Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\n
We wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\n
Throughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\n
We wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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In 2008 till 2015 he worked at Wildlife management office of Province of Pistoia, and from 2016 at Wildlife management office of Tuscany Region, Italy.",institutionString:"Wildlife management office - Region of Tuscany",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"781",title:"Environmental Conservation & Protection",slug:"environmental-conservation-and-protection"}],chapters:[{id:"65664",title:"Wildlife Population Monitoring Study among Endangered Animals at Protected Areas in Nepal",slug:"wildlife-population-monitoring-study-among-endangered-animals-at-protected-areas-in-nepal",totalDownloads:554,totalCrossrefCites:0,authors:[null]},{id:"65221",title:"Integrating Citizen Science and GIS for Wildlife Habitat Assessment",slug:"integrating-citizen-science-and-gis-for-wildlife-habitat-assessment",totalDownloads:715,totalCrossrefCites:1,authors:[null]},{id:"66330",title:"Ecology of Feral Pigeons: Population Monitoring, Resource Selection, and Management Practices",slug:"ecology-of-feral-pigeons-population-monitoring-resource-selection-and-management-practices",totalDownloads:458,totalCrossrefCites:0,authors:[null]},{id:"67071",title:"Cheetahs Race for Survival: Ecology and Conservation",slug:"cheetahs-race-for-survival-ecology-and-conservation",totalDownloads:610,totalCrossrefCites:0,authors:[null]},{id:"66845",title:"Wild Fodder Yielding Plants in the Protected Areas of Bangladesh",slug:"wild-fodder-yielding-plants-in-the-protected-areas-of-bangladesh",totalDownloads:281,totalCrossrefCites:0,authors:[null]},{id:"66955",title:"TSE Monitoring in Wildlife Epidemiology, Transmission, Diagnosis, Genetics and Control",slug:"tse-monitoring-in-wildlife-epidemiology-transmission-diagnosis-genetics-and-control",totalDownloads:698,totalCrossrefCites:0,authors:[null]},{id:"65529",title:"Infectious Disease Monitoring of European Bison (Bison bonasus)",slug:"infectious-disease-monitoring-of-european-bison-em-bison-bonasus-em-",totalDownloads:487,totalCrossrefCites:2,authors:[null]},{id:"66812",title:"An Assessment of the Human-Wildlife Conflict across Africa",slug:"an-assessment-of-the-human-wildlife-conflict-across-africa",totalDownloads:867,totalCrossrefCites:0,authors:[null]},{id:"67940",title:"Resident Hunting Ban in Serengeti District and Its Implications to People’s Livelihood and Wildlife Population",slug:"resident-hunting-ban-in-serengeti-district-and-its-implications-to-people-s-livelihood-and-wildlife-",totalDownloads:305,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"280415",firstName:"Josip",lastName:"Knapic",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/280415/images/8050_n.jpg",email:"josip@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copy-editing and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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\n\t\t\t
1. Introduction
\n\t\t\t
Acute pancreatitis is an inflammatory disease of the pancreas. The etiology and pathogenesis of acute pancreatitis have been intensively investigated for centuries worldwide. It can be initiated by several factors, including gallstones, alcohol, trauma, infections and hereditary factors. About 75% of pancreatitis is caused by gallstones or alcohol. In this chapter we discuss the causes, diagnosis, imaging findings, therapy, and complications of acute biliary pancreatitis.
\n\t\t
\n\t\t
\n\t\t\t
2. Anatomy and physiology
\n\t\t\t
The pancreas is perhaps the most unforgiving organ in the human body, leading most surgeons to avoid even palpating it unless necessary. Situated deep in the center of the abdomen, the pancreas is surrounded by numerous important structures and major blood vessels. Surgeons that choose to undertake surgery on the pancreas require a thorough knowledge of its anatomy. However, knowledge of the relationships of the pancreas and surrounding structures is also critically important for all surgeons to ensure that pancreatic injury is avoided during surgery on other structures.
\n\t\t\t
The pancreas is a retroperitoneal organ that lies in an oblique position, sloping upward from the C-loop of the duodenum to the splenic hilum. In an adult, the pancreas weighs 75 to 100 g and is about 15 to 20 cm long. The fact that the pancreas is situated so deeply in the abdomen and is sealed in the retroperitoneum explains the poorly localized and sometimes ill-defined nature with which pancreatic pathology presents.
\n\t\t\t
Surgeons typically describe the location of pathology within the pancreas in relation to four regions: the head, neck, body, and tail. The head of the pancreas is nestled in the C-loop of the duodenum and is posterior to the transverse mesocolon.
\n\t\t\t
Most of the pancreas drains through the duct of Wirsung, or main pancreatic duct, into the common channel formed from the bile duct and pancreatic duct. (Figure 1) The length of the common channel is variable. In about one third of patients, the bile duct and pancreatic duct remain distinct to the end of the papilla, the two ducts merge at the end of the papilla in another one third, and in the remaining one third, a true common channel is present for a distance of several millimeters.
\n\t\t\t
The main pancreatic duct is usually only 2 to 3 mm in diameter and runs midway between the superior and inferior borders of the pancreas, usually closer to the posterior than to the anterior surface. Pressure inside the pancreatic duct is about twice that in the common bile duct, which is thought to prevent reflux of bile into the pancreatic duct. The main pancreatic duct joins with the common bile duct and empties at the ampulla of Vater or major papilla, which is located on the medial aspect of the second portion of the duodenum. The muscle fibers around the ampulla form the sphincter of Oddi, which controls the flow of pancreatic and biliary secretions into the duodenum. Contraction and relaxation of the sphincter is regulated by complex neural and hormonal factors.
\n\t\t\t
Figure 1.
Pancreas and biliary system anatomy
\n\t\t\t
The exocrine pancreas accounts for about 85% of the pancreatic mass; 10% of the gland is accounted for by extracellular matrix, and 4% by blood vessels and the major ducts, whereas only 2% of the gland is comprised of endocrine tissue.
\n\t\t\t
The pancreas secretes approximately 500 to 800 mL per day of colorless, odorless, alkaline, isosmotic pancreatic juice. Pancreatic juice is a combination of acinar cell and duct cell secretions. The acinar cells secrete amylase, proteases, and lipases, enzymes responsible for the digestion of all three food types: carbohydrate, protein, and fat. The acinar cells are pyramid-shaped, with their apices facing the lumen of the acinus. Near the apex of each cell are numerous enzyme-containing zymogen granules that fuse with the apical cell membrane.
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Pancreatic amylase is secreted in its active form and completes the digestive process already begun by salivary amylase. Amylase is the only pancreatic enzyme secreted in its active form, and it hydrolyzes starch and glycogen to glucose, maltose, maltotriose, and dextrins. These simple sugars are transported across the brush border of the intestinal epithelial cells by active transport mechanisms. Gastric hydrolysis of protein yields peptides that enter the intestine and stimulate intestinal endocrine cells to release cholecystokinin (CCK)-releasing peptide, CCK, and secretin, which then stimulate the pancreas to secrete enzymes and bicarbonate into the intestine.
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The proteolytic enzymes are secreted as proenzymes that require activation. Trypsinogen is converted to its active form, trypsin, by another enzyme, enterokinase, which is produced by the duodenal mucosal cells. Trypsin, in turn, activates the other proteolytic enzymes. Trypsinogen activation within the pancreas is prevented by the presence of inhibitors that are also secreted by the acinar cells. Chymotrypsinogen is activated to form chymotrypsin. Elastase, carboxypeptidase A and B, and phospholipase are also activated by trypsin. Trypsin, chymotrypsin, and elastase cleave bonds between amino acids within a target peptide chain, and carboxypeptidase A and B cleave amino acids at the end of peptide chains. Individual amino acids and small dipeptides are then actively transported into the intestinal epithelial cells. Pancreatic lipase hydrolyzes triglycerides to 2-monoglyceride and fatty acid. Pancreatic lipase is secreted in an active form. Colipase is also secreted by the pancreas and binds to lipase, changing its molecular configuration and increasing its activity. Phospholipase A2 is secreted by the pancreas as a proenzyme that becomes activated by trypsin. Phospholipase A2 hydrolyzes phospholipids and, as with all lipases, requires bile salts for its action. Carboxylic ester hydrolase and cholesterol esterase hydrolyze neutral lipid substrates like esters of cholesterol, fat-soluble vitamins, and triglycerides. The hydrolyzed fat is then packaged into micelles for transport into the intestinal epithelial cells, where the fatty acids are reassembled and packaged inside chylomicrons for transport through the lymphatic system into the bloodstream.
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The centroacinar and intercalated duct cells secrete the water and electrolytes present in the pancreatic juice. About 40 acinar cells are arranged into a spherical unit called an acinus. Centroacinar cells are located near the center of the acinus and are responsible for fluid and electrolyte secretion. These cells contain the enzyme carbonic anhydrase, which is needed for bicarbonate secretion.
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The acinar cells release pancreatic enzymes from their zymogen granules into the lumen of the acinus, and these proteins combine with the water and bicarbonate secretions of the centroacinar cells. The pancreatic juice then travels into small intercalated ducts. Several small intercalated ducts join to form an interlobular duct. Cells in the interlobular ducts continue to contribute fluid and electrolytes to adjust the final concentrations of the pancreatic fluid. Interlobular ducts then join to form about 20 secondary ducts that empty into the main pancreatic duct. Destruction of the branching ductal tree from recurrent inflammation, scarring, and deposition of stones eventually contributes to destruction of the exocrine pancreas and exocrine pancreatic insufficiency.
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There are nearly 1 million islets of Langerhans in the normal adult pancreas. Alpha cells that secrete glucagon, Beta cells that secrete insulin, Delta cells that secrete somatostatin, Epsilon cells that secrete ghrelin, and PP cells that secrete PP.[\n\t\t\t\t\t1\n\t\t\t\t]
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3. Incidence
\n\t\t\t
Acute pancreatitis is a relatively common disease that affects about 300,000 patients per annum in America with a mortality of about 7%. Acute pancreatitis is mild and resolves itself without serious complications in 80% of patients, but it has complications and a substantial mortality in up to 20% of patients despite the agressive intervention[\n\t\t\t\t\t1\n\t\t\t\t]. The incidence of alcoholic pancreatitis is higher in male, and the risk of developing acute pancreatitis in patients with gallstones is greater in male. However, more women develop this disorder since gallstones occur with increased frequency in women[\n\t\t\t\t\t2\n\t\t\t\t].
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4. Etiology and pathophysiology
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The pathogenesis of acute pancreatitis has not been fully understood. The general belief today is that pancreatitis begins with the activation of digestive enzymes inside acinar cells, which cause acinar cell injury. The Factors in Acute Pancreatitis can be classified as:
Of note, 10% to 20% of patients with acute pancreatitis have no known associated processes. Although this condition is currently termed idiopathic.
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The underlying reason of gallstone disease and other conditions causing acute pancreatitis is ductal hypertension resulting from ongoing exocrine secretion into an obstructed pancreatic duct. Elevated intraductal pressure, due to ongoing exocrine secretion, causes rupture of the smaller ductules and leakage of pancreatic juice into the parenchyma. Pancreatic tissue favors activation of proteases when transductal extravasation of fluid occurs.
