Traumatic brain injury subtypes.
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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Traumatic brain injury (TBI) is a major cause of disability in adults, and is classified as mild, moderate, and severe according to the severity of head trauma [1]. Mild TBI poses a significant public health problem: it composes 70–90% of all TBI [1, 2, 3, 4]. The incidence of hospital-treated patients with mild TBI is 100–300/100,000 population although the true population-based rate including mild TBI not treated in hospitals is estimated above 600/100,000 [1, 2, 3, 4]. Mild TBI and concussion (a transient disorder of brain function without long-term sequelae) have been used interchangeably, although the two terms have different definitions and belong to different subtypes of TBI (Table 1) [5, 6, 7].
\nPathoanatomy | \n\n | \n | \n |
---|---|---|---|
Diffuse | \n\n | Focal | \n\n |
Concussion | \n\n | Contusion | \n\n |
Traumatic axonal injury/diffuse axonal injury | \n\n | Penetrating | \n\n |
Blast | \n\n | Hematoma | \n\n |
Abusive head trauma | \n\n | - Epidural - Subarachnoid - Subdural - Intraventricular - Intracerebral | \n\n |
Severity of head trauma | \nLoss of consciousness | \nPost-traumatic amnesia | \nGlasgow Coma Scale | \n
Mild | \n≤30 min | \n≤24 hours | \n13–15 | \n
Moderate | \n>30 min, ≤24 hours | \n>24 hours, ≤7 days | \n9–12 | \n
Severe | \n> 24 hours | \n>7 days | \n3–8 | \n
Traumatic brain injury subtypes.
Since the 1980s, the term “traumatic axonal injury (TAI)” that describes impaired axoplasmic transports, axonal swelling and disconnection after the head trauma, including mild TBI, has been used in pathological studies using animal brain [8, 9, 10, 11]. Since the 1960s, pathological studies using autopsy reported axonal injury in patients with mild TBI or concussion [12, 13, 14]. However, because conventional brain CT or MRI are not powered with contrast resolution to determine TAI in mild TBI, diagnosis of TAI in live patients with mild TBI was impossible for a long time. Since the development of diffusion tensor imaging (DTI) in the 2000s, many researchers demonstrated TAI in live patients with mild TBI [15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85]. Because mild TBI and TAI are different TBI subtypes, the precise diagnosis of TAI in patients with mild TBI is clinically important for proper management and prognosis prediction (Table 1) [6, 7].
\nIn this chapter, TAI in patients with mild TBI is described in terms of definition, history, and diagnostic approach.
\nThe American Congress of Rehabilitation Medicine in 1993 defined mild TBI as a traumatically induced physiological disruption of brain function resulting from the head being struck or striking an object, or an acceleration and deceleration movement of the brain, as manifested by at least one of the following: any period of loss of consciousness up to 30 min, post-traumatic amnesia not exceeding 24 hours, and an initial Glasgow Coma Scale score of 13–15 [86, 87, 88, 89]. Blast may also cause mild TBI [90].
\nOpinions critical of the use of the term “mild TBI,” as indicating a benign condition, have been expressed [5, 91, 92]. In 2012, Rapp et al. insisted that mild TBI is a category mistake because of the heterogeneity of the clinical population and features, and the complex idiosyncratic time course of the appearance of these deficits in patients with mild TBI [92]. Subsequently, McMahon et al. reported that the term “mild TBI” is a misnomer because some of the patients with mild TBI show severe neurological sequelae [91]. In 2015, Sharp and Jenkins insisted that mild TBI is not always a benign condition as its name implies and patients with mild TBI sometimes fail to recover [5]. These critical opinions appear to stem from the observations of concurrent TAI in patients with mild TBI that cannot be detected on conventional brain CT or MRI. Such lesions have been described by hundreds of DTI studies since the 2000s [15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85].
\nNeural axons in the white matter are particularly vulnerable to diffuse head trauma due to mechanical loading of the brain during TBI [8, 93]. TAI, a pathological term, is defined as tearing of axons due to indirect shearing forces during acceleration, deceleration, and rotation of the brain, or direct head trauma [6, 9, 10, 15, 16, 17, 18, 19, 20, 21, 22, 23, 94, 95].
