. The evaluated outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Different meta-analyses were stratified first by study design (RCTs or observational studies), and then by emergency type (cardiac arrest, trauma, medical) and population age (adult, pediatric, mixed-age). All meta-analyses outcomes were reported as favoring one of the two compared approaches, or no difference. Sufficient evidence was not available to address all outcomes and all patient characteristics, provider characteristics, and variations in techniques that were specified a priori. For adult trauma patients 1-month post incidence survival was not different when BVM was compared to endotracheal intubation. Other comparisons for adult trauma patients did not show sufficient evidence to favor an airway management strategy over another. Potential harms of airway management for the entire study population were also compared. When comparing BVM vs. SGA and BVM vs. endotracheal intubation, no difference was found. When comparing SGA to endotracheal intubation, SGA was superior in terms of multiple insertion attempts; endotracheal intubation was superior in terms of inadequate ventilation. No difference was recorded for aspiration, oral/airway trauma and regurgitation. The authors concluded that the currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. However, most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.
Similar to the prehospital setting the standard indications for an advanced airway establishment in the ER, include low GCS, failure to maintain a patent airway and the inability to oxygenate and ventilate the patient adequately. In the presence of a TBI a diminished level of consciousness with the concern for the loss of airway control is very common and likely the most frequent indication for ER intubation. Therefore, the GCS is most commonly used to decide whether an intubation should be performed or not.
Patients with TBI and a GCS ≤ 8 have been traditionally managed by ER endotracheal intubation. However, this practice is based mainly on expert opinion and long-standing dogma. There is very little evidence to support this policy! Recent work has challenged this practice! A recently published study including patients with isolated severe head injuries suggested that routine endotracheal intubation in the ER for GCS of 7 and 8 may be even harmful [3]. In this study 2727 patients with GCS 7/8 and isolated blunt head trauma were included. Overall, 1866 (68.4%) patients were intubated within 1 hour of admission (immediate intubation), 223 (8.2%) had an intubation >1 hour of admission (delayed intubation), and 638 (23.4%) patients were not intubated at all. After correcting for age, gender, overall comorbidities, tachycardia, GCS, alcohol, illegal drug use, and head injury severity, immediate intubation was independently associated with higher mortality (OR 1.79, CI 95% 1.31–2.44, p < 0.001) and more overall complications (OR 2.46, CI 95% 1.62–3.73, p < 0.001).
A study [20] evaluating a general trauma population with GCS of 6–8 came to a similar conclusion. An intubation within 1 hour of arrival was associated with an increase in mortality and longer ICU and overall length of stay compared to patients without an intubation. The authors also performed a subgroup analysis of patients with head injury and found similar results to that of the overall trauma population.
These two studies showing worse outcomes associated with immediate intubation and suggest that the existing GCS threshold to mandate intubation in patients with isolated head injuries should be revisited.
Beside the GCS, additional clinical criteria may help to guide the decision to intubate TBI patients in the future. A recently published study showed that head abbreviated injury scale (AIS), tachycardia and younger age were independent clinical factors associated with intubation [3]. These factors could potentially be taken into account to formulate a more selective approach to immediate intubation. In the mentioned study a policy of intubating all isolated blunt head injury patients ≤45 years with head AIS 5 and GCS 7 would have improved intubation management, with 7 immediate instead of delayed intubations and only three potentially unnecessary intubations. If these defined criteria are met (high specificity), an early intubation should be strongly considered. On the other hand, the defined criteria are not suitable to identify patients who definitely do not require an intubation (low sensitivity). Future research should focus on defining more adequate clinical parameters to identify patients requiring immediate intubation and should avoid fixed GCS threshold.
Muakkassa et al. [21] compared trauma patients who were intubated because of combativeness, and not because of medical necessity. In line with the findings above intubating for combativeness was associated with longer hospital LOS, increased rates of pneumonia, and worse discharge status when compared with matched non-intubated patients. It appears that the risks and adverse events of intubation may outweigh the potential benefits of intubation in specific trauma populations.