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In the normal pancreas, the inactive digestive zymogens and the lysosomal hydrolases are found separately in discrete organelles. However, in response to ductal obstruction, hypersecretion, or a cellular insult, these two classes of substances become improperly colocalized in a vacuolar structure within the pancreatic acinar cell. Coalescence of zymogen granules with lysosome vacuoles resulting in intrapancreatic activation of proteolytic enzymes. Small amounts of trypsin can be countered by endogenous pancreatic trypsin inhibitor. However, large amounts of trypsin release can overwhelm the serological defense mechanism (α-1-antitrypsin and α-2-macroglobulin) and activate other enzymes resulting in destruction of acinar cells, local and systemic complications commonly seen in the course of the disease. Activation of the enzyme phospolipase A2 has important consequences like destruction of pulmonary surfactant that can result in ARDS and liberation of prostaglandins and leucotriens that may be important in the pathogenesis of the systemic inflammatory response which can lead to multi organ failure. More than that, inflammatory mediators may be used as predictors of disease severity in the near future. Also, trypsin activates and complements kinin, kallikrein, possibly playing a part in disseminated intravascular coagulation, shock, renal failure and vascular instability. [\n\t\t\t\t\t3\n\t\t\t\t], [\n\t\t\t\t\t4\n\t\t\t\t].
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\n\t\t
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5. Diagnosis
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A detailed history and careful physical examination are the first step towards making the diagnosis. The diagnosis of gallstone pancreatitis should be suspected if the patient has a prior history of biliary colic. (5], (6] Acute pancreatitis typically presents with severe upper abdominal pain which may radiate through to the back and be associated with nausea and vomiting.
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On physical examination, the patient may show tachycardia, tachypnea, hypotension, and hyperthermia. The temperature is usually only mildly elevated in uncomplicated pancreatitis. Voluntary and involuntary guarding can be seen over the epigastric region. The bowel sounds are decreased or absent. There are usually no palpable masses. The abdomen may be distended with intraperitoneal fluid. There may be pleural effusion, particularly on the left side. With increasing severity of disease, the intravascular fluid loss may become life-threatening as a result of sequestration of edematous fluid in the retroperitoneum.
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6. Biochemical markers
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Due to the destruction of acinar cells, the levels of the enzymes that they contain (e.g., amylase, lipase, trypsinogen, and elastase) are found elevated in the serum of most pancreatitis patients. Serum amylase concentration increases almost immediately with the onset of disease and peaks within several hours. It remains elevated for 3 to 5 days before returning to normal. There is no significant correlation between the magnitude of serum amylase elevation and severity of pancreatitis. [7,8]\n\t\t\t
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Lipase is more specific for pancreatitis. Serum lipase has a longer half life than amylase and therefore tends to remain elevated for longer.
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Urinary clearance of pancreatic enzymes from the circulation increases during pancreatitis; therefore, urinary levels may be more sensitive than serum levels.
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Several tests can help differentiate biliary pancreatitis from other causes of pancreatitis. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl Transpeptidase (GGT ), alkaline phosphatase and serum bilirubin are the so-called liver function tests; they should be reviewed before making a confident diagnosis.
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Several recent research studies have suggested additional markers that may have prognostic value, including C-reactive protein (CRP), alpha2-macroglobulin, polymorphonuclear neutrophil–elastase, alpha1-antitrypsin, and phospholipase A2. [9],[10] Although CRP measurement is commonly available, many of the others are not. Therefore, at this time, CRP seems to be the marker of choice in clinical settings. The measurement of IL-6 has recently been shown to distinguish patients with mild or severe forms of the disease. Another prognostic marker under evaluation is urinary–trypsinogen activation peptide (TAP). It has a good correlation between the severity of pancreatitis and concentrations of TAP in urine.
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Currently, these new markers have limited clinical availability, but there is significant interest in better understanding markers of immune response and pancreatic injury because these could be valuable tools for reliably predicting the severity of acute pancreatitis and supplementing imaging modalities. [10],[11],[12]\n\t\t\t
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7. Radiologic imaging
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Ultrasound: Abdominal ultrasound (US) examination is the best way to confirm the presence of gallstones in suspected biliary pancreatitis. It also can detect extrapancreatic ductal dilations and reveal pancreatic edema, swelling, and peripancreatic fluid collections. But abdominal ultrasonography seldom visualizes the pancreas in patients with acute pancreatitis due to air in the distended loops of the small bowel. [13] (Figure 2)
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Computed Tomography Scan (CT): A CT allows identification of pancreatic edema, fluid or cysts, and the severity of pancreatitis to be graded, detects complications including development of pseudocysts, abscess, necrosis, hemorrhage, and vascular occlusion. The finding of gallstones and dilatation of the extra-hepatic biliary tree on cross-sectional abdominal imaging further support to the diagnosis of gallstone pancreatitis. [14]\n\t\t\t
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Currently the best method to stage the acute pancreatitis is CT. Specific CT findings can be categorized into pancreatic and peripancreatic changes. Pancreatic changes include diffuse or focal parenchymal enlargement, edema, or necrosis with liquefaction. Peripancreatic involvement includes blurring or thickening of the surrounding tissue planes. An approximate correlation exists between the degree of CT abnormalities and the clinical course and severity of acute pancreatitis.
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An early discrimination between mild edematous and severe necrotizing forms of the disease is of the utmost importance to provide optimal care to the patient. CT has become the gold standard for detecting and assessing the severity of pancreatitis. Although clinically mild pancreatitis is usually associated with interstitial edema, severe pancreatitis is associated with necrosis. The presence of air bubbles on a CT scan is an indication of infected necrosis or pancreatic abscess. [\n\t\t\t\t\t15\n\t\t\t\t]
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Figure 2.
Ultrasound image of the gallbladder demonstrates multiple dependent gallstones (curved arrow) with acustic shadowing (straight arrows). The patient had elevated pancreatic enzyme levels and underwent cholecystectomy because of gallstone pancreatitis.
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Magnetic Resonance Cholangiopancreatography (MRCP): MRCP has been found to be as accurate as contrast-enhanced CT in predicting the severity of pancreatitis and identifying pancreatic necrosis but is less sensitive for detection of small stones.
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Endoscopic Ultrasonography: It is useful in obese patients and patients with ileus, and can help determine which patients with acute pancreatitis would benefit most from therapeutic ERCP. [16], [17]\n\t\t\t
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Figure 3.
Acute biliary pancreatitis with a thickened pancreas and an effusion around the pancreatic tail and around the spleen - CT scan
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Figure 4.
Sigmoid configuration of the main pancreatic duct with distal dilation of both main and dorsal ducts, suggesting the presence of an obstructive condition at the level of both major and minor papillae.
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ADMISSION
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INITIAL 48 HOURS
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Gallstone Pancreatitis
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\n\t\t\t\t\t\t
Age "/ 70 yr
\n\t\t\t\t\t\t
Hct fall "/10
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
WBC "/18,000/mm3\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
BUN elevation "/2 mg/100 mL
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Glucose "/ 220 mg/100 mL
\n\t\t\t\t\t\t
Ca2+<8 mg/100 mL
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
LDH "/400 IU/L
\n\t\t\t\t\t\t
Base deficit "/5 mEq/L
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
AST "/250U/100 mL
\n\t\t\t\t\t\t
Fluid sequestration "/4 L
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Nongallstone Pancreatitis
\n\t\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Age "/55 yr
\n\t\t\t\t\t\t
Hct fall "/10
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
WBC "/16,000/mm3
\n\t\t\t\t\t\t
BUN elevation "/5 mg/100 mL
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Glucose "/200 mg/100 mL
\n\t\t\t\t\t\t
Ca2+<8 mg/100 mL
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
LDH "/350 IU/L
\n\t\t\t\t\t\t
Pao2<55 mm Hg
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
AST "/250U/100 mL
\n\t\t\t\t\t\t
Base deficit "/4 mEq/L
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
Fluid sequestration "/6 L
\n\t\t\t\t\t
\n\t\t\t\t
Table 1.
Adapted from Ranson JHC, Rifkind KM, Roses DF, et al: Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 139:69-81, 1974; and Ranson JHC: Etiological and prognostic factors in human acute pancreatitis: A review. Am J Gastroenterol 77:633, 1982. ( AST, aspartate transaminase; BUN, blood urea nitrogen; Ca2+, calcium; Hct, hematocrit; LDH, lactic dehydrogenase; Pao2, arterial oxygen; WBC, white blood cell count.)
\n\t\t
\n\t\t
\n\t\t\t
8. Scoring systems in acute pancreatitis
\n\t\t\t
A variety of scoring systems have been proposed for accurate assessment of the severity of acute pancreatitis. These include the clinical scoring scales as Ranson criteria, Glasgow scales, simplified acute physiology (SAP), score and acute physiology and chronic health evaluation II (APACHE II) score. The CT severity index (CTSI) derived by Balthazar grading of pancreatitis and the extent of pancreatic necrosis is now widely used in describing CT findings of acute pancreatitis and serves as the radiological scoring system. [18]\n\t\t\t
\n\t\t\t
Ranson identified a series of prognostic signs for early identification of patients with severe pancreatitis. Out of these 11 objective parameters, five are measured at the time of admission, whereas the remaining six are measured within 48 hours of admission. Morbidity and mortality of the disease are directly related to the number of signs present. It is important to realize that Ranson\'s prognostic signs are best used within the initial 48 hours of hospitalization and have not been validated for later time intervals.
\n\t\t\t
Another set of criteria often used to assess the severity of pancreatitis is the acute physiology and chronic health evaluation (APACHE-II) score. This grading system assesses severity on the basis of quantitative measures of abnormalities of multiple variables, including vital signs and specific laboratory parameters, coupled with the age and chronic health status of the patient. The main advantage of the APACHE-II scoring system is the immediate assessment of the severity of pancreatitis. A score of eight or more at admission is usually considered indicative of severe disease. APACHE II, although complicated, ensures the highest positive predictive value up to 69%. [19]\n\t\t\t
\n\t\t\t
The risk of severe acute pancreatitis is increased at Glasgow\'s or Ranson\'s score ≥3 in 48 hours, APACHE II on admission ≥8, Balthazar\'s score ≥4.
\n\t\t\t
In 1985, Balthazar and colleagues introduced a scoring system based on radiological findings by means of a 5- grade scale: the presence of pancreatic and peripancreatic inflammation and fluid accumulation. [\n\t\t\t\t\t20\n\t\t\t\t].
\n\t\t\t
Grade CT findings:
\n\t\t\t
Grade A Normal pancreas
\n\t\t\t
Grade B Pancreatic enlargement
\n\t\t\t
Grade C Pancreatic inflammation and/or peripancreatic fat
\n\t\t\t
Grade D Single peripancreatic fluid collection
\n\t\t\t
Grade E Two or more fluid collections and/or retroperitoneal air.
