*Review* **Digitalization for Sustainable Agri-Food Systems: Potential, Status, and Risks for the MENA Region**

**Rachel A. Bahn 1, Abed Al Kareem Yehya 1 and Rami Zurayk 2,\***

**Abstract:** Digital technologies offer a potential solution to improve sustainability—economic, social, and environmental—of agri-food systems around the globe. While developed countries have led the innovation and adoption of digital agriculture, the potential impact in developing countries including in the Middle East and North Africa (MENA) region—is massive. This article synthesizes existing evidence to review the potential and current contribution of digital technologies to the agri-food sectors in MENA. Digital agriculture shows promise in addressing the key challenges facing the agri-food sector across MENA countries. Improvements in primary production, supply chain and logistics performance, and optimized use of scarce natural resources (notably agricultural water) could be notable, if digital technologies can be implemented as envisioned. Available evidence shows that adoption of digital agriculture is at early stages, generally led by high-value agricultural production targeting domestic markets in Gulf countries and export markets in Mashreq countries. Economic sustainability appears the strongest force for current adoption, with less focus on social or environmental sustainability. Public policies should not only foster the adoption of digital technologies in MENA but also ensure equity of access, transparency of use, data protections, and labor protections. Policymakers should move beyond traditional, production-centric views to deliver also on social and environmental sustainability.

**Keywords:** productivity; efficiency; sustainability; food security; agriculture; digital agriculture; smart farming; digitalization; digital technologies; Middle East and North Africa


**3. Intra-arterial chemotherapy for retinoblastoma**

Intra-arterial chemotherapy (IAC), also known as ophthalmic artery chemosurgery (OAC), is an important treatment strategy for retinoblastoma that evolved rapidly and gained popularity worldwide. Today, this modality of treatment is being performed in many retinoblastoma treatment centers located in more than 45 countries across the globe [28]. This treatment modality was initially explored by Reese et al. [3] who directly injected the alkylating agent triethylene melamine (TEM) into the internal carotid artery; nevertheless, it was not until 2006 when Abramson and Gobin introduced the novel technique of super-selective ophthalmic artery catheterization via transfemoral artery approach which allowed immediate and effectual delivery of the administered agent (melphalan) into the diseased eye [29]. Thereafter, many oncology centers adopted this technique and started publishing their experience. In this section, we will be shedding the light on the important aspects and most recent results of IAC.

#### **3.1 Indications**

IAC opened the door to a new era in the treatment of retinoblastoma. The key exciting factor behind this local therapy is its ability to achieve adequate therapeutic intraocular concentrations of the delivered chemotherapeutic agents while minimizing the systemic toxicity induced by these infused drugs such as neutropenia and secondary tumors [30]. In view of this, IAC is utilized mainly in treating patients with intraocular disease without local or systemic spread. Previous studies on IAC have shown that it can be used successfully as a primary retinoblastoma treatment in

**75**

**3.2 IAC technique**

**3.3 Chemotherapeutic agents**

systemic side effects [34].

*Retinoblastoma Management: Advances in Chemotherapy*

naïve eyes (no previous therapy employed) or as a secondary treatment in eyes with recurrent or residual tumor after trying other treatment modalities such as systemic chemotherapy, external beam radiotherapy and others [29, 31–37]. Currently, the common indications for IAC in retinoblastoma patients include unilateral retinoblastoma that cannot be halted by local treatments alone (e.g., cryotherapy or laser photocoagulation) and advanced unilateral retinoblastoma (such as group D and E based on the ICRB) [30]. Several studies had previously reported the following advantages of using IAC in patients with group D retinoblastoma: better eye conservation rates and greater visual acuity compared to systemic chemotherapy, shorter treatment period and ability to repeat the therapy several times using multiple agents without endangering the patients' life and vision [28, 38]. It is also noteworthy to mention that IAC can save naïve eyes with advanced retinoblastoma from enucleation particularly when subretinal seeding is present (2 year ocular survival rate of 83%) [39]. Furthermore, IAC has a proven benefit even in patients presenting with advanced disease such as those having retinoblastoma-induced total or partial retinal detachment in which it can successfully achieve retinal re-attachment and thus help

in preserving the eye and the life with the least possible side effects [40, 41].

is probably attributed to their inherent genetic predisposition [42, 43].

available, however, this is out of the scope of this chapter [34].