Therefore, the following potential risks associated with intubation in TBI patients need to be considered by every health care provider. Laryngoscopy and the endotracheal tube can cause a sympathetic or parasympathetic stimulation. Sympathetic stimulation may increase heart rate, blood pressure [22] and ICP [23], whereas parasympathetic stimulation can trigger bronchospasm or hypotension. Especially the increase in ICP from the sympathetic surge can cause an increase in cerebral blood volume, cerebral edema, and development of worsening hemorrhage or hematoma. Finally, both, sympathetic and parasympathetic stimulations may increase mortality and brain injury.
Ventilation after intubation need to be monitored closely, because both hyper- and hypoventilation can contribute to worse outcomes. Severe hyperventilation (arterial pCO2 below 25 mm Hg) should be avoided due to the risk of vasoconstriction and cerebral ischemia. In general, a normo-ventilation with an arterial pCO2 within 35–45 mm Hg should be targeted. However, mild hyperventilation (arterial pCO2 within 30–34 mm Hg) is commonly used to address high intracranial pressure and may potentially be beneficial [24]. More important to address the elevated ICP in TBI patients is the initiation of hyperosmolar therapy with mannitol or hypertonic saline when additional bleeding is suspected [25].
Technical aspects and medications for endotracheal intubation carries also risks for TBI patients. The following section gives an overview including recommendations for pretreatment, induction, paralysis, and sedation of patients with TBI to prevent secondary brain damage.
Endotracheal intubation remains the gold standard for airway management in trauma patients and should be performed via the oral route and a manual in-line stabilization maneuver [26]. Rapid sequence induction (RSI) is widely used for emergency intubation and often considered as the gold standard for trauma patients. This technique uses a fast acting anesthetic in combination with a fast acting relaxant to achieve rapid intubation. Only a few people are aware that this technique was formally described by P. Safar back in 1970 [27]. The primary goal of this technique was to prevent regurgitation during induction of anesthesia in patients with bowel obstruction. Hypoxemia and hypotension were hardly considered at that time, when advanced monitoring and pulse oximetry were still tools of the future. From today’s point of view, this technique is not ideally suited to prevent hypoxemia and hypotension. While in standard OR practice, such short events will hardly result in more than a check on the Q/A sheet, they may have devastating consequences on outcomes in patients with TBI.
In addition, complication rate increases significantly with the number of intubation attempts, with a sharp increase if more than 2 attempts are needed [28]. This suggests that first pass success should be the gold standard in emergency intubation, and return to basic maneuvers or surgical airway should be considered if 2 attempts have failed.
Another important aspect is efficient airway clearance before intubation, which has been shown to significantly increase first pass success [29]. That is why suction of the airway, while having little relevance in the OR can be a game changer in emergency intubation.
Good oxygenation throughout the procedure is paramount in brain injured patients, so meticulous attention should be paid to optimizing precondition. A recent study [30] has shown that when intubation is attempted in a patient with a SpO2 < 93%, there is almost 100% incidence of severe hypoxemia while incidence goes down to 17% if SpO2 is 95% or more. While optimizing oxygenation status may take some time, it certainly pays off in terms of patient outcome.
Last but not least a close monitoring during intubation is mandatory. Studies have shown that episodes of hypoxemia during intubation attempts often go unrecognized, both in the field and in the ER. Furthermore, after intubation attention should be taken to avoid hyperventilation as it can cause hypocapnia and thus cerebral vasoconstriction; it also can impair venous return leading to hypotension. As trivial as it might seem, having a team member watching the vital signs is an important factor in the intubation process.
In the following section medication for pretreatment, induction, paralysis and sedation for endotracheal intubation in the presence of TBI are discussed.
There is currently no evidence to support the use of intravenous lidocaine as an intubation pretreatment for RSI in patients with TBI [23]. High-dose fentanyl (at 2–3 mcg/kg) can help to blunt the sympathetic stimulation of intubation and is currently recommended for neuroprotection in patients with increased ICP.