\n\t\t\t
A correlation was shown between the grade on CT performed within 10 days of admission and the clinical follow-up finding, morbidity, and mortality. Therefore, CT was appreciated as a useful prognostic indicator for outcome in Acute pancreatitis. The study showed a morbidity of only 4% and no mortality in patients with Acute pancreatitis and a CT grade of A, B, or C. In patients with CT grade D or E, the morbidity rate was 54% and the mortality 14%. The Balthazar radiological prognostic score was easy to assign without the need of contrast-enhanced CT. Unfortunately, this score did not assign any value to pancreatic necrosis as a prognostic parameter and did not make the distinction between Acute fluid collections and pseudocysts vs. post-necrotic fluid collections and walled-off pancreatic necrosis. With the introduction of newer CT-based scoring systems, some authors question the value of Balthazar’s score in predicting prognosis and severity in Acute Pancreatitis [\n\t\t\t\t\t21\n\t\t\t\t].
\n\t\t
\n\t\t
\n\t\t\t
9. Treatment
\n\t\t\t
Gallstones are the most common cause of acute pancreatitis worldwide. According to the physical examination, radiological findings and labarotory results the etiology of the acute pancreatitis is diagnosed as biliary or non-biliary. The most important initial treatment of biliary pancreatitis is conservative intensive care with the goals of oral food and fluid restriction, replacement of fluids and electrolytes parenterally as assessed by central venous pressure and urinary excretion, and control of pain. [22], [23]\n\t\t\t
\n\t\t\t
After stabilizing the patient, specific treatment and timing of the intervention have to be planned. The issue of when to intervene for clearance of gallstones is controversial. General consensus is either urgent intervention (cholecystectomy) within the first 48 to 72 hours of admission, or briefly delayed intervention (after 72 hours, but during the initial hospitalization) to give an inflamed pancreas time to recover. Cholecystectomy and common duct clearance is the best treatment of biliary acute pancreatitis. Patients who have persistent impacted stone in the distal common bile duct or ampulla should have confirmation by radiologic imaging (CT, magnetic resonance cholangiopancreatography, or endoscopic ultrasonography) before intervention. If common duct stone are diagnosed, stones are cleared and endoscopic sphincterotomy is done by ERCP and then laparoscopic cholecystectomy is performed.[24]\n\t\t\t
\n\t\t\t
Routine ERCP for examination of the bile duct is discouraged in cases of biliary pancreatitis, as the probability of finding residual stones is low, and the risk of ERCP-induced pancreatitis is significant. But in the case of acute biliary pancreatitis in which analytical studies suggest that the obstruction persists after 24 hours of observation, emergency ERCP has to be done to prevent biliary sepsis.
\n\t\t\t
Although ERCP with Endoscopic Sphincterotomy (ES) and stone extraction has been shown to be useful for early treatment of severe biliary pancreatitis, the incidence of bile duct stones at elective surgery is low and most of these ERCP are unnecessary. For this reason accurate predictors of common bile duct stones are required; studies have shown that the sensitivity of preoperative abdominal US for predicting common bile duct stones is 42% and specificity is 86% [25]. Furthermore, an endoscopic approach is unable to fully resolve the patient’s biliary pathology with one procedure and one anesthesia. This adds substantial risk of morbidity and even mortality. Concern remains also regarding the potential long-term risks of ES. Although the immediate complications of ES are well documented, the long-term effects are less defined. Stricture formation and stone recurrence account for nearly all longterm complications. Although most of the authors prefer the endoscopic to the surgical treatment of CBD stones, there is still some minor discussion on it[26].
\n\t\t\t
Timing of laparoscopic surgery in acute biliary pancreatitis depends upon the severity of the disease. In the case of mild pancreatitis it doesn’t matter when, within 1 week, laparoscopic cholecystectomy is performed. However, in patients with severe pancreatitis, laparoscopic cholecystectomy, when performed within the 1st week after the onset of symptoms, as other authors have observed [27], places patients at increased risk of operative morbidity and technical complications. In these patients, the management of complications of pancreatitis is strongly advisable before cholecystectomy.
\n\t\t\t
Delaying surgery for more than a week after hospitalization, in our experience, does not adversely affect technical difficulty. Delaying surgery for several weeks in severe acute pancreatitis allows acute inflammation to settle down and might allow stones in the common bile duct to clear spontaneously. However, studies showed that approximately one-quarter of patients have symptomatic recurrence within 6 weeks if gallstones are untreated, and it increases with time [28], [29]\n\t\t\t
\n\t\t\t
Cholangiogram of good quality during laparoscopic cholecystectomy, since the risk of common bile duct stones is 14–20%. [30] This strategy minimizes the need for common bile duct exploration and still achieves the goal of a limited hospital stay and the prevention of recurrence of pancreatitis. If common bile duct stones are found at cholangiogram they should be treated laparoscopically if at all possible. In most instances, it should be possible to retrieve the stones via the cystic duct, since acute pancreatitis is usually caused by the migration of small stones. If this is not feasible, one alternative is to perform a laparoscopic choledochotomy. These cases have a rather long hospital stay and delayed return to work, but their level of pain is diminished. Our current impression is that this procedure is possible though technically demanding. In case of failure, traditional exploration is mandatory.
\n\t\t\t
In severe acute pancreatitis, or when signs of infection are present, most experts recommend broad-spectrum antibiotics (e.g., imipenem) and careful surveillance for complications of the disease.
\n\t\t
\n\t\t
\n\t\t\t
10. Complications of acute pancreatitis
\n\t\t\t
Acute pancreatitis complications may be divided as systemic and local. Pancreatic phlegmon, pancreatic abscess, pancreatic pseudocyst, pancreatic ascites and involvement of adjacent organs, with hemorrhage, thrombosis, bowel infarction, obstructive jaundice, fistula formation, or mechanical obstruction are local complications. Systemic complications are classified as hematologic (Hemoconcentration, Disseminated intravascular coagulopathy), cardiovascular (Hypotension, Hypovolemia, Sudden death, Nonspecific ST-T wave changes, Pericardial effusion), pulmonary (Pneumonia, atelectasis, Acute respiratory distress syndrome, Pleural effusion), renal (Oliguria, Azotemia, renal artery/vein thrombosis), metabolic (Hyperglycemia, Hypocalcemia, Hypertriglyceridemia, Encephalopathy, Sudden blindness (Purtscher\'s retinopathy), central nervous system (Psychosis, Fat emboli, Alcohol withdrawal syndrome), gastro intestinal system (Peptic ulcer, Erosive gastritis, Portal vein or splenic vein thrombosis with varices)
\n\t\t
\n\t\n',keywords:null,chapterPDFUrl:"https://cdn.intechopen.com/pdfs/26182.pdf",chapterXML:"https://mts.intechopen.com/source/xml/26182.xml",downloadPdfUrl:"/chapter/pdf-download/26182",previewPdfUrl:"/chapter/pdf-preview/26182",totalDownloads:3421,totalViews:1866,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,dateSubmitted:"February 6th 2011",dateReviewed:"July 4th 2011",datePrePublished:null,datePublished:"January 18th 2012",dateFinished:null,readingETA:"0",abstract:null,reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/26182",risUrl:"/chapter/ris/26182",book:{slug:"acute-pancreatitis"},signatures:"Mehmet Ilhan and Halil Alıs",authors:[{id:"66078",title:"Dr.",name:"Mehmet",middleName:null,surname:"İlhan",fullName:"Mehmet İlhan",slug:"mehmet-ilhan",email:"milhan9786@yahoo.com",position:null,institution:{name:"Bakırköy Dr.Sadi Konuk Eğitim ve Araştırma Hastanesi",institutionURL:null,country:{name:"Turkey"}}}],sections:[{id:"sec_1",title:"1. Introduction ",level:"1"},{id:"sec_2",title:"2. Anatomy and physiology",level:"1"},{id:"sec_3",title:"3. Incidence",level:"1"},{id:"sec_4",title:"4. Etiology and pathophysiology",level:"1"},{id:"sec_5",title:"5. Diagnosis",level:"1"},{id:"sec_6",title:"6. Biochemical markers",level:"1"},{id:"sec_7",title:"7. Radiologic imaging",level:"1"},{id:"sec_8",title:"8. Scoring systems in acute pancreatitis",level:"1"},{id:"sec_9",title:"9. Treatment",level:"1"},{id:"sec_10",title:"10. Complications of acute pancreatitis",level:"1"}],chapterReferences:[{id:"B1",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCharles\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrunicardi\n\t\t\t\t\t\t\tD. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAndersen\n\t\t\t\t\t\t\tTimothy. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBilliar\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDunn\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHunter\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMatthews\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2005 Pollock Schwartz’s Principles of surgery,; 33\n\t\t\t\t\t1265\n\t\t\t\t\t73\n\t\t\t\t\n\t\t\t'},{id:"B2",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEland\n\t\t\t\t\t\t\tI. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSturkenboom\n\t\t\t\t\t\t\tM. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWilson\n\t\t\t\t\t\t\tJ. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tStricker\n\t\t\t\t\t\t\tB. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2000 Incidence and mortality of acute pancreatitis between 1985 and 1995". 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J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGalloway\n\t\t\t\t\t\t\tS. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKingsnorth\n\t\t\t\t\t\t\tA. N.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1995 Inflamatory mediators in acute pancreatitis. Br J Surg;82\n\t\t\t\t\t6\n\t\t\t\t\t13 .\n\t\t\t'},{id:"B6",body:'\n\t\t\t\t\n\t\t\t\t\tAcosta JM, Ledesma CL.\n\t\t\t\t\tGallstone migration as a cause of acute pancreatitis. N Engl J Med 290\n\t\t\t\t\t484\n\t\t\t\t\t7\n\t\t\t\t\t1974\n\t\t\t\t\n\t\t\t'},{id:"B7",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKelly\n\t\t\t\t\t\t\tT. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1980\n\t\t\t\t\tGallstone pancreatitis: the timing of surgery.\n\t\t\t\t\tKellyT. R. (1980). Gallstone pancreatitis: the timing of surgery. Surgery; . ;88\n\t\t\t\t\t345\n\t\t\t\t\t50 .\n\t\t\t'},{id:"B8",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMoody\n\t\t\t\t\t\t\tF. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSenninger\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRunkel\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1993Another challenge to the Opie’s theory. Gastroenterology;104\n\t\t\t\t\t927\n\t\t\t\t\t31 .\n\t\t\t'},{id:"B9",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCrunkel\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMoody\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMueller\n\t\t\t\t\t\t\tW.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1992 Experimental evidence against Opie’s common channel bile reflux theory. Digestion;52\n\t\t\t\t\t67\n\t\t\t\t\t67 .\n\t\t\t'},{id:"B10",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSmotkin\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTenner\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002\n\t\t\t\t\tLaboratory diagnostic tests in acute pancreatitis. J Clin Gastroenterol;34\n\t\t\t\t\t459\n\t\t\t\t\t62 .\n\t\t\t'},{id:"B11",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tClavien\n\t\t\t\t\t\t\tP. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBurgan\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMoossa\n\t\t\t\t\t\t\tA.R.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1989\n\t\t\t\t\tSerum enzymes and other laboratory tests in acute pancreatitis. Br J Surg;76\n\t\t\t\t\t1234\n\t\t\t\t\t43 .\n\t\t\t'},{id:"B12",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNeoptolemos\n\t\t\t\t\t\t\tJ. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKemppainen\n\t\t\t\t\t\t\tE. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMayer\n\t\t\t\t\t\t\tJ. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFitzpatrick\n\t\t\t\t\t\t\tJ. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRaraty\n\t\t\t\t\t\t\tM. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSlavin\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\tetal.\n\t\t\t\t\t\n\t\t\t\t\t2000\n\t\t\t\t\tEarly prediction of severity in acute pancreatitis by urinary trypsinogen activation peptide: a multicentre study.\n\t\t\t\t\tLancet;355\n\t\t\t\t\t1955\n\t\t\t\t\t60 .\n\t\t\t'},{id:"B13",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTenner\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2004 Initial management of acute pancreatitis: critical issues during the first 72 hours. Am J Gastroenterol;99\n\t\t\t\t\t2489\n\t\t\t\t\t94 .\n\t\t\t'},{id:"B14",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChak\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHawes\n\t\t\t\t\t\t\tR. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCooper\n\t\t\t\t\t\t\tG. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHoffman\n\t\t\t\t\t\t\tB.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCatalano\n\t\t\t\t\t\t\tM. F.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWong\n\t\t\t\t\t\t\tR. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t1999 Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis. Gastrointest Endosc;49\n\t\t\t\t\t599\n\t\t\t\t\t604 .\n\t\t\t'},{id:"B15",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBaron\n\t\t\t\t\t\t\tR. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tStanley\n\t\t\t\t\t\t\tR. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLee\n\t\t\t\t\t\t\tJ. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKoehler\n\t\t\t\t\t\t\tR. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLevitt\n\t\t\t\t\t\t\tR. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1983 Computed tomographic features of biliary obstruction. AJR Am J Roentgenol;140\n\t\t\t\t\t1173\n\t\t\t\t\t8 .\n\t\t\t'},{id:"B16",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKemppainen\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSainio\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHaapiainen\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKivisaari\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKivilaakso\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPuolakkainen\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\tEarly localization of necrosis by contrast-enhanced computed tomography can predict outcome in severe pancreatitis. Br J Surg 83\n\t\t\t\t\t924\n\t\t\t\t\t9\n\t\t\t\t\t1996\n\t\t\t\t\n\t\t\t'},{id:"B17",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMakary\n\t\t\t\t\t\t\tM. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDuncan\n\t\t\t\t\t\t\tM. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHarmon\n\t\t\t\t\t\t\tJ. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFreeswick\n\t\t\t\t\t\t\tP. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBender\n\t\t\t\t\t\t\tJ. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBohlman\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t2005 The role of magnetic resonance cholangiography in the management of patients with gallstone pancreatitis. Ann Surg;241\n\t\t\t\t\t119\n\t\t\t\t\t24\n\t\t\t\t\n\t\t\t'},{id:"B18",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNorton\n\t\t\t\t\t\t\tS. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlderson\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2000\n\t\t\t\t\tEndoscopic ultrasonography in the evaluation of idiopathic acute pancreatitis. Br J Surg;87\n\t\t\t\t\t1650\n\t\t\t\t\t5 .\n\t\t\t'},{id:"B19",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWahab\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKhan\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2010 2010. Imaging and clinical prognostic indicators of acute pancreatitis: a comparative insight. Sep;40\n\t\t\t\t\t3\n\t\t\t\t\t283\n\t\t\t\t\t7 .\n\t\t\t'},{id:"B20",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGravante\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGarcea\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tOng\n\t\t\t\t\t\t\tS. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMetcalfe\n\t\t\t\t\t\t\tM. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBerry\n\t\t\t\t\t\t\tD. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLloyd\n\t\t\t\t\t\t\tD. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t2009 Prediction of mortality in acute pancreatitis: asystematic review of the published evidence. Pancreatology;9\n\t\t\t\t\t601\n\t\t\t\t\t614 .\n\t\t\t'},{id:"B21",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBalthazar\n\t\t\t\t\t\t\tE. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRanson\n\t\t\t\t\t\t\tJ. H. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNaidich\n\t\t\t\t\t\t\tD. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t1985\n\t\t\t\t\tAcute-pancreatitis-prognostic value of CT.\n\t\t\t\t\tRadiology\n\t\t\t\t\t3\n\t\t\t\t\t767\n\t\t\t\t\t772\n\t\t\t\t\n\t\t\t'},{id:"B22",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJu\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChen\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLiu\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tZheng\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTeng\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2006\n\t\t\t\t\tValue of CT and clinical criteria in assessment of patients with acute pancreatitis. Eur J Radiol 1\n\t\t\t\t\t102\n\t\t\t\t\t107\n\t\t\t\t\n\t\t\t'},{id:"B23",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNeoptolemos\n\t\t\t\t\t\t\tJ. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCarr-Locke\n\t\t\t\t\t\t\tD. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLondon\n\t\t\t\t\t\t\tN. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBailey\n\t\t\t\t\t\t\tI. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJames\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFossard\n\t\t\t\t\t\t\tD. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1988\n\t\t\t\t\tControlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones.\n\t\t\t\t\tLancet;2\n\t\t\t\t\t979\n\t\t\t\t\t83 .\n\t\t\t'},{id:"B24",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCarroll\n\t\t\t\t\t\t\tB. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPhillips\n\t\t\t\t\t\t\tE. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1993 The early treatment of acute biliary pancreatitis [letter; comment]. N Engl J Med;329\n\t\t\t\t\t58\n\t\t\t\t\t9 .\n\t\t\t'},{id:"B25",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tUhl\n\t\t\t\t\t\t\tW.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMüller\n\t\t\t\t\t\t\tC. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKrδhenbühl\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSchmid\n\t\t\t\t\t\t\tS. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSchφlzel\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBüchler\n\t\t\t\t\t\t\tM. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1999 Acute gallstone pancreatitis: timing of laparoscopic cholecystectomy in mild and severe disease.\n\t\t\t'},{id:"B26",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSoper\n\t\t\t\t\t\t\tN. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrunt\n\t\t\t\t\t\t\tM. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCallery\n\t\t\t\t\t\t\tM. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEdmundowicz\n\t\t\t\t\t\t\tS. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAliperti\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1994 Role of laparoscopic cholecystectomy in the management of acute biliary pancreatitis. Am J Surg 167\n\t\t\t\t\t42\n\t\t\t\t\t51\n\t\t\t\t\n\t\t\t'},{id:"B27",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGraham\n\t\t\t\t\t\t\tS. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFlowers\n\t\t\t\t\t\t\tJ. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tScott\n\t\t\t\t\t\t\tT. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t1993 Laparoscopic cholecystectomy and common bile duct stones. Ann Surg 218\n\t\t\t\t\t61\n\t\t\t\t\t67\n\t\t\t\t\n\t\t\t'},{id:"B28",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTang\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tStain\n\t\t\t\t\t\t\tS. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTang\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFroes\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBerne\n\t\t\t\t\t\t\tT. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1995 Timing of laparoscopic surger in gallstones pancreatitis. Arch Surg 130\n\t\t\t\t\t496\n\t\t\t\t\t500\n\t\t\t\t\n\t\t\t'},{id:"B29",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPatti\n\t\t\t\t\t\t\tM. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPellegrini\n\t\t\t\t\t\t\tC. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1990\n\t\t\t\t\tGallstone pancreatitis. Surg Clin North Am 70: 1277 EOF\n\t\t\t\t\t95 EOF\n\t\t\t\t\n\t\t\t'},{id:"B30",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPellegrini\n\t\t\t\t\t\t\tC. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1993\n\t\t\t\t\tSurgery for gallstone pancreatitis. Am J Surg 165\n\t\t\t\t\t515\n\t\t\t\t\t518\n\t\t\t\t\n\t\t\t'},{id:"B31",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAcosta\n\t\t\t\t\t\t\tJ. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRossi\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGalli\n\t\t\t\t\t\t\tM. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPellegrini\n\t\t\t\t\t\t\tC. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSkinner\n\t\t\t\t\t\t\tD. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1978 Early surgery for acute gallstone pancreatitis: evaluation of a systemic approach. Surgery 83\n\t\t\t\t\t367\n\t\t\t\t\t370\n\t\t\t\t\n\t\t\t'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Mehmet Ilhan",address:null,affiliation:'
Ministry of Health Bakırkoy, Dr Sadi Konuk Training andResearch Hospital General Surgery, Istanbul,, Turkey
Ministry of Health Bakırkoy, Dr Sadi Konuk Training andResearch Hospital General Surgery, Istanbul,, Turkey
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Sticking to a Gluten-Free Diet",slug:"i-can-t-eat-that-sticking-to-a-gluten-free-diet",signatures:"Ricardo Fueyo-Díaz, Santiago Gascón-Santos and Rosa Magallón-\nBotaya",authors:[{id:"202314",title:"Dr.",name:"Ricardo",middleName:null,surname:"Fueyo-Díaz",fullName:"Ricardo Fueyo-Díaz",slug:"ricardo-fueyo-diaz"},{id:"204604",title:"Dr.",name:"Santiago",middleName:null,surname:"Gascón-Santos",fullName:"Santiago Gascón-Santos",slug:"santiago-gascon-santos"},{id:"204605",title:"Dr.",name:"Rosa",middleName:null,surname:"Magallón-Botaya",fullName:"Rosa Magallón-Botaya",slug:"rosa-magallon-botaya"}]}]}]},onlineFirst:{chapter:{type:"chapter",id:"72954",title:"Value-Based HealthCare",doi:"10.5772/intechopen.93378",slug:"value-based-healthcare",body:'
1. Introduction
Value-based healthcare (VBHC) is a term coined by Harvard Professor Michael Porter. Along with Elizabeth Teisberg, he published his book in 2006 entitled Redefining Health Care Creating Value-Based Competition on Results [1]. They proposed that healthcare should be restructured and focused on competition and improved outcomes for patients.
Some level of competition is important to drive improvement forward. In other fields of expertise, competition is what drives knowledge forward and thus improve value to its consumers, such as in technology. In health, this competition also occurs today but is dysfunctional and does not equate to value to the patient.
Value is defined, according to Dr. Porter, around the costumer and that is achieving the best outcome at the lowest cost, in other words better health per dollar spent. Conrad defines health as maximum health benefit at minimum cost [2]. The shift from today’s model and the value-based model is a change that must be physician led and focused around three principles: 1—the goal is value, 2—medical practice should be organized around medical conditions and care cycle, and 3—results must be measured [3].
Moving to a value-based structure is challenging but feasible and the best way to contain costs is to improve outcomes [4], but containing costs alone will not solve the problem. The focus on value is key to a sustainable health-care system [5]. Achieving and maintaining good health is less costly than dealing with poor health, according to Dr. Porter [4].