Simultaneous IAC (tandem therapy) to both eyes consecutively is also a valuable and safe treatment method in patients with bilateral germline retinoblastoma whether used primarily or secondarily. This was demonstrated in two recent studies, which reported excellent globe salvage rates (ocular survival rate > 90%) even in patients with advanced disease. Despite that the safety profile of this simultaneous therapy was considerably high where no treatment-associated deaths occurred, these children were still at risk of secondary tumors such as pineoblastoma and this

The technique of IAC is carried out on patients who are generally anesthetized and is usually coordinated by a specialized and experienced oncology/radiology team. The common femoral artery on the ipsilateral treatment side is usually used to gain access to the internal carotid artery and then the ophthalmic artery (OA) is selectively catheterized under fluoroscopic guidance at its ostium (origin) while heparin is infused intravenously to prevent coagulation. Then, in order to verify the proper placement of the microcatheter, selective angiography is done by contrast infusion to delineate the vascular anatomy and ocular perfusion. Due to the variability of vascular territory anatomy and blood flow patterns, OA catheterization might fail and other routes are

The most commonly used intra-arterial chemotherapeutic agent is melphalan,

a potent alkylating agent. Melphalan is by far the strongest chemotherapeutic drug acting effectually against human retinoblastoma cells [44]. It is very safe when administered locally but very toxic when infused systemically due to the resultant severe myelosuppression [45]. In fact, it is currently considered an ideal agent due to its favorable safety profile, short half-life and ability to be used in combination with other agents to achieve greater tumor control when needed [34, 46]. Topotecan, a topoisomerase inhibitor, and carboplatin, an alkylating agent, are other agents that have been used alone or as a part of a multi-drug regimen in advanced cases that fail to respond to melphalan solitarily or in bilateral tandem therapy where the dose of melphalan is decreased to prevent

*DOI: http://dx.doi.org/10.5772/intechopen.86820*

#### *Retinoblastoma Management: Advances in Chemotherapy DOI: http://dx.doi.org/10.5772/intechopen.86820*

*Retinoblastoma - Past, Present and Future*

vulnerable subset of patients [23].

**2.4 Outcomes and success rate**

in patients receiving it [26].

does not seem that IVC increases the risk ominously. A long term follow-up study demonstrated that the rate of secondary tumors in germline retinoblastoma patients treated with systemic chemotherapy was 4%, which is less than expected for this

The introduction of systemic chemotherapy resulted in an improved eye salvage rate, not to mention the enhanced visual outcome. Chemoreduction success can be predicted in patients with retinoblastoma following the ICRB classification as following: 100% in group A, 93% in group B, 90% in group C and <50% in group D and E [24]. The success rate in the advanced stages can be augmented when combining IVC with other modalities of treatment such as IAC or IVitC. Long-term studies have shown that chemotherapy with or without adjunctive therapies maintains ambulatory vision of ≥6/60 in almost two-thirds of the patients, particularly those with multiple tumors and/or no foveolar tumors [25]. Furthermore, IVC seems to exert a protective effect against pineoblastoma as its occurrence is usually very low

The effect of systemic chemotherapy as a monotherapy appears to be satisfactory especially in patients with less advanced disease whereas in patients with advanced disease, its remedial action is complementary to the selective recent therapies. A recently published meta-analysis comparing IVC to the more selective IAC revealed that both methods are equivalent in terms of tumor recurrence and metastasis. IAC evidently had a higher total success rate and ocular sparing effect in group D patients compared to IVC [27]. Despite this, we believe that IVC will continue to be an integral part of the treatment regimen of retinoblastoma.