In TBI the induction with etomidate is popular all over the world because of its mild hemodynamic profile. Particularly, in TBI a drop in mean arterial pressure (MAP) and the subsequent decrease in cerebral perfusion pressure (CPP) may have devasting consequences. It’s important to be aware that etomidate has no analgesic properties, and neuroexcitation may need to be addressed separately.
Ketamine for induction is a good option, with the additional benefit of analgesic properties. The concern of sympathetic stimulation, leading to an increase in ICP is no longer valid. On the contrary, ketamine may, in fact, be neuroprotective due to an increase in MAP and CPP [31], without an increase in cerebral oxygen consumption or reducing regional glucose metabolism [32]. Ketamine may best be used for induction in the presence of hypotension because of for the described effect of increasing MAP and CPP [33].
For paralysis succinylcholine or rocuronium can be utilized [34]. Succinylcholine, as a depolarizing neuromuscular blocking agent has the advantage of rapid onset and offset properties, which is beneficial in TBI patients regarding early neurological examinations. Rocuronium on the other hand can lead to delays in proper neurological examinations due to prolonged paralysis. A retrospective study of 2016 compared 233 TBI patients requiring intubation in the ER. RSI was either performed with succinylcholine or rocuronium. Overall mortality rate was similar between the two groups. However, for patients with a high head AIS score (4–6), succinylcholine was associated with increased mortality compared with rocuronium (44% vs. 23%, odds ratio (OR) 4.10, 95% confidence interval (CI) 1.18–14.12; p = 0.026). Prospective studies are need to clarify these findings.
Propofol in TBI patients for post-intubation sedation is widely used and has the advantage of rapid onset of action and short duration of action. However, since it has no analgesic effect, it needs to be combined with medication for pain control. Furthermore, care should be taken in hypotensive patients because it may lower the MAP and subsequently the CPP. For post-intubation continuous sedation, a combination of propofol and fentanyl in the normotensive or hypertensive patient is therefore recommended. Fentanyl is a potent analgesia without appropriate sedation properties. While the hemodynamic properties of fentanyl are relatively stable, a decrease in MAP and HR frequently occur due to the cessation of the sympathetic stimulus triggered by pain. In addition, an increase in ICP has been described in several studies. A minimal appropriate dose for TBI patients is therefore recommended.
In hypotensive patients a combination of midazolam and fentanyl or ketamine alone is a good option. Midazolam as a sedative has the additional benefit of anxiolytic and anticonvulsant properties. Compared to propofol the effect on ICP and CPP are comparable. However, it’s important to have in mind that the onset and offset action of midazolam is initially relatively fast but tissue accumulation over time may be associated with delayed awakening. This is particularly disadvantageous in patients with TBI, as rapid clinical assessment after cessation of the drug is wanted.
A relatively new approach for emergency intubation is the delayed sequence induction (DSI) technique described by Weingart and colleagues [35]. In contrast to RSI, the technique of delayed sequence intubation temporally separates administration of the induction agent from the administration of the muscle relaxant to allow adequate pre-intubation preparation. This technique uses ketamine sedation to optimize preoxygenation with CPAP or assisted ventilation before muscle relaxant is given and intubation performed. Recent studies have shown an improved safety profile in emergency intubation using this technique. A ketamine-only breathing intubation, in which ketamine is used without a paralytic is another promising alternative. In this case the patient continues to breathe spontaneously, while ketamine provide hemodynamic benefits compared to standard RSI and is also a valuable agent for post-intubation analgesia and sedation. When RSI is not an optimal airway management strategy, ketamine’s unique pharmacology can be harnessed to facilitate alternative approaches that may increase patient safety [36].
Airway control is particularly important for patients with TBI because hypoxemia and hypercarbia may cause secondary brain damage.
In a prehospital setting the indication to establish an airway depends on multiple factors such as (a) severity of patients’ condition including the presence of hypoxia, (b) the training and skills of the EMS personnel including the available equipment, (c) the safety and environment on scene.