Not only physicians but the industry itself is moving toward a value-based system. For example, in orthopedics, we have value-based implants [6]. To cut costs of sterilization and sales representatives, they are manufacturing single-use kits. There are some barriers to the use of these implants such as the surgeon’s conflict of interest with the industry [6], but they can be overcome.
Right now, we have a fee-for-service model for reimbursement that over the past several years is shifting toward this value-based model that attempts to link quality and value to payment [7]. The difficulty in implementing it is to quantify quality and value. Professional societies are trying to develop different programs to attempt to define what high value is.
Tools that quantify if we are achieving our goals are needed. In VBHC, we need quality measures that quantify health-care processes, outcomes, patient’s experiences, and organizational systems to evaluate the effectiveness of delivered care as it benefits the patient [8]. Value and good outcome may differ from person to person and from condition to condition. It is hard to build a single tool that can be used for every condition.
But how does this model fit in the real world and how can we make the transition to this value-based model keeping in mind we need to improve value to patients? That’s what we are trying to answer in this chapter. It is a rather simple question but with a complex answer. A few hospitals in the United States and around the world are adhering to this type of healthcare based on value to the patient [9]. We are going to review a few of them and how they implemented it.
Value-based healthcare may be considered a merge between evidence-based medicine, patient-centered care, and cost-effectiveness [10], even though in essence they are not the same thing.
2. The goal is value for patients
Today’s healthcare is not necessarily structured that way. Hospitals want to increase revenue, health plans want to cut costs, and physicians want to increase revenue to their practices. Those practices not necessarily mean better outcome or results for the patient. Patients only want good outcomes with less office visits, less procedures, and less tests [3]. A more individualized practice is needed to meet all these goals.
Many argue that genetic testing is a possibility in the near future [11], but that raises many other questions. The majority of physicians are not trained to interpret the results of a genetic test and that may lead to wrong interpretations and harmful treatments. When that is done correctly, by a specialist, that raises the concern that sometimes an asymptomatic patient or one that did not developed the disease, whether they need treatment or not.
The concept of value remains misunderstood. It is not supposed to be confused with cost reduction, although it encompasses it. Value should be defined around the patient and what they see as a good result, and the creation of value should be rewarded. Value depends on results not volume of services, and the two should not be confused [12].
The cost related to value is the total cost of care cycle, not only the cost of a single procedure or surgery as it is today. Often we need to spend more money in some services to reduce the need for others, which in the end will reduce the total cost of care. The outcome is condition specific, and no single outcome captures the results of care [12].
This value-based model strengthens the role of primary care. There are four features of primary care as stated by Starfield in his 2005 paper: 1—first-contact access, 2—long-term person-focused care, 3—comprehensive care for most health needs, and 4—coordinated care [13]. In primary care, value should be defined for similar groups with similar needs. Primary care and preventive medicine should be divided by need, for example, healthy children, single chronic disease, and so on [12]. This will be addressed further along the text.
The structure we have today makes it difficult to measure value, and most providers fail to do so. Some argue that measurement is necessary but not sufficient to improve quality. One of the barriers to improve quality and value to the patient is the lack of a uniform, simple, and reliable measurement. This difficulty is being addressed by The International Consortium for Health Outcomes Measurement (ICHOM), as we will see next.
Outcomes must be reported publicly to benefit patients and providers. These public reports will further accelerate innovation by motivating their peers to improve their own results. The costs for achieving value to the patient must be measured around the patient, not specialty or around departments. Measuring cost around an entire cycle of care will reduce costs through reallocation of servicer, elimination of others, and better use of the local capacity.
The change in the reimbursement model from a volume-based to a value-based model will allow a reform in payment. It will reward value by providing bundled payment covering the full cycle of care, covering periods of months to 1 year, or longer, according to the condition treated. We will cover this topic further along.
The payment must fit five conditions: payment covers the overall care required to treat the condition, payment is contingent on delivering good outcomes, payment is adjusted for risk, payment provides a fair profit for effective and efficient care, and providers are not responsible for unrelated care or catastrophic cases [14].
3. Medical practice should be organized around medical conditions and care cycle
The organization we have today is by specialty, so a patient who has a condition that needs the effort of different specialties will bounce around from office to office to get his treatment. The reform should be made that patients only go to one place and have a team ready to address their different problems related to the initial condition in the same visit. Organizing around medical conditions and care cycle will be a major change for physicians but a great improvement for patients [3].
Effective care should be centered around a medical condition. That will need the effort of multiple physicians and other health professionals. This organization is known as integrated practice unit (IPU). The IPU is formed by physicians and nonphysicians who provide the full cycle of care for the patient. We will review them further along the text.
The scope of services should be accounted for concentrating volume in fewer locations, choosing the right location for each service line, and integrating care across locations.
Defining the scope of service is to reduce or eliminate service lines where value cannot be achieved. Another possibility is to create partnerships or affiliations with services that you have eliminated because of the lack of possibility of creating value for patients [15].
The concentration of volume in fewer locations is to create a consumer-oriented healthcare. Volume matters for value. The more you treat a disease and the more you learn, the better your treatment will be and more value will be created for the patient. This can be very difficult for organizations to achieve [15].
To choose the right location for each service line is of high value for patients. Less complex conditions should be moved away from high-value facilities to low-cost facilities. It’s important to match complexity and the skills needed to the right location. That will optimize cost and productivity [15].
The integration of care across locations is the final component for health system integrations. This concentration of services around different locations must be tied together to improve patient’s experience across the sites. All have been directed by IPUs and their physician managers [15].
Value for the patient comes from the effect of the entire set of activities and not only from a single specialty, and the value is greater when all of the four changes above are made.
The MD Anderson Cancer Center in Texas is one of the places where this set up was made. They are organizing around cancer type, and all relevant specialties needed are found in every one of those centers [1].
This approach changes the way physicians manage their practices and their patients. In primary care, for example, they will participate in a number of care cycle teams and they will focus, maybe, in disease diagnosis [3]. The complete cycle of care includes many areas and may take months or even years for the cycle to come to an end. Surgery is one part of care and physical therapy another.
It is thought that increasing value for the patient and the patient feeling well taken care of will reduce the number of malpractice suits. When you have more outcomes measured and a good data collection system, if you get sued you have better data that you can use to defend yourself.
4. Results must be measured
There cannot be an improvement in value for patients without measuring the results. The outcomes for every medical condition and the cost for achieving it need to be measured. Good measures are vital, and they enable professional insight and the development of expertise [16].
This is easier said than done because it may not be so straightforward to measure value or outcome. They can mean different things to different people, and unifying that is a challenge. Many medical associations all over the world are trying to do just that, some with relative success.
One thing we need to recognize is that health consists of physical, mental, and social health. All three must be in order to consider someone healthy and that need to be taken in consideration when measuring results for patients [17] and when a measurement tool is being done. To measure results by improvement on the initial condition alone is not good enough and should not be done.
The results should be measured by condition and care cycle, not specialty or even intervention. It should cover the full cycle of care until after care is completed and taken in consideration the social and mental status. According to Dr. Porter, the outcomes fall into three tiers. Tier 1 involves the health status achieved. Tier 2 outcome relates to the nature of the care cycle and recovery. Tier 3 outcomes relate to the sustainability of health [15]. If all tiers of outcome work well, costs will go down and productivity will go up.
If we want the value-based model to be successful, we need to measure outcomes. If we measure a minimum sufficient set of outcomes for every major medical condition and then standardize them nationally, we are one step closer to this model’s success, but that has proven to be difficult.
First, quality is not defined as improvement in outcomes by today’s standards. Second, the measurements that have been done are done by specialty societies but the aim is to treat the patient around a care cycle, not by a single specialty or a single procedure. Third, outcome measurements have focused on clinical status rather than functional outcome, which is the patient goal after all, to improve quality of life. And finally, every organization and even physician have their own set of measurements and outcomes, and that leads to inconsistencies in definitions and results. A regional, national, and global standardization is needed, but that is hard to achieve [18].
The International Consortium for Health Outcomes Measurement (ICHOM) has convened groups of experts on specific diseases to set a minimum standard set outcome and risk factors using a structured process [18]. Once this is done, it should be fairly easy to spread round the country and around the world.
One important thing for this to work is the implementation of information technology. The development of software that can automatically collect and aggregate the data for future analysis, such as electronic medical records.
It is believed that in the near future, this is something that will be implemented all over the world with good results for everyone involved in healthcare, especially with excellent outcomes for the patients.
5. Integrated practice units
An integrated practice unit (IPU) is a multispecialty team that collaborates to provide the best outcome to the patient at the lowest cost. These IPUs are encouraged to compete among themselves for the best possible outcome at the lowest cost during the cycle of care. The IPU will treat not only the disease but also all related conditions of the patient.
The team is responsible for the patient’s full cycle of care. That encompasses outpatient, inpatient, rehabilitation, and supporting services such as nutrition, social work, and others. The team is also accountable for the outcomes and costs.
Usually with IPUs, we have faster treatment, better outcomes, and lower costs. All that are achieved by the amount of patients they are able to see.
Since the IPU focuses on disease, it is not clear how a patient with multiple diseases at the same time, and not necessarily correlated, will be conducted. Does he have to seek multiple IPUs to treat each of his diseases or only the one? Some say that the need to go to multiple IPUs may cause almost the same problem we have in today’s system.
The West German Headache Center can be considered an IPU. It includes neurologists, physical therapists, and psychologists who work together to treat every patient. The patient sees all experts they need in a single visit. If diagnostic imaging is needed, it is obtained from a nearby partner provider [19].
Care delivered in an IPU should be structured. Just the fact that everybody is in the same place does not mean it works well and is integrated. The creation of evidence-based guidelines will incrementally improve value to patients.
One important thing for an IPU is volume. Volume is needed to achieve better results and improve value to patients. The more you study and the more you treat a disease, the better you get at it. Experience is a key point for the deliverance of value. With that you can incorporate more parts of the cycle of care in your facility.
The creation of an IPU can be challenging. A good example of how to make it work is as follows. The Navy launched in Jacksonville at their hospital a value-based program. They selected four of the most common condition to be the starting point [20]. A physician and a nurse were selected to lead each of the four IPUs that were created, and then they recruited other physicians, physical therapists, nurses, and others to be on the IPU. The teams received training on VBHC by external experts and the entire hospital too. Evidence-based treatment and outcomes were defined for later examination; the location, structure, and schedule were also defined by the team. The IPUs met weekly to monthly to discuss patients and treatments. When a treatment was not working, the team would come to an agreement to change it [20]. Three out of the four IPUs created were successful.
Another example of an IPU is at the Dell Medical School at the University of Texas. The musculoskeletal group implemented an IPU team. They followed these steps. First, they choose a condition, symptom, or patient segment to focus. They choose lower extremity joint pain. Next, they set the standards to meet for the patient to be able to go back to primary care. The next step is to define the clinical and nonclinical staff of the IPU, such as the IPU multidisciplinary team and the physical location of the IPU, for example, the building they are located. For their lower extremity joint pain IPU, all patients were initially evaluated by a mid-level orthopedic provider and if surgery was as option they would consult with the orthopedic surgeon and address any questions of the patient. All decisions were discussed with the patients as a shared-decision making. Data collection and feedback is an important step in an IPU since those measurements will be used to address the value of care. The final step is to identify opportunities to improve value to the patient, increasing the overall health and maintaining the patient engaged in care [21].