\nSince the 1980s, many researchers, including Povlishock, have used the term “TAI” in their pathological studies using animal brain [8, 9, 10, 11]. In the human brain, several studies have demonstrated trauma-related axonal injury in pathological autopsy studies of patients who died of other causes following TBI, including concussion or mild TBI, since the middle of the last century [12, 13, 14, 96]. However, due to insensitivity of conventional brain MRI for detection of TAI in mild TBI, diagnosis of TAI in live patients with mild TBI was impossible for a long time. In the 1990s, the development of DTI opened a new era for diagnosis of the subcortical white matter pathology in the live human brain. Because DTI provides invaluable information about subcortical white matter that cannot be obtained by conventional MRI, DTI was initially used to detect white matter pathology undetectable by conventional CT or MRI in brain pathologies such as cerebral palsy, hypoxic-ischemic brain injury, and congenital brain disease [97, 98, 99]. Since Arfanakis’s study in 2002, TAI has been demonstrated in hundreds of DTI studies in mild TBI [15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85]. As a result, DTI become an important diagnostic tool for TAI in patients with mild TBI, particularly in patients whose conventional brain CT or MRI is negative.
\nThe history of the use of term TAI with regard to the term “diffuse axonal injury (DAI)” has given rise to some confusion [6]. Adams et al. began to use the term “DAI” by defining DAI as the presence of microscopic axonal injury in the white matter of the cerebral hemisphere, corpus callosum, and brainstem caused by mechanical forces during head injury [100, 101, 102]. After that, instead of DAI, “TAI” or “diffuse TAI” was used to correct the mistaken term “diffuse” (because the distribution of the lesions of axonal injury is not diffuse but multifocal), and to include the meaning of trauma in terms of the etiology of axonal injury [6, 7, 8, 93]. Generally, the traditional definition of DAI indicates patients in profound and prolonged coma at the onset of head trauma, and who suffer a poor outcome [6, 7, 8, 93, 102, 103]. Because more restricted patterns of axonal injury than the traditional DAI were detected in milder TBI with the development of DTI, the term “TAI” is used for these more limited injuries: in practice, TAI indicates milder injury than DAI [6, 7, 8, 93, 98, 103].
\nThe left corticospinal tract shows partial tearing (arrow) at the subcortical white matter. When a researcher measures diffusion tensor imaging parameters using the region of interest (ROI) method, if the ROI is placed in the partially torn area (B), traumatic axonal injury of the left corticospinal tract can be detected, whereas if the ROI is placed in the normal-appearing area (D), traumatic axonal injury of the left corticospinal tract cannot be detected.
\nTwo methods are used to detect TAI in mild TBI: (1) region of interest (ROI) method: measurement of DTI parameters in a certain ROI of the brain, and (2) diffusion tensor tractography (DTT) for the neural tracts (Figure 1). DTT allows for visualization and estimation of the neural tracts three dimensionally by reconstruction from DTI data: measurement of DTT parameters and configurational analysis of the reconstructed neural tracts [19, 20, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 61, 72, 98]. Many more studies have used the ROI method than DTT; however, this method can yield false results for the following reasons. First, high individual variability of the anatomical location of the neural tracts in the human brain can lead to measurement of DTI parameters in a false location for the target neural tract, especially in compact areas such as the corona radiata, posterior limb of the internal capsule, or brainstem [104]. In addition, the results can differ depending on whether a ROI is placed in a TAI lesion (for example, a partially torn area) or normal-appearing area. For example, when a neural tract was partially torn by TAI following mild TBI, if the ROI was placed in the normal-appearing area, TAI cannot be detected using the ROI method although this patient had TAI following mild TBI (Figure 1). Second, high interanalyzer variability of the ROI method can lead to false results [105].
\nPossible false measurement of diffusion tensor imaging parameters in a partially torn corticospinal tract in a patient with mild traumatic brain injury.
