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1. Introduction
1.1 Definition of cardiac arrhythmias
Accelerated, slowed, or irregular heart rates caused by abnormalities in the electrical impulses of the myocardium.
Cardiac arrhythmias are very common in the general population and are a significant cause of morbidity and mortality of both cardiac and noncardiac surgical procedures during the perioperative period. While the incidence of perioperative arrhythmias is extremely high (the Multicenter Study of General Anesthesia reported a 70.2% incidence of Brady and tachyarrhythmias in 17,201 patients having general anesthesia for a variety of surgical procedures), only 1.6% of these required clinically significant management [1, 2, 3]. For cardiac surgery, the patients are more prone to develop arrhythmias with a reported incidence of greater than 90%, while incidence for patients undergoing non-cardiac surgery is lower and varies from 16.3 to 61.7% [4, 5, 6]. Patients with pre-existing cardiac disease for cardiac surgery are more prone to develop perioperative rhythm disturbances. It is obvious that arrhythmias that occur during surgery are clinically important as it can evolve to life-threatening malignant arrhythmias with severe hemodynamic instability and cardiovascular collapse, necessitating prompt initiation of adequate cardiopulmonary resuscitation (CPR) and defibrillation or electrical cardioversion. Hence, a thorough understanding and prompt diagnosis and intervention are critical for the anesthesiologist in order to reduce severe perioperative adverse outcomes.
An understanding of normal cardiac physiology is essential before rhythm disturbances can be understood. The normal cardiac electrical conduction system is responsible for the contraction of the heart muscle and is represented on the electrocardiogram.
Normal cardiac conduction begins with cardiac impulses coming from the sinoatrial node and travels to both atria. The atria depolarizes and generates the P wave. From here, the impulse propagates to the atrioventricular node, then reaches the his bundle and Purkinje fibers transforming into conduction, causing ventricular contraction and generates the QRS wave [6]. The resting sinus heart rate in adults is usually between 60 and 100 beats/min.
In the heart, electrical stimulation is created by a sequence of ion fluxes through specialized channels in the cardiomyocytes that generate action potential and lead to a coordinated cardiac contraction in systole. Each action potential corresponds to one beat of the heart and the inherent frequency of these cells is essential for maintaining proper rate control. Antiarrhythmic drugs act by modifying this action potential, which results from the alteration of ion channels (Table 1).
Class
Actions
Drugs (examples)
I
Sodium channel blockade
IA
~moderate
Quinidine, procainamide
IB
~weak
Lidocaine, mexiletine
IC
~strong
Flecainide, propafenone
II
β blockade
Propranolol, esmolol, sotalol
III
Potassium (K+) channel blocker
Amiodarone, ibutilide
IV
Calcium (Ca2+) channel blocker
Diltiazem, verapamil
Table 1.
Choice of antiarrhythmic therapies based on Vaughan-Williams classification (classes I–IV).
Five phases of cardiac action potential (as illustrated in Figure 1):
Phase 4: resting potential at –90 mV with minor depolarization from –90 mV to –70 mV; the passive outflow of potassium.
Phase 0: rapid depolarization from –70 mV to +50 mV; inward voltage-gated sodium channels.
Phase 1: minor repolarization; outward voltage-gated potassium channels.
Phase 2: plateau at +50 mV; outward voltage-gated potassium channels and inward voltage-gated calcium channels.
Phase 3: repolarization from +50 mV to –90 mV; outward voltage-gated potassium channels.
Figure 1.
Cardiac action potential.
Damage to the normal conduction system of the heart can lead to rhythm disturbances which can be either benign or more serious in nature depending on the hemodynamic consequence of the arrhythmia and the possibility of evolving into a lethal arrhythmia.
Bradyarrhythmias result from decreased intrinsic pacemaker function or blocks in conduction, principally within the AV-node or the His-Purkinje system. Most tachyarrhythmias are caused by re-entry, some result from enhanced normal automaticity or from abnormal mechanisms of automaticity.