This is the basic structure to initiate an IPU at your local hospital to get started. At first, we can select a few specific conditions, the most common ones. Later, when you have the first data collected and analyzed, if they are successful, others IPUs can be created. For the data collection and patient information to be readily available, we need the implementation of information technology, such as electronic data records.
We will cover this topic of the collection of data next.
6. Primary care
Primary care is essential for healthcare. Primary care physicians are hard to find, and when patients do, they feel frustrated with the ability of primary care to meet their needs. The problem is that primary care needs to be organized to deliver and demonstrate measured value [22].
Primary care needs to be deconstructed. Instead of one single set of services, it is actually a group of services delivered for multiple subgroups of patients [22]. Like VBHC is organized around conditions so should value-based primary care. It will be needed to transform care into subgroups of patients with new ways of measuring outcome and costs, new payment models, and new approaches to integrate primary care with specialty care [22].
The problem with primary care is that the patients are heterogeneous. The diversity of needs these different patients create is the challenge to implement value-based primary care. It is impractical to measure outcomes achieved relative to costs for such diverse patients [22]. There are five elements to shift primary care to a value-based model [22].
The first element is basing primary care on patients’ needs. It is to group patients by their needs. It is designed to create value to patients. The “needs” include types of services and effective methods for patients to access care [22].
The second element is integrating delivery models by subgroup. Once the subgroups are defined, we can move over to the second element. A few questions must be answered. First, the team should be composed of the physician and other personnel according to the subgroup and their needs. Second, the facilities should also be organized around the subgroup and their needs, and they can be arranged to each day of the week to receive a different group of patients. Third, providers must function as teams, a leader must be recognized, and the team must meet regularly to address the patients’ needs [22].
The third element is measuring value for each patient’s subgroup. Identification of the outcome that matters to patients is key; also, the measurement of the total cost should be done, including those costs outside primary care. All of the care processes must be mapped by subgroups; then, the resources needed can be identified and the costs ascertained.
The fourth element is aligning payment with value. The payment system should be redesigned to a time-based bundled payment or a payment for a total package of services for a defined primary care subgroup during a specified time period. Additional fee-for-service payment could be available for patient’s acute care need [22].
The final element is integrating subgroup teams and specialty care. Some patients will need coordination between primary care and specialty secondary and tertiary care. Healthy children and adult may have all their needs met by primary care. Chronic conditions will need to be integrated with specialty care according to their needs [22].
This concept of organizing care around subgroups may seem different than the purpose of primary care but this approach is something that will make primary care more efficient, integrative, and holistic [22]. Electronic data record systems are needed in primary care also. All the participants of the teams must have access to it, and it must be integrated with secondary and tertiary care units and their IPUs. We will revise this topic on information technology up next in further detail.
7. Information technology
All over the world the interest in VBHC is growing. With this growing interest and rapid acceptance of both patient and providers, it is important to have the right tools to record and analyze patient’s data toward a value-based model. That is why the implementation of a value-enhancing information technology system, such as a patient electronic data record, is so important.
It is critical for the implementation of value-based healthcare to be successful such as the use of electronic data record. The completion of data and reduction of the potential loss of data, by not keeping patient paper records, are critical for the correct measurement of outcomes [23].
Some electronic records today are very good for keeping data but make it hard to export those records for later analysis. There are six elements that are key for a value-enhancing IT platform for the IPUs [15].
First, the platform must be centered on the patient. The system needs to follow the patients across the services and through time for the full cycle of care. Data are aggregated around the patients not locations. So, all parts of the team have access to the same and complete records, instead of the physicians having access only to his notes or other physicians’ notes, he is capable of accessing the records from the nurse staff, physical therapists, and so on [15].
Second, it needs to use common data definitions. The data fields related to diagnose, medical history, and other aspects of care are standard according to the condition being treated so everyone can understand what it means and it is easy to export when needed across the entire system [15].
Third, it encompasses all types of patient data. Notes, images, laboratory tests, and many other are stored in the same place and in a standard format. Like said before, everybody has access to everybody’s notes and to the complete patient record. Access is not limited to the IPU team leader [15].
Fourth, the access is available to all parties involved in care. That means that the data collected have to be available to the patients and any referring physicians. The best information technology system possible is the one in that the patients can schedule appointments, refill their prescription, and communicate with their physicians and to the rest of the IPU team, in a simple and easy way. It also should be made easy to access some types of information needed for the evaluation of the care given to the patient [15].
Fifth, every medical condition should have its own template. This set of templates makes it easy and efficient for the IPU teams to retrieve the data they need in order to execute procedures and measure the patient’s outcomes and risk factors and the costs of the full cycle of treatment [15].
And finally, the system must be easy to extract information. In a value-enhancing system, the data to measure outcomes, track costs, and control the patient risk factors must be easy to extract. They should also allow the patient to report on his/her own outcomes, so that clinicians can make better decisions [15].
The Cleveland Clinic is a good example of an institution that followed all those steps when adopting a value-enhancing data system [24].
8. Reimbursement
The reimbursement changes in a value-based model. Instead of fee-for-service like in a volume-based model, the reimbursement occurs after the full cycle of care. It is essential to have this payment reform. Physicians paid in a fee-for-service tend to provide more care compared with salaried physicians [25]. Also, the fee-for-service payment method is not necessarily aligned with value to the patient.
Payment per activities encourages more procedure done, maintains fragmentation, and discourages prevention, which does not stimulate high-quality care to the patient [26]. According to the authors, high-value care should limit per capita cost, improve patient experience, and improve population health [27].
Emphasis of VBHC is developing and implementing a bundled-payment known as pay-for-performance (P4P). This payment method focuses on aspects of value that can be measured using indicators of quality [27]. Cattel and Eijkenaar in their 2019 article give a comprehensive view on a new payment initiative that combines two elements: 1—global base payments and 2—explicit quality incentives [27].
The rationale of their initiative is that in essence, the global payment is a bundled payment, with the bundle being constructed at a higher level than at the level of conditions or treatments. The second component, the quality incentives, is sort of a P4P payment that rewards measurable aspects of value [27].
Some aspects of value cannot be explicitly measured such as well-coordinated care or many health outcomes are difficult or impossible to measure. While important, they cannot be explicitly accounted for in the payment contract [28]. Designing the base payment as a global payment facilitates cost-consciousness and well-coordinated care across the full cycle of care, with a focus on the patient instead of on separate conditions [27].
Global base payment transfers the risk from payer to provider which may cause a few problems such as diminishing quality or attempting to underprovide expensive services. These concerns have been addressed by Frakt and Meyers [29], and they can be addressed by risk-sharing arrangements in global payment and explicit quality incentives.
The components of the global base payment are, to a multidisciplinary provider group, for a cohesive set of care activities to a predefined population, fixed for a defined period of time, risk-adjusted, and with risk-mitigating measures. The components of the explicit quality incentives need to have a method of linking payment to quality, with quality measures and with quality incentive structure [26].
This payment initiative described above is a little different than that proposed by Dr. Porter. In his initial model, reimbursement would be done after the complete cycle of care and would include all services and medications, and treating inpatients and outpatient’s services together. This model would reward true value and incentivate innovation among physicians [3]. Bundled reimbursement allows for all the system to benefit from value improvement [9].
Today, reimbursement takes place for discrete services not for the entire cycle of care. This works against value, according to Dr. Porter [9]. Value is created by the entire care cycle, not the parts. A change in the payment method is required for the VBHC to work. In essence independently of what reimbursement model you use, for value-based healthcare to work, reform is needed. A fee-for-service model, which is the prevailing way of reimbursement today, does not work in a value-based health-care model.
9. Comparison
The fee-for-service is the prevailing model of healthcare in the US and around the world. The patient pays for a medical service, such as visits, tests, and surgical procedures. In theory, the physician charges to cover their costs and for a profit, the patient knows through itemized bills what they are paying for and they can compare the prices with other providers. This competition will drive prices down.
The value-based health-care model has a pay-for-performance reimbursement system. In primary care, for example, the patient pays a monthly, quarterly, or annual retainer fee. This fixed price is regardless how many visits or test the patient requires. As long as the patient is satisfied to continue this plan, physicians will get paid.
10. Limitations and obstacles
The limitations of the value-based health-care model are that it must be led by physicians and that can pose as a problem. If physicians sense that this new model can limit their gains with reimbursement, they may be inclined not to follow through with the necessary steps to make it work.
Physicians are also worried they have little to no time with the IPU team, lack of transparency with the providers, and find it hard to meet quality expectations. Some physicians are not implementing a value-based healthcare because they fear it is too risky with no real assurances.
Other physicians say that this model is beyond the scope of their practices. Should an internist be concerned about organizing someone’s efforts to quit smoking? And so, this only adds on to the physicians’ responsibilities and with their work load.
Another problem raised is that some fear that tying the physician salaries directly to outcomes might encourage them to refuse to treat the sickest patients who are more likely not to get better.
11. Conclusion
There is a strategic agenda for creating value-based health-care system. It should encompass what we have seen so far in this chapter: organize into IPUs, measure outcome and costs for every patient, move to value-based reimbursement models and bundled payments, integrate and coordinate care in multi-site care delivery systems, expand across geography, and build an enabling information technology platform [30].
When we have achieved all these goals, we will have reached a VBHC system. The road getting there is rough but rewarding. This shift in health-care design from volume to value is already happening all over the world in all specialties, some with success and some not, but the first step in the right direction must be taken.
It is possible to achieve better results at lower costs as we have seen, and at the same time, creating value to patients. This topic needs to be further studied, but all the components to make it work all already in place and ready to be put to the test.
Conflict of interest
The author declares no conflict of interest.