By contrast, DTT for reconstruction of the neural tracts usually employs a combined ROI method that reconstructs only neural fibers passing more than two ROI areas. The ROI areas and reconstruction conditions for the neural tracts are well defined for each neural tract [6, 50, 106, 107, 108, 109, 110, 111, 112, 113]. High repeatability and reliability of DTT method for the neural tracts have been demonstrated in many studies [6, 24, 50, 106, 107, 108, 109, 110, 111, 113]. Therefore, experienced analyzers can reconstruct the neural tracts without significant inter- and intra-analyzer variation. The main advantage of DTT over DTI is that the entire neural tract can be evaluated in terms of DTT parameters, including fractional anisotropy, mean diffusivity and tract volume, and configurational analysis. Fractional anisotropy value indicates the degree of directionality of microstructures, such as axons, myelin, and microtubules, while mean diffusivity value suggests the magnitude of water diffusion [114]. Tract volume is determined by counting the number of voxels contained within a neural tract [114]. Therefore, a significant decrement of fractional anisotropy or tract volume, or increment of mean diffusivity compared with normal subjects, indicates injury of a neural tract. In addition, on configuration analysis of the reconstructed neural tracts, abnormal findings including tearing, narrowing, or discontinuation have been used to detect TAI of the neural tracts in patients with mild TBI (Figure 2) [19, 20, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56]. As a result, DTT would be better than DTI to detect TAI in a neural tract in an individual patient. More than 30 papers have demonstrated TAI in individual patients with mild TBI in the corticospinal tract, corticoreticulospinal tract, spinothalamic tract, fornix, cingulum, optic radiation, ascending reticular activating system, papez circuit, pre-fronto-thalamic tracts, inferior cerebellar peduncle, corticofugal tracts form the secondary motor area, arcuate fasciculus, corticobulbar tract, and dentatorubrothalamic tract [19, 20, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56]. However, DTT may underestimate the neural tracts due to regions of fiber complexity and crossing that can prevent full reflection of the underlying fiber architecture [105, 115, 116]. In addition, TAI on DTT often cannot be discriminated from abnormalities by previous head trauma, other concurrent neurological diseases, aging, or immaturity, although some findings suggest characteristic features of TAI in several neural tracts [26, 28, 29, 39, 48, 51, 52, 53, 54].
\nConfigurational analysis of the spinothalamic tract in patients with mild traumatic brain injury.
TAI is a diagnostic term with a pathological meaning; therefore, pathological study by brain biopsy is required to confirm TAI of a neural tract in patients with mild TBI. However, performing brain biopsy for an injured neural tract in patients with mild TBI is impossible because mild TBI is not a life-threatening disease like, for example, brain tumor. The sensitivity and specificity of DTT for diagnosis of TAI of a neural tract in patients with mild TBI can be calculated only through direct comparison of DTT findings of an injured tract with the pathological results of brain tissue, if we accept the latter as the diagnostic “gold standard.” As a result, precise demonstration of sensitivity and specificity of DTT for diagnosis of TAI of an injured neural tract in live patients with mild TBI is impossible. However, in 2007, Mac Donald et al. demonstrated that TAI on pathological and DTI results agree in a mouse model of mild TBI that showed normal findings on conventional MRI [117]. They concluded that DTI is highly sensitive for detection of TAI and conventional MRI is not as sensitive as DTI for axonal injury [117].
\nThere are more than 30 recent papers that reported TAI in individual patients with mild TBI using DTT [19, 20, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56]. The methods to diagnose TAI of the neural tracts of the above studies can be summarized as follows (Flow Sheet 1). First, head trauma history compatible with mild TBI is required. According to the definition of mild TBI from the American Congress of Rehabilitation Medicine, the patient must have a head trauma history with three conditions of mild TBI: loss of consciousness, post-traumatic amnesia, and Glasgow Coma Scale [86]. If a patient did not suffer loss of consciousness, any alteration in mental state (feeling dazed, disoriented, or confused) at the time of the accident is necessary. Second, development of new clinical symptoms and signs after head trauma is required. The patient must show new clinical features after the head trauma, which were never observed before the head trauma. The possibility of delayed onset of the clinical symptom due to secondary axonal injury that refers to a condition in which axons were not damaged at the time of injury, but undergo axonal injury caused by the sequential neural injury process of an injured neural tract, should also be considered [9, 10, 24, 26, 27]. Third, evidence of TAI of a neural tract on DTT is required [19, 20, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56]. TAI of a neural tract can be detected by configuration (tearing, narrowing, or discontinuation) or DTT parameters (significant decrement of fractional anisotropy or tract volume, or increment of mean diffusivity) on DTT for a neural tract (Figure 2). Fourth, DTT abnormality by previous head trauma, concurrent neurological disease, aging, immaturity, or artifact of DTT should be ruled out. In addition, the newly developed clinical features and the function of the injured neural tracts must coincide. Fifth, other pathologies including peripheral nerve injury, spinal cord injury, and musculoskeletal problems should be ruled out through other studies such as electromyography study, radiological study, or ultrasonography. Additionally, improvement of a clinical symptom with management of an injured neural tract could be an additional evidence for TAI. For example, when a patient develops central pain due to injury of the spinothalamic tract following mild TBI, and if the patient’s pain improves with the administration of specific drugs for central pain, it would be an additional evidence for TAI in this patient. In addition, the clinical features and DTT findings of other neural tracts should be considered because TAI usually occurs in multiple neural tracts following diffuse head trauma like mild TBI [29, 30, 34].