Intra-arterial chemotherapy (IAC), also known as ophthalmic artery chemosurgery (OAC), is an important treatment strategy for retinoblastoma that evolved rapidly and gained popularity worldwide. Today, this modality of treatment is being performed in many retinoblastoma treatment centers located in more than 45 countries across the globe [28]. This treatment modality was initially explored by Reese et al. [3] who directly injected the alkylating agent triethylene melamine (TEM) into the internal carotid artery; nevertheless, it was not until 2006 when Abramson and Gobin introduced the novel technique of super-selective ophthalmic artery catheterization via transfemoral artery approach which allowed immediate and effectual delivery of the administered agent (melphalan) into the diseased eye [29]. Thereafter, many oncology centers adopted this technique and started publishing their experience. In this section, we will be shedding the light on the important

IAC opened the door to a new era in the treatment of retinoblastoma. The key exciting factor behind this local therapy is its ability to achieve adequate therapeutic intraocular concentrations of the delivered chemotherapeutic agents while minimizing the systemic toxicity induced by these infused drugs such as neutropenia and secondary tumors [30]. In view of this, IAC is utilized mainly in treating patients with intraocular disease without local or systemic spread. Previous studies on IAC have shown that it can be used successfully as a primary retinoblastoma treatment in

**3. Intra-arterial chemotherapy for retinoblastoma**

aspects and most recent results of IAC.

**74**

**3.1 Indications**

naïve eyes (no previous therapy employed) or as a secondary treatment in eyes with recurrent or residual tumor after trying other treatment modalities such as systemic chemotherapy, external beam radiotherapy and others [29, 31–37]. Currently, the common indications for IAC in retinoblastoma patients include unilateral retinoblastoma that cannot be halted by local treatments alone (e.g., cryotherapy or laser photocoagulation) and advanced unilateral retinoblastoma (such as group D and E based on the ICRB) [30]. Several studies had previously reported the following advantages of using IAC in patients with group D retinoblastoma: better eye conservation rates and greater visual acuity compared to systemic chemotherapy, shorter treatment period and ability to repeat the therapy several times using multiple agents without endangering the patients' life and vision [28, 38]. It is also noteworthy to mention that IAC can save naïve eyes with advanced retinoblastoma from enucleation particularly when subretinal seeding is present (2 year ocular survival rate of 83%) [39]. Furthermore, IAC has a proven benefit even in patients presenting with advanced disease such as those having retinoblastoma-induced total or partial retinal detachment in which it can successfully achieve retinal re-attachment and thus help in preserving the eye and the life with the least possible side effects [40, 41].

Simultaneous IAC (tandem therapy) to both eyes consecutively is also a valuable and safe treatment method in patients with bilateral germline retinoblastoma whether used primarily or secondarily. This was demonstrated in two recent studies, which reported excellent globe salvage rates (ocular survival rate > 90%) even in patients with advanced disease. Despite that the safety profile of this simultaneous therapy was considerably high where no treatment-associated deaths occurred, these children were still at risk of secondary tumors such as pineoblastoma and this is probably attributed to their inherent genetic predisposition [42, 43].

## **3.2 IAC technique**

The technique of IAC is carried out on patients who are generally anesthetized and is usually coordinated by a specialized and experienced oncology/radiology team. The common femoral artery on the ipsilateral treatment side is usually used to gain access to the internal carotid artery and then the ophthalmic artery (OA) is selectively catheterized under fluoroscopic guidance at its ostium (origin) while heparin is infused intravenously to prevent coagulation. Then, in order to verify the proper placement of the microcatheter, selective angiography is done by contrast infusion to delineate the vascular anatomy and ocular perfusion. Due to the variability of vascular territory anatomy and blood flow patterns, OA catheterization might fail and other routes are available, however, this is out of the scope of this chapter [34].


*5.1. Findings*

Our first research question was: How have education finance, economic development, and educational systems influenced tertiary short-cycle vocational education after controlling for population characteristics? The review of policy literature demonstrates the commitment of national governments to invest in VET education, a pattern evident in both the EU and ASEAN nations. The EU guides economic, educational, and social policies that promote national development.

All except one of the developed nations providing World Bank data were European. New Zealand, the additional case, had followed a British developmental pattern and was thus influenced by the UK system and traditions, as was Ireland (included as a case). In the early 1980s, nations in the British Commonwealth began transforming technical programs into more advanced collegiate programs. The ASEAN countries in Southeast Asia, including some Islamic countries, engaged in this process with the support of the Colombo Plan Staff College. These initiatives supported autonomous development, moving through the post-colonial stage, and collective inter-governmental efforts promoting the indigenous social and economic development of member countries in Asia and the Pacific region.