In the presence of a TBI a diminished level of consciousness with the concern for the loss of airway control is very common and likely the most frequent indication for intubation. Traditionally patients with TBI and Glasgow Coma Scale (GCS) ≤ 8 have been managed by prehospital or ER endotracheal intubation. However, recent evidence challenged this practice and even suggested that routine intubation may be harmful. There is evidence that intubation according to a strict GCS threshold is associated with risks and adverse events that may outweigh the potential benefits of intubation in TBI patients. Future research should focus on defining more adequate clinical parameters to identify patients requiring immediate intubation and should avoid fixed GCS threshold. Furthermore, less invasive airway management strategies such as BVM ventilation or the use of SGA devices may be equally effective and potentially associated with less complications. The cornerstone of prehospital airway management should focus on aggressive prevention and treatment of hypoxemia, hypotension, and, if the patient receiving positive pressure ventilation, prevention of hyperventilation. If an intubation is performed in a TBI patient induction with etomidate or ketamine in the presence of hypotension is recommended. For paralysis succinylcholine or rocuronium can be used. Recommendations for post-intubation continuous sedation medications include a combination of propofol and fentanyl in the normotensive or hypertensive patient. A combination of midazolam and fentanyl or ketamine alone should be considered in the hypotensive patient. Delayed sequence induction (DSI) or a ketamine-only intubation, in which ketamine is used without a paralytic are very promising options for emergency intubation and may become the standard of care in the future. The benefit of these strategies compared to RSI need to be confirmed in large randomized clinical trials.
We thank Clerc EMS Monthey, Switzerland for providing Figure 1.
The authors declare no conflict of interest.
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After almost 32 years of teaching at the University of Trás-os-Montes and Alto Douro, she recently moved to the University of Évora, Department of Veterinary Medicine, where she teaches in the field of Animal Reproduction and Clinics. Her primary research areas include the molecular markers of the endometrial cycle and the embryo–maternal interaction, including oxidative stress and the reproductive physiology and disorders of sexual development, besides the molecular determinants of male and female fertility. She often supervises students preparing their master's or doctoral theses. She is also a frequent referee for various journals.",institutionString:null,institution:{name:"University of Évora",country:{name:"Portugal"}}},{id:"283019",title:"Dr.",name:"Oudessa",middleName:null,surname:"Kerro Dego",slug:"oudessa-kerro-dego",fullName:"Oudessa Kerro Dego",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/283019/images/system/283019.png",biography:"Dr. Kerro Dego is a veterinary microbiologist with training in veterinary medicine, microbiology, and anatomic pathology. Dr. Kerro Dego is an assistant professor of dairy health in the department of animal science, the University of Tennessee, Institute of Agriculture, Knoxville, Tennessee. He received his D.V.M. (1997), M.S. (2002), and Ph.D. (2008) degrees in Veterinary Medicine, Animal Pathology and Veterinary Microbiology from College of Veterinary Medicine, Addis Ababa University, Ethiopia; College of Veterinary Medicine, Utrecht University, the Netherlands and Western College of Veterinary Medicine, University of Saskatchewan, Canada respectively. He did his Postdoctoral training in microbial pathogenesis (2009 - 2015) in the Department of Animal Science, the University of Tennessee, Institute of Agriculture, Knoxville, Tennessee. Dr. Kerro Dego’s research focuses on the prevention and control of infectious diseases of farm animals, particularly mastitis, improving dairy food safety, and mitigation of antimicrobial resistance. Dr. Kerro Dego has extensive experience in studying the pathogenesis of bacterial infections, identification of virulence factors, and vaccine development and efficacy testing against major bacterial mastitis pathogens. Dr. Kerro Dego conducted numerous controlled experimental and field