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Heston"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. The goal is value for patients",level:"1"},{id:"sec_3",title:"3. Medical practice should be organized around medical conditions and care cycle",level:"1"},{id:"sec_4",title:"4. Results must be measured",level:"1"},{id:"sec_5",title:"5. Integrated practice units",level:"1"},{id:"sec_6",title:"6. Primary care",level:"1"},{id:"sec_7",title:"7. Information technology",level:"1"},{id:"sec_8",title:"8. Reimbursement",level:"1"},{id:"sec_9",title:"9. Comparison",level:"1"},{id:"sec_10",title:"10. Limitations and obstacles",level:"1"},{id:"sec_11",title:"11. Conclusion",level:"1"},{id:"sec_15",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Porter ME, Teisberg E. Redefining Health Care: Creating Value-Based Competition on Results. 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DOI: 10.1007/s10840-016-0166-x'},{id:"B8",body:'DeBaun MR, Chen MJ, Bishop JA, Gardner MJ, Kamal RN. Orthopaedic trauma quality measures for value-based health care delivery: A systematic review. Journal of Orthopaedic Trauma. 2019;33(2):104-110'},{id:"B9",body:'Porter ME. Value-based health care delivery. Annals of Surgery. 2008;28(4):503-509'},{id:"B10",body:'Sampaio SGSM, Motta LB, Caldas CP. Value-based medicine and palliative care: How do they converge? Expert Review of Pharmacoeconomics & Outcomes Research. 2019;5:509-515. DOI: 10.1080/14737167.2019.1651645'},{id:"B11",body:'Vilhelmsson A. Value-based health care delivery, preventive medicine and the medicalization of public health. Cureus. 2017;9(3):e1063. DOI: 10.7759/cureus.1063'},{id:"B12",body:'Porter ME. What is value In health care? The New England Journal of Medicine. 2010;363:26'},{id:"B13",body:'Starfield B, Shi L, Macinko J, et al. Contribution of primary care to health systems and health. The Milbank Quarterly. 2005;83:457-502. DOI: 10.1111/j.1468-0009.2005.00409.x'},{id:"B14",body:'Porter ME, Kaplan RS. How to Pay for health Care. Available from: https://hbr.org/2016/07/how-to-pay-for-health-care [Accessed: 02 June 2020]'},{id:"B15",body:'Porter ME, Lee TH. The Strategy That Will Fix Health Care. Harvard Business Review; 2013. Available from: https://hbr.org/2013/10/the-strategy-that-will-fix-health-care'},{id:"B16",body:'Berwick DM, James B, Coye MJ. Connections between quality measurement and improvement. Medical Care. 2003;41(suppl):I30-I38'},{id:"B17",body:'Putera I. Redefining health: Implication for value-based healthcare reform. Cureus. 2017;9(3):e1067. DOI: 10.7759/cureus.1067'},{id:"B18",body:'Porter ME, Larsson S, Lee TH. Standardizing patient outcomes measurement. The New England Journal of Medicine. 2016;374:6. DOI: 10.1056/NEJMp1511701'},{id:"B19",body:'Porter ME, Guth C, Dannemiller E, et al. The West German Headache Center: Integrated Migraine Care. Harvard Business School Publishing; May 2007. HBS Case No. 707-559 (Revised July 2011)'},{id:"B20",body:'Hernandez A, Kaplan RS, Witkowski ML, Faison CF III, Porter ME. Navy medicine introduces value-based health care. Health Affairs. 2019;38(8):1393-1400. DOI: 10.1377/hlthaff.2019.00280'},{id:"B21",body:'Keswani A, Koenig KM, Bozic KJ. Value-based healthcare: Part 1—Designing and implementing integrated practice units for the management of musculoskeletal disease. Clinical Orthopaedics and Related Research. 2016;474:2100-2103. DOI: 10.1007/s11999-016-4999-5'},{id:"B22",body:'Porter ME, Pabo EA, Lee TH. Redesigning primary care: A strategic vision to improve value by organizing patients needs. Health Affairs. 2013;32(3):516-525. DOI: 10.1377/hlthaff.2012.0961'},{id:"B23",body:'Johansen NJ, Saunders CM. Value-based care in the worldwide battle against cancer. Cureus. 2017;9(2):e1039. DOI: 10.7759/cureus.1039'},{id:"B24",body:'Porter ME, Teisberg EO. Cleveland Clinic: Transformation and Growth 2015.” HBS Case No. 709-473. Boston: Harvard Business School Publishing; 2019'},{id:"B25",body:'Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, et al. Capitation, salary, fee-for-service and mixed systems of payment: Effects on the behaviour of primary care physicians. The Cochrane Database of Systematic Reviews. 2000;3(3):CD002215'},{id:"B26",body:'Cattel D, Eijkenaar F. Value-base provider payment initiatives combining global payments with explicit quality incentives: A systematic review. Medical Care Research and Review. 2019. DOI: 10.1177/1077558719856775. [Published online ahead of print, 19 Jun 2019]'},{id:"B27",body:'Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Affairs. 2008;27:759-769'},{id:"B28",body:'Eggleston K. Multitasking and mixed systems for provider payment. Journal of Health Economics. 2005;24:211-223'},{id:"B29",body:'Frakt AB, Mayes R. Beyond capitation: How new payment experiments seek to find the “sweet spot” in amount of risk providers and payers bear. Health Affairs. 2012;31:1951-1958'},{id:"B30",body:'Kaplan RS. VBHC Intensive Seminar. Value-Based Health Care Delivery: Core Concepts. Boston, MA: Harvard Business School; 2020'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Patrick Rech Ramos",address:"prramos@terra.com.br",affiliation:'
Santa Monica Hospital, Erechim, Brazil
'}],corrections:null},book:{id:"9566",title:"Bioethics",subtitle:null,fullTitle:"Bioethics",slug:null,publishedDate:null,bookSignature:"Dr. Thomas F. Heston and Dr. Sujoy Ray",coverURL:"https://cdn.intechopen.com/books/images_new/9566.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-83881-178-5",printIsbn:"978-1-83881-177-8",pdfIsbn:"978-1-83881-179-2",editors:[{id:"217926",title:"Dr.",name:"Thomas F.",middleName:null,surname:"Heston",slug:"thomas-f.-heston",fullName:"Thomas F. Heston"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},profile:{item:{id:"189612",title:"Dr.",name:"Luca",middleName:null,surname:"Riccioni",email:"luca.riccioni@crea.gov.it",fullName:"Luca Riccioni",slug:"luca-riccioni",position:null,biography:null,institutionString:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",totalCites:0,totalChapterViews:"0",outsideEditionCount:0,totalAuthoredChapters:"1",totalEditedBooks:"0",personalWebsiteURL:null,twitterURL:null,linkedinURL:null,institution:null},booksEdited:[],chaptersAuthored:[{title:"Chitosan in Agriculture: A New Challenge for Managing Plant Disease",slug:"chitosan-in-agriculture-a-new-challenge-for-managing-plant-disease",abstract:"In recent years, environmental-friendly measures have been developed for managing crop diseases as alternative to chemical pesticides, including the use of natural compounds such as chitosan. In this chapter, the common uses of this natural product in agriculture and its potential uses in plant disease control are reviewed. The last advanced researches as seed coating, plant resistance elicitation and soil amendment applications are also described. Chitosan is a deacetylated derivative of chitin that is naturally present in the fungal cell wall and in crustacean shells from which it can be easily extracted. Chitosan has been reported to possess antifungal and antibacterial activity and it showed to be effective against seedborne pathogens when applied as seed treatment. It can form physical barriers (film) around the seed surface, and it can vehicular other antimicrobial compounds that could be added to the seed treatments. Chitosan behaves as a resistance elicitor inducing both local and systemic plant defence responses even when applied to the seeds. The chitosan used as soil amendment was shown to give many benefits to different plant species by reducing the pathogen attack and infection. Concluding, the chitosan is an active molecule that finds many possibilities for application in agriculture, including plant disease control.",signatures:"Laura Orzali, Beatrice Corsi, Cinzia Forni and Luca Riccioni",authors:[{id:"189361",title:"Ph.D.",name:"Laura",surname:"Orzali",fullName:"Laura Orzali",slug:"laura-orzali",email:"laura.orzali@gmail.com"},{id:"189612",title:"Dr.",name:"Luca",surname:"Riccioni",fullName:"Luca Riccioni",slug:"luca-riccioni",email:"luca.riccioni@crea.gov.it"},{id:"189614",title:"Dr.",name:"Beatrice",surname:"Corsi",fullName:"Beatrice Corsi",slug:"beatrice-corsi",email:"CorsiBeatrice@gmail.com"},{id:"189615",title:"Prof.",name:"Cinzia",surname:"Forni",fullName:"Cinzia Forni",slug:"cinzia-forni",email:"forni@uniroma2.it"}],book:{title:"Biological Activities and Application of Marine Polysaccharides",slug:"biological-activities-and-application-of-marine-polysaccharides",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"27644",title:"Prof.",name:"Fabien",surname:"Salaün",slug:"fabien-salaun",fullName:"Fabien Salaün",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:"Fabien Salaün is a full professor at ENSAIT/GEMTEX, France. His research interests focus on polymer synthesis, encapsulation, and functional coatings for textile applications. He received his Ph.D. from Lille 1 University in 2004 and he was promoted professor in 2014. He has more than 50 publications to his credit, including research papers, reviews and book chapters.",institutionString:"Ecole Nationale Supérieure des Arts et Industries Textiles",institution:null},{id:"148678",title:"Dr.",name:"Noemi",surname:"Zaritzky",slug:"noemi-zaritzky",fullName:"Noemi Zaritzky",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"188340",title:"Prof.",name:"Melissa",surname:"Gurgel Adeodato Vieira",slug:"melissa-gurgel-adeodato-vieira",fullName:"Melissa Gurgel Adeodato Vieira",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"State University of Campinas",institutionURL:null,country:{name:"Brazil"}}},{id:"188572",title:"Associate Prof.",name:"Nechita",surname:"Petronela",slug:"nechita-petronela",fullName:"Nechita Petronela",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:'"Dunarea de Jos" University of Galati',institutionURL:null,country:{name:"Romania"}}},{id:"189338",title:"Prof.",name:"Ada",surname:"Ferri",slug:"ada-ferri",fullName:"Ada Ferri",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"189339",title:"Dr.",name:"Stéphane",surname:"Giraud",slug:"stephane-giraud",fullName:"Stéphane Giraud",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"189340",title:"M.Sc.",name:"Jagadish",surname:"Roy",slug:"jagadish-roy",fullName:"Jagadish Roy",position:"Scientific Researcher",profilePictureURL:"https://mts.intechopen.com/storage/users/189340/images/4545_n.jpg",biography:"Microcapsule Formulation of Active Ingredient (AI), Controlled release, Aquatic Toxicology, ISO 17045 & 9001, REACH & CLP, Life Cycle Assessment (LCA)",institutionString:null,institution:null},{id:"189341",title:"Dr.",name:"Jinping",surname:"Guan",slug:"jinping-guan",fullName:"Jinping Guan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"194536",title:"Dr.",name:"Jimena Bernadette",surname:"Dima",slug:"jimena-bernadette-dima",fullName:"Jimena Bernadette Dima",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"194537",title:"Dr.",name:"Cynthia",surname:"Sequeiros",slug:"cynthia-sequeiros",fullName:"Cynthia Sequeiros",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null}]},generic:{page:{slug:"terms-and-conditions",title:"Terms and Conditions",intro:'
These Terms and Conditions outline the rules and regulations pertaining to the use of IntechOpen’s website www.intechopen.com and all the subdomains owned by IntechOpen located at 5 Princes Gate Court, London, SW7 2QJ, United Kingdom.
',metaTitle:"Terms and Conditions",metaDescription:"These terms and conditions outline the rules and regulations for the use of IntechOpen Website at https://intechopen.com and all its subdomains owned by Intech Limited located at 7th floor, 10 Lower Thames Street, London, EC3R 6AF, UK.",metaKeywords:null,canonicalURL:"/page/terms-and-conditions",contentRaw:'[{"type":"htmlEditorComponent","content":"
1. Terms
\\n\\n
By accessing the website at www.intechopen.com you are agreeing to be bound by these Terms of Service, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. Use and/or access to this site is based on full agreement and compliance of these Terms. All materials contained on this website are protected by applicable copyright and trademark laws.