Some less-developed European nations providing data had been in the Soviet bloc. Post-Soviet countries were slower to create competitive postsecondary systems because of central control, the factory-like approach, and corrupt admissions, with wealthy families buying access [101,102]. In contrast, the former Soviet countries in the EU passed through the development barrier and have obtained higher GDP per capita. Of course, selection into the EU is vital because the EU's economy, workforce, education, and social openness provide more avenues for development.

The longitudinal trend analysis revealed changing patterns of trade and manufacturing after 2012 in less-developed countries, with an upward trajectory for enrollment in shortcycle courses before 2007. There were also changes in manufacturing patterns, with lessdeveloped countries producing less manufacturing output and the developed nations increasing their manufacturing after 2012. However, changes in the supply chain were not the only factor.

The less-developed nations started spending more on tertiary education after 2014, as the European countries had throughout the period studied. The regression analysis demonstrates that tertiary spending as a share of all government spending on education bears a statistically significant and positive relationship with short-cycle tertiary enrollment. The impact of population size on enrollment in short-cycle programs ceased to be statistically significant in the second step of the fixed-effects analysis. We expect these findings would be different had China and India provided data. However, the question is beyond the parameters of our study. Thus, the European and less-developed nations in this study shifted VET programs from short-cycle to bachelor's level programs, a pattern of educational development that differs substantially from the US. The Biden administration's investment in building infrastructure, computer chips, and the environment could influence demand

for technical and vocational programs. The movement toward bachelor's programs in US community colleges [103] could also result in a meaningful and substantial change.

The second research question was: Do the influences of education finance, economic development, and educational systems on short-cycle tertiary education (primarily vocational and technical programs) differ between developed and less-developed countries? The best indicator of putting policy into practice is public investment. Among the nations providing World Bank data, we found that public spending on tertiary education was a key indicator of participation in VET education.

Collaboration within regional trade and education also appears to be a crucial factor in this period of global trade. Commonwealth nations engaged in innovation during economic globalization in the 1980s, especially in Southeast Asia. The evolution of the EU as an organizing entity fostering within-region trade and educational exchange seems to have accelerated economic development and supported economic equity better than in the USA. The UK becomes an exceptional case within this pattern. It pioneered upgrading technical education, influencing educational growth in Southeast Asia, Australia, and New Zealand. Still, Brexit symbolizes a go-it-alone strategy that differs substantially from the productive pattern of regional cooperation in education and trade evident in EU and ASEAN nations. It remains to be seen whether the UK's recent development of a trade agreement with the EU will change Brexit's apparent negative economic consequences.

#### *5.2. Implications*

These analyses have implications for economic and educational development across nations, particularly those countries included in the dataset. While neoliberal policy dominated the international trajectory in education and economic development early in the twenty-first century, national economies have entered a period of uncertainty and deep conflict about future directions. Underlying the new uncertainty lurk tensions between the development of democratic institutions promoting equity and support for uplift across generations, including short-cycle technical and vocational education preparing workers for new industries in a global economy.

The challenges created by the decline of democratic institutions are now evident in many nations. Many less-developed countries have not overcome totalitarian governments. Some Latin American nations suffer from elected leaders using demagogic tactics to maintain power [104]. Further, the development of universities in post-Soviet countries is hampered by the legacy of central control in government and universities [102]. The EU strategy supports the capacity of rising generations to learn, work, and engage in economic development. The current period of uncertainty affects citizens, students, administrators, and policymakers seeking a better financial future with stable social structures.

**Author Contributions:** Conceptualization, L.Y.; methodology, L.Y. and E.P.S.J.; software, L.Y.; validation, L.Y.; formal analysis, L.Y. and E.P.S.J.; investigation, L.Y. and E.P.S.J.; resources, L.Y. and E.P.S.J.; data curation, L.Y.; writing—original draft preparation, L.Y. and E.P.S.J.; writing—review and editing, L.Y. and E.P.S.J.; visualization, L.Y.; supervision, L.Y. and E.P.S.J.; project administration, L.Y. and E.P.S.J.; funding acquisition, E.P.S.J. All authors have read and agreed to the published version of the manuscript.