vaccine efficacy studies, vaccination, and evaluation of immunological responses in several species of animals, including rodents (mice) and large animals (bovine and ovine).",institutionString:"University of Tennessee at Knoxville",institution:{name:"University of Tennessee at Knoxville",country:{name:"United States of America"}}},{id:"251314",title:"Dr.",name:"Juan Carlos",middleName:null,surname:"Gardón Poggi",slug:"juan-carlos-gardon-poggi",fullName:"Juan Carlos Gardón Poggi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/251314/images/system/251314.jpeg",biography:"Juan Carlos Gardón Poggi received University degree from the Faculty of Agrarian Science in Argentina, in 1983. Also he received Masters Degree and PhD from Córdoba University, Spain. He is currently a Professor at the Catholic University of Valencia San Vicente Mártir, at the Department of Medicine and Animal Surgery. He teaches diverse courses in the field of Animal Reproduction and he is the Director of the Veterinary Farm. He also participates in academic postgraduate activities at the Veterinary Faculty of Murcia University, Spain. His research areas include animal physiology, physiology and biotechnology of reproduction either in males or females, the study of gametes under in vitro conditions and the use of ultrasound as a complement to physiological studies and development of applied biotechnologies. Routinely, he supervises students preparing their doctoral, master thesis or final degree projects.",institutionString:null,institution:{name:"Valencia Catholic University Saint Vincent Martyr",country:{name:"Spain"}}},{id:"309529",title:"Dr.",name:"Albert",middleName:null,surname:"Rizvanov",slug:"albert-rizvanov",fullName:"Albert Rizvanov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/309529/images/9189_n.jpg",biography:'Albert A. Rizvanov is a Professor and Director of the Center for Precision and Regenerative Medicine at the Institute of Fundamental Medicine and Biology, Kazan Federal University (KFU), Russia. He is the Head of the Center of Excellence “Regenerative Medicine” and Vice-Director of Strategic Academic Unit \\"Translational 7P Medicine\\". Albert completed his Ph.D. at the University of Nevada, Reno, USA and Dr.Sci. at KFU. He is a corresponding member of the Tatarstan Academy of Sciences, Russian Federation. Albert is an author of more than 300 peer-reviewed journal articles and 22 patents. He has supervised 11 Ph.D. and 2 Dr.Sci. dissertations. Albert is the Head of the Dissertation Committee on Biochemistry, Microbiology, and Genetics at KFU.\nORCID https://orcid.org/0000-0002-9427-5739\nWebsite https://kpfu.ru/Albert.Rizvanov?p_lang=2',institutionString:"Kazan Federal University",institution:{name:"Kazan Federal University",country:{name:"Russia"}}},{id:"210551",title:"Dr.",name:"Arbab",middleName:null,surname:"Sikandar",slug:"arbab-sikandar",fullName:"Arbab Sikandar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210551/images/system/210551.jpg",biography:"Dr. Arbab Sikandar, PhD, M. Phil, DVM was born on April 05, 1981. He is currently working at the College of Veterinary & Animal Sciences as an Assistant Professor. He previously worked as a lecturer at the same University. \nHe is a Member/Secretory of Ethics committee (No. CVAS-9377 dated 18-04-18), Member of the QEC committee CVAS, Jhang (Regr/Gen/69/873, dated 26-10-2017), Member, Board of studies of Department of Basic Sciences (No. CVAS. 2851 Dated. 12-04-13, and No. CVAS, 9024 dated 20/11/17), Member of Academic Committee, CVAS, Jhang (No. CVAS/2004, Dated, 25-08-12), Member of the technical committee (No. CVAS/ 4085, dated 20,03, 2010 till 2016).\n\nDr. Arbab Sikandar contributed in five days hands-on-training on Histopathology at the Department of Pathology, UVAS from 12-16 June 2017. He received a Certificate of appreciation for contributions for Popularization of Science and Technology in the Society on 17-11-15. He was the resource person in the lecture series- ‘scientific writing’ at the Department of Anatomy and Histology, UVAS, Lahore on 29th October 2015. He won a full fellowship as a principal candidate for the year 2015 in the field of Agriculture, EICA, Egypt with ref. to the Notification No. 12(11) ACS/Egypt/2014 from 10 July 2015 to 25th September 2015.; he received a grant of Rs. 55000/- as research incentives from Director, Advanced Studies and