2. Mechanism of intraoperative arrhythmias
The principal mechanisms of Brady and tachyarrhythmias which are observed in clinical practice are as follows [5]:
Injury to the cardiac conduction system.
Re-entry: a mechanism that may precipitate a wide variety of supraventricular and ventricular arrhythmias, implying the presence of a pathologic circuit of an electrical impulse around a functional or anatomic loop.
Automaticity: Abnormal depolarization of atrial or ventricular muscle cells during periods of the action potential can lead to arrhythmias.
Mutations in ion channels.
Ectopic foci.
3. Contributing factors and causes of arrhythmias during anesthesia for surgery
Although the incidence of intraoperative arrhythmias is extremely high, the majority of such arrhythmias are benign and self-limiting. They require no emergency treatment and respond well to pharmacologic interventions or both. However, in certain patients, some arrhythmias may pose an immediate threat to life by causing profound hemodynamic instability and require urgent clinical attention.
There are several factors likely to contribute to the generation of intraoperative arrhythmias, which can be classified according to patient, anesthesia, and procedures (Table 2) [5, 7]. Identifying the causes mainly responsible for intraoperative arrhythmias is prudent before instituting specific therapy or intervention.
Patient-related
Anesthesia related
Surgical related
Pre-existing cardiac disease, thyrotoxicosis, central nervous system disease (e.g., subarachnoid hemorrhage)
Direct laryngoscopy and intubation
Cardiac surgery (intracardiac surgical manipulation)
Insufficient level of anesthesia
Surgical manipulation during non-cardiac surgery (e.g., traction to the intestine, oculocardiac reflex). Neurosurgical causes, dental surgery, and laparoscopic surgery
Elderly
Local anesthesia (central neuraxial blockade is associated with pharmacological sympathectomy)
Contributing factors and causes of intraoperative arrhythmias.
Patients with pre-existing heart disease (e.g., myocardial ischemia) have a much higher incidence of arrhythmias intraoperatively. Intracranial pathology such as subarachnoid hemorrhage and raised intracranial pressure can result in ECG abnormalities because of stimulation of the autonomic nervous system.
Airway manipulation most often associated with hemodynamic disturbances is a well-described cause of intraoperative arrhythmias [4, 7, 8]. During anesthesia, arrhythmias can be produced in the presence of a variety of triggering agents and clinical situations such as light plane of anesthesia with hypertension and tachycardia, hypoxemia, and hypercarbia.
Vital organs, such as the brain, heart, and kidneys, must be perfused adequately during general anesthesia and surgery. Most of the anesthetic agents have direct myocardial depressant effects which result in reduced cardiac contractility and sympathetic stimulation of the peripheral vasculature. The net effect is a fall in cardiac output with a fall in perfusing pressure of vital organs secondary to vascular vasodilation. Conversely, tachycardia can have detrimental effects in patients susceptible to ischemia due to reduced myocardial filling time. Even relatively minor fluctuations in cardiovascular and hemodynamic parameters due to arrhythmias can have a significant incidence of various complications, including cardiovascular events, renal failure, infection, and cerebral infarction, particularly among the elderly co-morbid patients undergoing elective and emergency surgery. The use of halothane during induction in children as well as maintenance of anesthesia has been largely superseded by sevoflurane, which is safer. Electrolyte imbalances, abnormal blood gases, and direct cardiac stimulation via catheters influence the occurrence of arrhythmia and conduction abnormalities. The anesthesiologists should be aware of all the drugs used and able to manage the consequences accordingly [8, 9].
Surgical manipulation and cardiopulmonary bypass during cardiac surgery may precipitate arrhythmias. Vagal stimulation in surgical procedures such as during carotid surgery and peritoneal traction produces bradycardia, conduction block, or even asystole. Dental surgery causes profound stimulation of the autonomic nervous system. Thoracic surgery is associated with an incidence of atrial fibrillation.