**Funding:** This Special Issue Was Funded by the International Joint Research Project "Education Development and Social Justice", Faculty of Education, Beijing Normal University.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** This study draws data from the World Development Indicators (WDI) published by the World Bank. The data are publicly available online: https://databank.worldbank. org/source/world-development-indicators (accessed on 24 May 2023).

**Conflicts of Interest:** The authors declare no conflict of interest.


(2) The Level-3 model

Notable evolutions of estuarine morphology generally take days, months, or even years, which is much slower than the variations of flow and sediment concentration fields. Impacts of short-term morphology evolutions of riverbeds on tidal currents and sediment transport are also minor. Using these facts, an accelerated calculation of bed deformations could be incorporated in sediment models through multiplying the flux of sediment exchange (between the flow and the riverbed) by a morphological scale factor [10,13,14]. This kind of model is called the Level-3 model.

For a Level-3 model, upstream boundary conditions (e.g., river discharges and sediment concentrations) of a given time interval are set with the average data in this time interval (often a month). Monthly averaged data is used to set the upstream boundary conditions, while water levels of two full-period neap-spring tides are imposed at seaward boundaries. As a result, for each month, only the process of two full neap-spring tides is simulated, and the bed deformation is scaled by a morphological scale factor. Obviously, a Level-3 model using a morphological scale factor does not simulate the real process of the flow, sediment transport, and bed evolution in the estuary.

(3) The Level-2 model

On the one hand, in an estuary, the rate of bed deformation is generally much slower than that of flow evolution, so a Level-1 model is not necessary. On the other hand, the Level-3 model does not simulate a real process of flow-sediment-riverbed evolution. In this study, the real hydrological and tidal processes are simulated. At each time step of a simulation, the calculation of hydrodynamics is done first, and the sediment transport is then solved, followed by a timely riverbed update. This kind of model is called the Level-2 model. Obviously, it is simpler than the Level-1 model and is expected to achieve higher accuracy than the widely used Level-3 model.

### *5.3. Di*ff*erences between the Spillover of Saltwater and Sediment*

A few quantitative studies on the spillover of saltwater from the North to the South Branches have been reported. Gu et al. [51] found that the spillover of saltwater might occur when the upstream runo ff was less than 30,000 m3/s and the tidal range at Station QLG was greater than 2 m, and became remarkable when the upstream runo ff was less than 20,000 m3/s and the tidal range at Station QLG was greater than 2.5 m. The mechanics and quantitative studies on the spillover of saltwater from the North to the South Branches can be found in [5]. These research results provide references for our study on the spillover of sediment-carrying flow.

It must be pointed that the spillover of sediment in the Yangtze Estuary is quite di fferent from that of saltwater. First, the source for the saltwater spillover is simply from seas, which is uniform at o ffshore boundaries. As stated in this study, the source for the sediment spillover is produced by the erosion of local riverbed mainly in the middle and upper reaches of the North Branch. Second, salinity can be regarded as a solute whose transport is assumed to fully follow the motion of flows. However, the transport of sediment is quite sensitive to flow intensities. Under weak flow intensity, the heavier particles of sediment will deposit on the riverbed. The flow intensity will determine if and when spillover occurs and its extent. Moreover, the intensity of the sediment spillover is also closely related to the constituents of bed materials. Studies on the sediment spillover are more challenging. This may be one reason that quantitative studies on the sediment spillover in the Yangtze Estuary have not been reported.

According to the aforementioned analysis, a qualified simulation of flow and sediment transport in the Yangtze Estuary (which can reproduce detailed fields of tidal flows and sediment concentration) generally requires a grid resolution higher than that used in the simulation of saltwater transport. High grid resolution is achieved with as few cells as possible by using a channel-refined unstructured grid in this study. Moreover, the semi-implicit method, the ELM, and the FVELM were combined to achieve solve the e fficiency problems of the model.