Research, UVAS, Lahore upon publications of research papers in IF Journals (DR/215, dated 19-5-2014.. He obtained his PhD by winning a HEC Pakistan indigenous Scholarship, ‘Ph.D. fellowship for 5000 scholars – Phase II’ (2av1-147), 17-6/HEC/HRD/IS-II/12, November 15, 2012. \n\nDr. Sikandar is a member of numerous societies: Registered Veterinary Medical Practitioner (life member) and Registered Veterinary Medical Faculty of Pakistan Veterinary Medical Council. The Registration code of PVMC is RVMP/4298 and RVMF/ 0102.; Life member of the University of Veterinary and Animal Sciences, Lahore, Alumni Association with S# 664, dated: 6-4-12. ; Member 'Vets Care Organization Pakistan” with Reference No. VCO-605-149, dated 05-04-06. :Member 'Vet Crescent” (Society of Animal Health and Production), UVAS, Lahore.",institutionString:"University of Veterinary & Animal Science",institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}},{id:"311663",title:"Dr.",name:"Prasanna",middleName:null,surname:"Pal",slug:"prasanna-pal",fullName:"Prasanna Pal",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311663/images/13261_n.jpg",biography:null,institutionString:null,institution:{name:"National Dairy Research Institute",country:{name:"India"}}},{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. Dr. Rutland has also written popular science books for the public. https://orcid.org/0000-0002-2009-4898. www.nottingham.ac.uk/vet/people/catrin.rutland",institutionString:null,institution:{name:"University of Nottingham",country:{name:"United Kingdom"}}},{id:"283315",title:"Prof.",name:"Samir",middleName:null,surname:"El-Gendy",slug:"samir-el-gendy",fullName:"Samir El-Gendy",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRduYQAS/Profile_Picture_1606215849748",biography:"Samir El-Gendy is a Professor of anatomy and embryology at the faculty of veterinary medicine, Alexandria University, Egypt. Samir obtained his PhD in veterinary science in 2007 from the faculty of veterinary medicine, Alexandria University and has been a professor since 2017. Samir is an author on 24 articles at Scopus and 12 articles within local journals and 2 books/book chapters. His research focuses on applied anatomy, imaging techniques and computed tomography. Samir worked as a member of different local projects on E-learning and he is a board member of the African Association of Veterinary Anatomists and of anatomy societies and as an associated author at local and international journals. Orcid: https://orcid.org/0000-0002-6180-389X",institutionString:null,institution:{name:"Alexandria University",country:{name:"Egypt"}}},{id:"246149",title:"Dr.",name:"Valentina",middleName:null,surname:"Kubale",slug:"valentina-kubale",fullName:"Valentina Kubale",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/246149/images/system/246149.jpg",biography:"Valentina Kubale is Associate Professor of Veterinary Medicine at the Veterinary Faculty, University of Ljubljana, Slovenia. Since graduating from the Veterinary faculty she obtained her PhD in 2007, performed collaboration with the Department of Pharmacology, University of Copenhagen, Denmark. She continued as a post-doctoral fellow at the University of Copenhagen with a Lundbeck foundation fellowship. She is the editor of three books and author/coauthor of 23 articles in peer-reviewed scientific journals, 16 book chapters, and 68 communications at scientific congresses. Since 2008 she has been the Editor Assistant for the Slovenian Veterinary Research journal. She is a member of Slovenian Biochemical Society, The Endocrine Society, European Association of Veterinary Anatomists and Society for Laboratory Animals, where she is board member.",institutionString:"University of Ljubljana",institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"258334",title:"Dr.",name:"Carlos Eduardo",middleName:null,surname:"Fonseca-Alves",slug:"carlos-eduardo-fonseca-alves",fullName:"Carlos Eduardo Fonseca-Alves",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/258334/images/system/258334.jpg",biography:"Dr. Fonseca-Alves earned his DVM from Federal University of Goias – UFG in 2008. He completed an internship in small animal internal medicine at UPIS university in 2011, earned his MSc in 2013 and PhD in 2015 both in Veterinary Medicine at Sao Paulo State University – UNESP. Dr. Fonseca-Alves currently serves as an Assistant Professor at