\\n\\n
The following terminology applies to these Terms and Conditions, Privacy Statement, Disclaimer Notice, and any or all Agreements:
\\n\\n
“Client”, “Customer”, “You” and “Your” refers to you, the person accessing this website and accepting the Company’s Terms and Conditions;
\\n\\n
“The Company”, “Ourselves”, “We”, “Our” and “Us”, refers to our Company, IntechOpen;
\\n\\n
“Party”, “Parties”, or “Us”, refers to both the Client and ourselves, or either the Client or ourselves.
\\n\\n
All Terms refer to the offer, acceptance, and consideration of payment necessary to provide assistance to the Client in the most appropriate manner, whether by formal meetings of a fixed duration, or by any other agreed means, for the express purpose of meeting the Client’s needs in respect of provision of the Company’s stated services/products, and in accordance with, and subject to, the prevailing laws of the United Kingdom.
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Any use of the above terminology, or other words in the singular, plural, capitalization and/or he/she or they, are taken as interchangeable.
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2. License
\\n\\n
Unless otherwise stated, IntechOpen and/or its licensors own the intellectual property rights for all materials on www.intechopen.com. All intellectual property rights are reserved. You may view, download, share, link and print pages from www.intechopen.com for your own personal use, subject to the restrictions set out in these Terms and Conditions.
\\n\\n
3. Cookies
\\n\\n
We employ the use of cookies. By using the IntechOpen website you consent to the use of cookies in accordance with IntechOpen’s Privacy Policy. Most modern day interactive websites use cookies to enable the retrieval of user details for each visit. On our site, cookies are predominantly used to enable functionality and ease of use for those visiting the site.
\\n\\n
4. Limitations
\\n\\n
In no circumstances shall IntechOpen or its suppliers be liable for any damages (including, without limitation, damages for loss of data or profit, or due to business interruption) arising out of the use, or inability to use, the materials on IntechOpen's websites, even if IntechOpen or an IntechOpen authorized representative has been notified orally or in writing of the possibility of such damage. Some jurisdictions do not allow limitations on implied warranties, or limitations of liability for consequential or incidental damages; consequently, these limitations may not apply to you.
\\n\\n
5. Accuracy of Materials
\\n\\n
Intechopen.com website content and services are provided on an "AS IS" and an "AS AVAILABLE" basis. Material appearing on www.intechopen.com could include minor technical, typographical, or photographic errors. IntechOpen may make changes to any material contained on its website at any time without notice.
\\n\\n
6. Links
\\n\\n
IntechOpen has no formal affiliation to any external sites that link to www.intechopen.com, unless otherwise specifically stated. As such, it is not responsible for content that appears on any such sites. The inclusion of any link to IntechOpen does not imply endorsement by IntechOpen. Use of any such linked website is done solely at the user's own discretion.
\\n\\n
We reserve the right of ownership over our entire website www.intechopen.com, and all contents. By using our services, you agree to remove all links to our website immediately upon request. We also reserve the right to amend these Terms and Conditions and our linking policy at any time. By continuing to link to our website, you agree to be bound to, and abide by, these linking Terms and Conditions.
\\n\\n
If you find any link on our website, or any linked website, objectionable for any reason, please Contact Us. We will consider all requests to remove links but will have no obligation to do so.
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7. Frames
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Without prior approval and express written permission, you may not create frames around our web pages or use other techniques that alter in any way the visual presentation or appearance of our website.
\\n\\n
8. Modifications
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IntechOpen may revise its Terms of Service for its website at any time without notice. By using this website, you are agreeing to be bound by the current version of all Terms at the time of use.
\\n\\n
9. Governing Law
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These Terms and Conditions are governed by and construed in accordance with the laws of the United Kingdom and you irrevocably submit to the exclusive jurisdiction of the courts in London, United Kingdom.
\\n\\n
Croatian version of Terms and Conditions available here
By accessing the website at www.intechopen.com you are agreeing to be bound by these Terms of Service, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. Use and/or access to this site is based on full agreement and compliance of these Terms. All materials contained on this website are protected by applicable copyright and trademark laws.
\n\n
The following terminology applies to these Terms and Conditions, Privacy Statement, Disclaimer Notice, and any or all Agreements:
\n\n
“Client”, “Customer”, “You” and “Your” refers to you, the person accessing this website and accepting the Company’s Terms and Conditions;
\n\n
“The Company”, “Ourselves”, “We”, “Our” and “Us”, refers to our Company, IntechOpen;
\n\n
“Party”, “Parties”, or “Us”, refers to both the Client and ourselves, or either the Client or ourselves.
\n\n
All Terms refer to the offer, acceptance, and consideration of payment necessary to provide assistance to the Client in the most appropriate manner, whether by formal meetings of a fixed duration, or by any other agreed means, for the express purpose of meeting the Client’s needs in respect of provision of the Company’s stated services/products, and in accordance with, and subject to, the prevailing laws of the United Kingdom.
\n\n
Any use of the above terminology, or other words in the singular, plural, capitalization and/or he/she or they, are taken as interchangeable.
\n\n
2. License
\n\n
Unless otherwise stated, IntechOpen and/or its licensors own the intellectual property rights for all materials on www.intechopen.com. All intellectual property rights are reserved. You may view, download, share, link and print pages from www.intechopen.com for your own personal use, subject to the restrictions set out in these Terms and Conditions.
\n\n
3. Cookies
\n\n
We employ the use of cookies. By using the IntechOpen website you consent to the use of cookies in accordance with IntechOpen’s Privacy Policy. Most modern day interactive websites use cookies to enable the retrieval of user details for each visit. On our site, cookies are predominantly used to enable functionality and ease of use for those visiting the site.
\n\n
4. Limitations
\n\n
In no circumstances shall IntechOpen or its suppliers be liable for any damages (including, without limitation, damages for loss of data or profit, or due to business interruption) arising out of the use, or inability to use, the materials on IntechOpen's websites, even if IntechOpen or an IntechOpen authorized representative has been notified orally or in writing of the possibility of such damage. Some jurisdictions do not allow limitations on implied warranties, or limitations of liability for consequential or incidental damages; consequently, these limitations may not apply to you.
\n\n
5. Accuracy of Materials
\n\n
Intechopen.com website content and services are provided on an "AS IS" and an "AS AVAILABLE" basis. Material appearing on www.intechopen.com could include minor technical, typographical, or photographic errors. IntechOpen may make changes to any material contained on its website at any time without notice.
\n\n
6. Links
\n\n
IntechOpen has no formal affiliation to any external sites that link to www.intechopen.com, unless otherwise specifically stated. As such, it is not responsible for content that appears on any such sites. The inclusion of any link to IntechOpen does not imply endorsement by IntechOpen. Use of any such linked website is done solely at the user's own discretion.
\n\n
We reserve the right of ownership over our entire website www.intechopen.com, and all contents. By using our services, you agree to remove all links to our website immediately upon request. We also reserve the right to amend these Terms and Conditions and our linking policy at any time. By continuing to link to our website, you agree to be bound to, and abide by, these linking Terms and Conditions.
\n\n
If you find any link on our website, or any linked website, objectionable for any reason, please Contact Us. We will consider all requests to remove links but will have no obligation to do so.
\n\n
7. Frames
\n\n
Without prior approval and express written permission, you may not create frames around our web pages or use other techniques that alter in any way the visual presentation or appearance of our website.
\n\n
8. Modifications
\n\n
IntechOpen may revise its Terms of Service for its website at any time without notice. By using this website, you are agreeing to be bound by the current version of all Terms at the time of use.
\n\n
9. Governing Law
\n\n
These Terms and Conditions are governed by and construed in accordance with the laws of the United Kingdom and you irrevocably submit to the exclusive jurisdiction of the courts in London, United Kingdom.
\n\n
Croatian version of Terms and Conditions available here
\n'}]},successStories:{items:[]},authorsAndEditors:{filterParams:{sort:"featured,name"},profiles:[{id:"6700",title:"Dr.",name:"Abbass A.",middleName:null,surname:"Hashim",slug:"abbass-a.-hashim",fullName:"Abbass A. Hashim",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/6700/images/1864_n.jpg",biography:"Currently I am carrying out research in several areas of interest, mainly covering work on chemical and bio-sensors, semiconductor thin film device fabrication and characterisation.\nAt the moment I have very strong interest in radiation environmental pollution and bacteriology treatment. The teams of researchers are working very hard to bring novel results in this field. I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. I have served as the editor for many books, been a member of the editorial board in science journals, have published many papers and hold many patents.",institutionString:null,institution:{name:"Sheffield Hallam University",country:{name:"United Kingdom"}}},{id:"54525",title:"Prof.",name:"Abdul Latif",middleName:null,surname:"Ahmad",slug:"abdul-latif-ahmad",fullName:"Abdul Latif Ahmad",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"20567",title:"Prof.",name:"Ado",middleName:null,surname:"Jorio",slug:"ado-jorio",fullName:"Ado Jorio",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidade Federal de Minas Gerais",country:{name:"Brazil"}}},{id:"47940",title:"Dr.",name:"Alberto",middleName:null,surname:"Mantovani",slug:"alberto-mantovani",fullName:"Alberto Mantovani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"12392",title:"Mr.",name:"Alex",middleName:null,surname:"Lazinica",slug:"alex-lazinica",fullName:"Alex Lazinica",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/12392/images/7282_n.png",biography:"Alex Lazinica is the founder and CEO of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). He is the member of many Pharmaceutical Associations and acts as a reviewer of scientific journals and European projects under different research areas such as: drug delivery systems, nanotechnology and pharmaceutical biotechnology. Dr. Sezer is the author of many scientific publications in peer-reviewed journals and poster communications. Focus of his research activity is drug delivery, physico-chemical characterization and biological evaluation of biopolymers micro and nanoparticles as modified drug delivery system, and colloidal drug carriers (liposomes, nanoparticles etc.).",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"61051",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"100762",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"St David's Medical Center",country:{name:"United States of America"}}},{id:"107416",title:"Dr.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Texas Cardiac Arrhythmia",country:{name:"United States of America"}}},{id:"64434",title:"Dr.",name:"Angkoon",middleName:null,surname:"Phinyomark",slug:"angkoon-phinyomark",fullName:"Angkoon Phinyomark",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/64434/images/2619_n.jpg",biography:"My name is Angkoon Phinyomark. I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. I had been a visiting research student at Faculty of Computer Science, University of Murcia, Murcia, Spain for three months.\n\nI have published over 40 papers during 5 years in refereed journals, books, and conference proceedings in the areas of electro-physiological signals processing and classification, notably EMG and EOG signals, fractal analysis, wavelet analysis, texture analysis, feature extraction and machine learning algorithms, and assistive and rehabilitative devices. I have several computer programming language certificates, i.e. Sun Certified Programmer for the Java 2 Platform 1.4 (SCJP), Microsoft Certified Professional Developer, Web Developer (MCPD), Microsoft Certified Technology Specialist, .NET Framework 2.0 Web (MCTS). 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