\nDiagnostic approach of traumatic axonal injury of a neural tract in patients with mild traumatic brain injury.
For example, a 43-year-old female patient suffered injury from a car accident. She hit her head on the seats with acceleration-deceleration injury while sitting in a passenger seat in a minibus after a collision with a car from behind. She had no head trauma history, and findings were consistent with the three conditions of mild TBI [86, 87]. Since the head trauma, she noticed memory impairment, mild weakness of both hands, and central pain of the entire body. On DTT, the injuries of cingulum (discontinuations of both anterior cingula), the fornix (discontinuation of the left fornical crus), corticospinal tract (partial tearing at the subcortical white matter of both corticospinal tracts), and spinothalamic tract (partial tearing of the left spinothalamic tract) were detected (Figure 3). In this patient, TAI by this car accident was confidently diagnosed by the head trauma history, development of new clinical features, and injury evidence of the various neural tracts on DTT. The patient provided written informed consent.
\nTraumatic axonal injuries of several neural tracts in a patient with mild traumatic brain injury. (->:traumatic axonal injury, *suspicious traumatic axonal injury).
In this chapter, TAI in patients with mild TBI is described in terms of definition, history, and diagnostic approach. Precise diagnosis of TAI in patients with mild TBI is clinically important. The introduction of DTI has enabled diagnosis of TAI in the live patients with mild TBI [15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85]. Several requirements are necessary for diagnosis of TAI in patients with mild TBI: head trauma history, development of new clinical symptoms and signs after head trauma, evidence of TAI of the neural tracts on DTI or DTT, and coincidence of the newly developed clinical features and the function of injured neural tracts. DTT seems a better tool than the ROI method on DTI to locate partial injury in a neural tract in an individual patient, because DTT can evaluate the entire neural tract. Limitations of DTT should be considered, although the reconstruction methods of various neural tracts have been well defined, and high repeatability and reliability of these methods have been demonstrated [6, 24, 50, 105, 106, 107, 108, 109, 110, 111, 113, 115, 116, 118, 119]. Further studies of the diagnostic criteria for TAI with sensitivity, specificity, and reliability in mild TBI should be encouraged.
\nThis work was supported by the National Research Foundation (NRF) of Korea Grant funded by the Korean Government (MSIP) (2015R1A2A2A01004073).
\nA society that fosters resilience to changes in living function (a “living function-resilient society”) is required now. We need social and industrial systems that ensure safety and high-level community involvement when we experience changes in cognitive function, physical function, or family function as we move toward an aging society (a dementia society). Figure 1 shows the current age distribution of the Japanese population and that of accident rates, birth, and caregiving. Rapid, mental, and physical developments occur during infancy. Women experience significant changes during pregnancy and around birth. There are times when they or their child or parent needs nursing care. Changes in their physical and mental functions or in being able to care for someone in the family occur rather frequently in the family context. When viewed in terms of changes in living function, this means that a society will emerge in which we have to address changes in living function over generations, from a parenting generation that deals with development in children to a caregiver generation that deals with the declining living function of the elderly. The UN’s 2030 Agenda for Sustainable Development, adopted in 2015, indicates the need to ensure the safety of people of all ages and the physically and intellectually challenged, ensure access to services, and implement urban design with consideration of safety and accessibility [1].
Changes in living function and a living function-resilient society.