Paulista University – UNIP teaching small animal internal medicine.",institutionString:null,institution:{name:"Universidade Paulista",country:{name:"Brazil"}}},{id:"245306",title:"Dr.",name:"María Luz",middleName:null,surname:"Garcia Pardo",slug:"maria-luz-garcia-pardo",fullName:"María Luz Garcia Pardo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/245306/images/system/245306.png",biography:"María de la Luz García Pardo is an agricultural engineer from Universitat Politècnica de València, Spain. She has a Ph.D. in Animal Genetics. Currently, she is a lecturer at the Agrofood Technology Department of Miguel Hernández University, Spain. Her research is focused on genetics and reproduction in rabbits. The major goal of her research is the genetics of litter size through novel methods such as selection by the environmental sensibility of litter size, with forays into the field of animal welfare by analysing the impact on the susceptibility to diseases and stress of the does. Details of her publications can be found at https://orcid.org/0000-0001-9504-8290.",institutionString:null,institution:{name:"Miguel Hernandez University",country:{name:"Spain"}}},{id:"350704",title:"M.Sc.",name:"Camila",middleName:"Silva Costa",surname:"Ferreira",slug:"camila-ferreira",fullName:"Camila Ferreira",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/350704/images/17280_n.jpg",biography:"Graduated in Veterinary Medicine at the Fluminense Federal University, specialist in Equine Reproduction at the Brazilian Veterinary Institute (IBVET) and Master in Clinical Veterinary Medicine and Animal Reproduction at the Fluminense Federal University. She has experience in analyzing zootechnical indices in dairy cattle and organizing events related to Veterinary Medicine through extension grants. I have experience in the field of diagnostic imaging and animal reproduction in veterinary medicine through monitoring and scientific initiation scholarships. I worked at the Equus Central Reproduction Equine located in Santo Antônio de Jesus – BA in the 2016/2017 breeding season. I am currently a doctoral student with a scholarship from CAPES of the Postgraduate Program in Veterinary Medicine (Pathology and Clinical Sciences) at the Federal Rural University of Rio de Janeiro (UFRRJ) with a research project with an emphasis on equine endometritis.",institutionString:null,institution:null},{id:"41319",title:"Prof.",name:"Lung-Kwang",middleName:null,surname:"Pan",slug:"lung-kwang-pan",fullName:"Lung-Kwang Pan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41319/images/84_n.jpg",biography:null,institutionString:null,institution:null},{id:"125292",title:"Dr.",name:"Katy",middleName:null,surname:"Satué Ambrojo",slug:"katy-satue-ambrojo",fullName:"Katy Satué Ambrojo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/125292/images/system/125292.jpeg",biography:"Katy Satué Ambrojo received her Veterinary Medicine degree, Master degree in Equine Technology and doctorate in Veterinary Medicine from the Faculty of Veterinary, CEU-Cardenal Herrera University in Valencia, Spain.Dr. Satué is accredited as a Private University Doctor Professor, Doctor Assistant, and Contracted Doctor by AVAP (Agència Valenciana d'Avaluació i Prospectiva) and currently, as a full professor by ANECA (since January 2022). To date, Katy has taught 22 years in the Department of Animal Medicine and Surgery at the CEU-Cardenal Herrera University in undergraduate courses in Veterinary Medicine (General Pathology, integrated into the Applied Basis of Veterinary Medicine module of the 2nd year, Clinical Equine I of 3rd year, and Equine Clinic II of 4th year). Dr. Satué research activity is in the field of Endocrinology, Hematology, Biochemistry, and Immunology in the Spanish Purebred mare. She has directed 5 Doctoral Theses and 5 Diplomas of Advanced Studies, and participated in 11 research projects as a collaborating researcher. She has written 2 books and 14 book chapters in international publishers related to the area, and 68 scientific publications in international journals. Dr. Satué has attended 63 congresses, participating with 132 communications in international congresses and 19 in national congresses related to the area. Dr. Satué is a scientific reviewer for various prestigious international journals such as Animals, American Journal of Obstetrics and Gynecology, Veterinary Clinical