4. Anesthetic agents and adjuvants related to arrhythmias
Prolonged cardiac repolarization (represented as QT interval on ECG) induced by various anesthetic agents and adjuvant drugs may trigger the appearance of torsade de pointes (TdP), which in some patients degenerate towards malignant ventricular arrhythmias and sudden cardiac arrest [6, 7, 10]. The duration of QT interval, QT corrected for heart rate (QTc), JT interval, QT dispersion (QTd), QT variability index, and transmular dispersion of repolarization (TDR) are the commonly used ECG markers to check for the possibility of various degrees of TdP under different conditions [11]. All volatile anesthetics, especially isoflurane and desflurane cause QTC prolongation, while sevoflurane demonstrated no effects on TDR. Propofol is generally considered to be non-torsadogenic. The sympathomimetic properties of ketamine may promote the incidents of TdP [11]. Most opioids have no effect on QTc when used at clinically relevant doses. Succinylcholine has been shown to increase QTc, especially when used in conjunction with thiopental while most nondepolarizing muscle relaxants have no effect on the QT interval. Sugammadex at therapeutic doses has no effect on QTc whereas anticholinesterase-anticholinergic antagonism of neuromuscular blockade with neostigmine and glycopyrrolate or atropine causes clinically significant QTc prolongation. The commonly used local anesthetic agents are relatively safe; nevertheless, extensive central neuraxial blocks may increase the duration of QTc. Several antiemetic drugs, such as droperidol, domperidone, and most 5-HT3 antagonists, produce a significant prolongation of QT. The FDA’s black box warning of fatal arrhythmias associated with the administration of droperidol leads to a decrease in the use of this medication in recent years. Midazolam seems to have no effect on QTc and TDR. Although dexmedetomidine may cause mild prolongation of QT interval, it is unlikely to cause TdP. It should also be prudent to use dexmedetomidine with caution, especially in patients with bradyarrhythmias tendencies where the risk of QT prolongation is increased [12, 13, 14, 15].
5. Diagnostic evaluation
During surgery, it is not always possible to get 12-lead ECG done. The anesthesiologists would have to make the diagnosis by looking at the continuous ECG monitor in the operating room. Changing the sweep speed on the ECG monitor (from 50 to 25 mm/s) may help with the identification of arrhythmias and their management. Lead II and V5 are superior for arrhythmia detection and diagnosis. All available leads are displayed on the intraoperative monitor if arrhythmia develops and cannot be readily diagnosed. For non-cardiac surgery, 12-lead ECG can be obtained as soon as feasible [9, 16].
The blood pressure, arterial oxygen saturation, and temperature also need to be monitored. More advanced monitoring such as invasive arterial pressure, pulmonary artery catheterization, and transoesophageal echocardiography can provide additional clues when assessing the patient for causes of cardiovascular collapse. End-tidal carbon dioxide may help with the effectiveness of chest compressions during cardiopulmonary resuscitation. Estimation of serum electrolytes for verification of renal function is important in patients on medications for arrhythmias.
Adequate precautions should be taken during surgery to prevent the development of intraoperative arrhythmias:
Surgical manipulations which can precipitate arrhythmias should be kept to a minimum.
Adequate depth of anesthesia may prevent or control intraoperative arrhythmias.
Hypoxia, hypotension, hypovolemia, hypothermia should be prevented during surgery.
Whenever an arrhythmia develops in the intraoperative period, the anesthesiologists should first be able to eliminate the possible causes of arrhythmia before instituting specific interventions. Attempts to correct them should be made while continuing to evaluate the arrhythmia.
6. Specific intra-operative arrhythmias
6.1 Antiarrhythmic drugs
Patients requiring oral antiarrhythmic should continue the medication until the time of surgery. Specific cardiologist consultation is advised for patients who require pacing-cardioverter devices to suppress or terminate tachyarrhythmias. With life-threatening circulatory compromise, prompt pacing or electroversion is required. Obvious electrolyte imbalance should be corrected, and management provided for underlying heart disease. Specific antiarrhythmic agents are used to suppress arrhythmias and prevent recurrences (Table 3).