Figure 1 shows a snapshot of the current Japanese society. Significant changes will occur in a short period of 10 years or so: Japan’s aging population will continue to grow until 2025 as the baby boomer generation grows old. As a result, our society will have a rapidly growing population that will need support in daily living. Compared to 2015, the elderly people aged 75 or over will increase by 5,000,000, and the number of dementia patients will increase by 2,000,000. China, as a driving force in the global economy, is also faced with an aging population: the proportion of its population aged 65 and over will be 16% by 2030. So China is likely to have the same issues as Japan, incurring enormous social costs. Today, Japan’s social costs associated with dementia are huge, at US$ 127 billion. The costs are projected to reach US$ 181 billion in 2025 in Japan and US$ 2 trillion in 2030 globally. Thus, the issue of how society can develop adaptability to changes in living function will be increasingly important and is a key issue leading to a new growth strategy to develop adaptability (resilience) to changes in living function as a social mechanism separate from the issue of individual efforts.
In recent years, low-cost sensors, storage devices, and cloud computing services have become widely available. Artificial intelligence (AI) based on big data is rapidly advancing. These developments will make it possible to build a society that fosters resilience to changes in living function (a “living function-resilient society”) that can adapt flexibly to changes in diverse physical and cognitive functions of children, women, the elderly, and the physically and intellectually challenged and allow people to exploit their potential to the fullest. There is an expectation that in the next 10 years, a new industry that helps translate the need for living function resilience into innovation will grow significantly.
This report identifies issues in building living function resilience and discusses, on the basis of our research, the potential for AI and the Internet of things (IoT) in building a living function-resilient society.
The variety in living function needs to be acknowledged. A one-size-fits-all or universal intervention strategy is not necessarily effective: we need a mixed strategy combining universal, selective, and individual strategies [2]. We must have a basic understanding of what issues are involved in designing interventions based on a mixed strategy and where they arise. However, we do not fully understand them. We need to reveal the whole picture of issues associated with changes in the living function of the elderly and to base intervention design (precision intervention [2]) on that picture. To this end, we must have a system that collects data on changes of living functions and issues stemmed from the changes.
In the area of nursing care, providing one-to-one care services using human labor is considered ideal. In reality, it is difficult to provide services in terms of social costs. On the other hand, a universal strategy does not allow the variety in living function to be addressed. Precision care, which is defined as intermediate between universal and one-to-one strategies, is important. The use of AI technology may make it possible to align the variety in living function with individual adaptability by properly dividing the variety in living function into segments and selecting services that match each segment.
Various intervention approaches have been proposed. An approach that is shown to have efficacy under laboratory conditions or under specific circumstances may have no effectiveness in other situations, such as the local community or society more broadly [3]. This is an issue of a lack of understanding of a local community or an individual life as a complex system and of error arising from the incorporation of a simplified model used in laboratory research into a complex system [4]. It is suggested that researchers act to hear user requests with a serious mind, for example, by conducting a complete interview survey. The issue is often discussed in terms of attitude or mindset in conducting research. However, we think that this discussion misses the point and that it is not a matter of mindset and effort but is a scientific issue arising from lack of science and technology and methodology for dealing with complex systems in field settings. Recently, it has been pointed out that the incremental approach (incrementalism) has a limit and design should be implemented in a manner that allows scaling (big change). We need to put in place in individual lives and facilities a system to evaluate the effectiveness of interventions and make continuous improvements. We need a method of designing and evaluating effective interventions in complex life systems that are present in individual lives and in facilities and in communities.
Data on life are fragmented by facility and life situations. For example, data on illness, data on living function change, data on daily activities, and data on accidents/incidents exist in different facilities. It is necessary to use the data in an integrated manner and thereby to evaluate the variety in living function among children and elderly people, identify issues associated with the variety, and evaluate potential solutions. More importantly, we need a method of detecting their changes in daily life.
In addition to data fragmentation, services as solutions are fragmented. A collective impact model has been proposed to achieve effectiveness by collectively using stakeholders and social resources with a common purpose [5]. There is a need for a system for implementing the collective impact model based on the data.
The definition of personal information has been changing. Besides that, there are a variety of ideas about privacy exposure. This means that there is a “one-size-fits-all” issue also in privacy policy; we need a system and technology to control information according to the variety of ideas of individuals and facilities about privacy, instead of developing a privacy policy common to all people and facilities. For example, there are facilities that are positive about installing cameras to prevent abuse of the elderly.
To address issues in the variety in living function, intervention needs, data fragmentation, and variety in privacy exposure, we believe in the importance of an approach referred to as “connective AI” that allows individual lives to be connected with each other and efficacy to be scaled to effectiveness by computerizing places of living in accordance with the private policy of individual facilities and connecting them with each other through a network. We believe that connective AI is essential to building a living function-resilient society.