Pathology, Journal of Equine Veterinary Science, Reproduction in Domestic Animals, Research Veterinary Science, Brazilian Journal of Medical and Biological Research, Livestock Production Science and Theriogenology, among others. Since 2014 she has been responsible for the Clinical Analysis Laboratory of the CEU-Cardenal Herrera University Veterinary Clinical Hospital.",institutionString:null,institution:null},{id:"201721",title:"Dr.",name:"Beatrice",middleName:null,surname:"Funiciello",slug:"beatrice-funiciello",fullName:"Beatrice Funiciello",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/201721/images/11089_n.jpg",biography:"Graduated from the University of Milan in 2011, my post-graduate education included CertAVP modules mainly on equines (dermatology and internal medicine) and a few on small animal (dermatology and anaesthesia) at the University of Liverpool. After a general CertAVP (2015) I gained the designated Certificate in Veterinary Dermatology (2017) after taking the synoptic examination and then applied for the RCVS ADvanced Practitioner status. After that, I completed the Postgraduate Diploma in Veterinary Professional Studies at the University of Liverpool (2018). My main area of work is cross-species veterinary dermatology.",institutionString:null,institution:null},{id:"291226",title:"Dr.",name:"Monica",middleName:null,surname:"Cassel",slug:"monica-cassel",fullName:"Monica Cassel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/291226/images/8232_n.jpg",biography:'Degree in Biological Sciences at the Federal University of Mato Grosso with scholarship for Scientific Initiation by FAPEMAT (2008/1) and CNPq (2008/2-2009/2): Project \\"Histological evidence of reproductive activity in lizards of the Manso region, Chapada dos Guimarães, Mato Grosso, Brazil\\". Master\\\'s degree in Ecology and Biodiversity Conservation at Federal University of Mato Grosso with a scholarship by CAPES/REUNI program: Project \\"Reproductive biology of Melanorivulus punctatus\\". PhD\\\'s degree in Science (Cell and Tissue Biology Area) \n at University of Sao Paulo with scholarship granted by FAPESP; Project \\"Development of morphofunctional changes in ovary of Astyanax altiparanae Garutti & Britski, 2000 (Teleostei, Characidae)\\". She has experience in Reproduction of vertebrates and Morphology, with emphasis in Cellular Biology and Histology. She is currently a teacher in the medium / technical level courses at IFMT-Alta Floresta, as well as in the Bachelor\\\'s degree in Animal Science and in the Bachelor\\\'s degree in Business.',institutionString:null,institution:null},{id:"442807",title:"Dr.",name:"Busani",middleName:null,surname:"Moyo",slug:"busani-moyo",fullName:"Busani Moyo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Gwanda State University",country:{name:"Zimbabwe"}}},{id:"439435",title:"Dr.",name:"Feda S.",middleName:null,surname:"Aljaser",slug:"feda-s.-aljaser",fullName:"Feda S. Aljaser",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"423023",title:"Dr.",name:"Yosra",middleName:null,surname:"Soltan",slug:"yosra-soltan",fullName:"Yosra Soltan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Alexandria University",country:{name:"Egypt"}}},{id:"349788",title:"Dr.",name:"Florencia Nery",middleName:null,surname:"Sompie",slug:"florencia-nery-sompie",fullName:"Florencia Nery Sompie",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sam Ratulangi University",country:{name:"Indonesia"}}},{id:"428600",title:"MSc.",name:"Adriana",middleName:null,surname:"García-Alarcón",slug:"adriana-garcia-alarcon",fullName:"Adriana García-Alarcón",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}},{id:"428599",title:"MSc.",name:"Gabino",middleName:null,surname:"De La Rosa-Cruz",slug:"gabino-de-la-rosa-cruz",fullName:"Gabino De La Rosa-Cruz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}},{id:"428601",title:"MSc.",name:"Juan Carlos",middleName:null,surname:"Campuzano-Caballero",slug:"juan-carlos-campuzano-caballero",fullName:"Juan Carlos Campuzano-Caballero",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}}]}},subseries:{item:{id:"95",type:"subseries",title:"Urban Planning and Environmental Management",keywords:"Circular Economy, Contingency Planning and Response to Disasters, Ecosystem Services, Integrated Urban Water Management, Nature-based Solutions, Sustainable Urban Development, Urban Green Spaces",scope:"