While our lives and living environments have individuality and are different from each other, there are many similar phenomena and environments. Skillful processing of information should make it possible to share information and convert it into knowledge. As pointed out by Herbert Simon, a physical phenomenon is essentially nonlinear when viewed hierarchically. We can develop a science based on the assumption that a physical phenomenon in the target layer can be modeled by associating it with feature quantities in the sublayers.
As Figure 2 shows, to work with connective AI in concrete terms, we at the National Institute of Advanced Industrial Science and Technology (AIST) have developed a smart living lab in cooperation with children’s hospitals, rehabilitation hospitals, intensive care homes for the elderly, and private homes. The term “smart living lab” here means (1) a place where we identify needs in field settings with user participation and adaptively explore whether new proposals to meet the needs are acceptable to the users in these “living labs” and (2) a place where we collect data, using AI and sensors, on activities of daily living of users (including children as non-main users) with a variety in living function (a smart field).
Smart living lab developed by AIST.
A system that allows daily life data fragmented in these places to be shared is essential to understanding the variety in living function. We need a new approach for information processing (AI for reality) to clarify real conditions. A system to link the verification of efficacy at the laboratory level to verification of effectiveness in facilities and communities is essential to developing solutions to support daily life. There is a strong need for a direction (reality for AI) for support technology to be put in place. We need to develop a living ecosystem suitable for individuals by combining stakeholders involved and social resources. We need to understand a field system as a complex system from a system science perspective and develop solutions that scale to different field settings. The next section describes connective AI technology being developed at AIST to build a living function-resilient society and smart living lab activities using the technology.
A recent text mining technique allows us to process quantities of data that are too big for humans to process. It has the potential for social function, which can be referred to as awareness (issue identification). Using data on medical treatment costs and situations resulting in injury from the Japan Sport Council, we at AIST are developing a technique that automatically analyzes situations that may result in severe injury. This technique identifies phrases unique to situations resulting in severe injury from free descriptive text, based on the assumption that treatment costs increase with increasing severity of injury. It is called “severity cliff analysis [6].” As shown in Figure 3, when similar situations are plotted in descending order of treatment costs, a cliff appears where the treatment costs change sharply. The technique allows us to identify the inflection point of the cliff and analyze what causes the severity of injury to increase.
Severity cliff analysis, using big data, to identify factors involved in situations resulting in severe injury.
Using this new technique, we analyzed injuries in school environments. Among injuries that involve running and tripping, the severity of injury is higher for hurdle running than for rope jumping and running on flat ground, because it involves hurdles. We investigated measures to prevent hurdle injury and found a hurdle with a top bar that opens like a double door when struck by the foot, which is in use at high schools in Miyagi Prefecture. Thus, severe injuries can be significantly reduced by taking effective preventive measures like this.
The technique allows us to understand in detail situations that result in severe injury by compiling incident data scattered across multiple organizations into big data for analysis by AI. Consequently, we can develop new prevention measures and associate them with existing measures. With data available only at some organizations (some schools, care facilities, etc.), we cannot know the overall occurrence and extent of severe injuries. As a result, known preventive measures remain isolated, and their widespread introduction is delayed. A new approach to improving situations in real-life settings by identifying problems and connecting them with solutions will be increasingly important in the future.
Elderly people typically lose cognitive and motor functions with age and experience increasing challenges in daily life. There is a need for IoT sensors to detect changes in the living function of individual elderly people as they occur and to call for appropriate interventions. A recent projection for the next 10 years holds that smart homes will provide a market for sensors to support not only home security but also healthcare and safety in the home.
We developed a sensor to make it possible to measure how fast the elderly can walk and how well they can walk unaided. The sensor is designed to be built into an object used in daily life, in this case a handrail [7]. It collects only relevant data (maintaining privacy) and does not need to be attached and detached. We verified the basic functions of the sensor in the living lab at AIST and then installed it in the home of an 88-year-old woman who lives alone. Our study will verify the efficacy of the sensor through long-term monitoring.
Figure 4 shows how the sensor works and its installation. The sensor comprises two strain gauges fixed above and below a steel bracket secured to the wall. When the subject puts her hand on the handrail, the downward load is detected by the strain gauges.
Handrail-type IoT sensor (left, configuration; right, picture).
We conducted a verification test of the sensor in a real-world setting. We installed several sensors on a handrail in the hallway in the subject’s house (Figure 4, right). Figure 5 (left) shows a sequence of images of the subject walking while holding the handrail. We collected data continuously for 24 months and plotted the subject’s walking speed by using the installation’s position-estimation capability (Figure 5, right).
The subject using the handrail (left) and motion data obtained (right).
We plotted the monthly median walking speed to reveal any changes in the walking pace from January 2016 to December 2017. As Figure 6 shows, it changed substantially over the period: it decreased from February to August as physical strength declined, increased again from September to November, but declined again from January to March. The subject told us that she initially lost physical strength but regained it from September, but knee pain caused increasing difficulty in walking from January 2017. In May 2017, she broke her thighbone and was admitted to a hospital. In August 2017, she discharged from the hospital. Our results show that the sensor can detect some problems in daily life, although not the cause.
Results of 15-month monitoring of walking pace as a health indicator.
The walking pace of the elderly decreases with advancing age, along with walking patterns such as stride length, walking pace, and lower limb muscle strength. Such declines increase the need for in-home support services for people who retain a strong need to remain in their own home. Low-cost monitoring of health and mobility would allow quick identification of risks to safety such as by falls. Such monitoring of individual elderly people would allow the timely implementation of appropriate interventions as a form of precision care or individualized care. Continued advances in AI and IoT will support this.
If we can detect changes in walking pace and other changes in daily life, what is the best way to use this information? One way is to provide services that support community involvement according to changes in living function.
To understand the living conditions and living function of the elderly, we interviewed elderly participants at home and collected data on their living conditions as a technological element for providing tailored support for community involvement. We developed a system to describe daily life data in terms of relationships between elements such as community involvement, experience, emotions, people, things, and activities related to community involvement [8]. We included elements and experiences used to describe daily life in the International Classification of Functioning, Disability and Health. Figure 7 shows an example of graphically represented life data of an elderly person at one time point. The plot represents the overall life structure. Such graphic representation allows an understanding of the entire life structure, including the relationships between individual elements, the use of graphic structure analysis, and numerical representation of the degree of similarity between individual graphic structures and searching on life data. Using this method, we have developed a life database of more than 70 elderly people.
Example of graphical representation of life structure data.
The use of graphic representation of daily life allows calculation of the degree of similarity between individual graph structures and identification of those who have a similar life structure. Figure 8 shows the life structures of 20 elderly people and plots the degree of similarity between them. It reveals groups concentrated at the top left corner of the graph, where the life structures have a degree of similarity, along with one person at the right edge (G15) and one at the bottom edge (G10), both substantially different from the others. The placement of G15 indicates that that person mostly feels happy about community involvement but sometimes feels sad, angry, or worried about it. The placement of G10 indicates that the person has mostly negative feelings such as loneliness, sadness, and anger. Such graphical representation allows us to identify elderly people with a different life structure from the majority who might therefore require interventions to support them in changing their living conditions.
Visualization of life structure patterns (life structure distance space or life structure manifold).
For example, when we design an intervention to improve living conditions, by using a life structure distance space (or life structure manifold), we can identify people with similar life structures and encourage them to become involved in community activities, instead of putting together people with very different life structures. If a person’s life structure later changes, we can again encourage community involvement with people with more similar life structures. This is a scientific approach to changing people’s life structure step-by-step to bring it closer to what they want or by revising goals. We think that this approach will lead to a data-based scientific approach (life design methodology) to process design to achieve a desirable life structure.
Figure 9 shows the output of software that has read the life structure data of an 80-year-old woman and has searched for elderly persons with similar life structures and for things that make her happy. Figure 10 shows a group of elderly people mapping the locations of little-known community involvement events. Currently, we are working with a community association and a local elderly care management center to provide the participants with advanced support, tailored to their individual living conditions, in community involvement, by combining life design support technology and local maps and making good use of resources available in the local community.
Software to support life design based on an enormous amount of life data and life geometric operations (digital crystal ball).
Working with a local elderly care management center and a community association to create a map to support community involvement.
In collaboration with care homes, we are undertaking a project to develop monitoring technology, tailored to individual elderly persons, to prevent accidents and detect early changes in behavior in anticipation of the time when an elderly person with declining living function needs care or support. Figure 11 shows a system to measure the location of an elderly person with dementia and monitor his or her behavior, using a beacon embedded in the sole of the person’s shoe [9]. Using sensors like this, we can monitor changes in walking patterns. Figure 12 shows a case in which monitoring over 45 days revealed a change in the walking pattern of an elderly person with dementia: the distance walked decreased greatly about halfway through the monitoring period. Later, we found that the decrease was due to a broken bone caused by a fall. This case shows how the use of sensors allows us to quantify changes in individual persons’ behaviors and to accurately detect changes that can be missed.
Shoe-embedded location sensor for monitoring of the elderly.
Results of long-term monitoring with a shoe-embedded location sensor.
Both wearable sensors and smartphones can collect information on individuals, but they use battery power. This is a major hindrance, because devices that require frequent battery changes are not acceptable in real-life settings. At the same time, the use of AI technology not just to find people but also to identify them has made tremendous improvements. Such “non-wearable” has begun to appear. The combination of mounted RGBD cameras and face identification software can allow unintrusive long-term monitoring of individuals, as the monitors are not worn [10]. Some facilities have started to use it. Figures 13 and 14 show a RGBD camera and a plot of a person’s walking posture captured by RGBD camera. This person’s walking pace tended to be slow in the morning and to vary greatly.
Camera image (left) and measurement of walking posture (right).
Plot of walking pace monitored by mounted camera in a home.
The facility staff made the following comments on individualized monitoring:
The video of events that may not be accurately communicated by humans is recorded. This allows information on events to be shared accurately (video can be used, e.g., when passing information onto another staff member).
By watching the video of actual positioning of things and people at a care facility, instead of reading textbooks, staff awareness is raised, and crisis management training can be improved.
By watching the video, staff can know what happens when they are not on hand and can take action immediately.
Staff can monitor daily changes in the walking pace of elderly people and can associate the changes with medications, mental state (dementia), excretion, and pain. Many medications, notably sleeping pills, can cause falls. However, support tools for personal health management have not been available.
By associating the profile of an elderly person with risks, staff can know at a glance what risks the person faces, group people with similar needs for better management, and provide better care.
Being able to identify daily changes in individuals and their long-term trend, staff can determine the need for intervention and evaluate the effectiveness of intervention. The monitoring function can also be used as tool for nursing care.
Amid increasing reports of elder abuse, more facilities and users favor the use of sensors. Staff alone will not be able to monitor residents in the level of detail that this will entail. While acknowledging the need for privacy, we need to identify what services can be made possible by what sensing technology (with attendant risks to privacy). It is important to provide levels of services that suit users’ needs best by preparing a variety of options for such services.
Changes in living function vary among the elderly. Unlike in the case of children, this makes it difficult to classify events by age, because living function varies significantly among people of the same age. We can specify “a bed for babies up to 24 month old,” but not “a chair for persons 75 years old and older”. As a means to understanding life dimensions in the elderly, we created a library of videos showing how different products (beds, chairs, wheelchairs, canes, doors, kitchen tools, handrails) are used by the elderly, depending not only on age but also on cognitive ability, physical ability, and level of care needed [11]. Figure 15 shows snapshots of the developed library. The library was launched in March 2018. Its use requires registration. The library is a pioneering attempt to show how elderly use items, such as to identify handrails that are easy to use. We intend that it will be used to identify problems and develop solutions. If you are interested, please contact us at the address provided on the website [12].
Searchable library of elderly behaviors for identifying changes in living function.
In this report, based on our research, we describe “a living function-resilient society” as a desirable society and show the potential of AI and IoT technology to identify problems and resolve them. In terms of intelligence, to resolve issues associated with the variety in living function, we need to find innovative solutions using the variety in intelligence. Today, a society is emerging in which problems, data, and intelligence are ubiquitous. Sensing and recording technology is advancing and spreading throughout the society. Various organizations now store big data. In recent years, AI, such as data analysis technology, has been advancing. Human resources spread among universities, administrative organizations, care homes, regions, and companies can be linked to create an intelligence-ubiquitous society. New social issues emerge constantly. The type of innovation required today is the transformation of the society into an advanced interconnected society by using the ubiquity of data and intelligence in modern society to address newly emerging issues.
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He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. 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