Drug
Action
Dose
Adenosine
AV nodal blockade
6–12 mg
Amiodarone
Class III antiarrhythmic
Bolus 150 mg over 10 min; repeat, if necessary, maintenance of 1 mg/min for 6 hours, then 0.5 mg/min Total dose over 24 h ≤2.4 g
Digoxin
Indirect vagomimetic and slows conduction through AV node
0.5–1.0 mg loading (dose 1: 50%; 25% at 4 hourly intervals; then 0.125–0.25 mg daily) Digoxin levels must be monitored for toxicity (therapeutic blood level: 0.8–2.0 ng/mL; if >3 ng/ml is indicative of toxicity)
Diltiazem
Ca channel antagonist
20 mg × 1 min (0.25 mg/kg) 0.125 mg/kg
Esmolol
Ultrashort-acting β-blocker
150–500 μg/kg × 1 min. 50–200 μg/kg/min
Isoproterenol
β-agonist
2–20 μg/min (0.02–0.15 μg/kg/min)
Lidocaine
Na channel action decreasing duration of action potential
1.0–1.5 mg/kg; 1–4 mg/min (20–50 μg/kg/min)
Propranolol
β-blocker
0.5–3 mg (10–30 μg/kg) q 2 min to max 6–10 mg
verapamil
Ca channel antagonist
5–10 mg. Repeat bolus if needed (maximum dose 30 mg)
Procainamide
Class Ia antiarrhythmic
20–50 mg/min or 100 mg every 5 min until arrhythmia is controlled, QRS prolonged by 50% of original width, hypotension occurs, or total cumulative dose of 17 mg/kg
Sotalol
Class III antiarrhythmic
75 mg over 5 h
Table 3.
The main intravenous agents useful in management of intraoperative arrhythmias.
The administration of antiarrhythmic drugs may paradoxically aggravate the arrhythmias that are being treated or cause new rhythm disorders. This is known as proarrhythmia generally occurs when the dosage of drugs does not exceed the therapeutic range [17]. Proarrhythmia is now considered omnipresent with all antiarrhythmic medications. Care should be taken when using antiarrhythmic drugs in patients with structural heart disease, as they are at higher risk of proarrhythmia with antiarrhythmic medications. These patients, such as heart failure or cardiomyopathy are not candidates for Class IC or Class III antiarrhythmics other than amiodarone or sotalol.
Antiarrhythmic agents, in general, have a narrow therapeutic index. As a result, they are often susceptible to drug interactions with anesthetic agents and can cause significant adverse effects (Table 4).
Antiarrhythmic drugs
Interaction with anesthetic agents
adenosine
Vasodilation with isoflurane and central neuraxial block
Bronchoconstriction with neostigmine
Asystole with neostigmine, dexmedetomidine, and opioids
Antagonism with aminophylline
digoxin
Bradycardia is potentiated by halothane and succinylcholine
Caution when using calcium and diuretics (digoxin toxicity)
β blocker
Myocardial depression with halothane
Bronchoconstriction with neostigmine and atracurium
quinidine
Prolongs the effects of neuromuscular blocking agents
procainamide
Antagonizes neostigmine
calcium channel blocker
Bradycardia and myocardial depression with halogenated agents and dantrolene
Potentiates neuromuscular blockers
lidocaine
Potentiates the sympathetic blockade of opioids
Table 4.
Antiarrhythmics and its interaction with anesthetics agents.
6.2 Pacing and cardiac electroversion
Both cardiac pacing and electroversion provide a more prompt therapeutic effect and easier dose titration (i.e., pacing mode, rate, current) than with drugs [8, 18]. They have advantages over drugs for the management of intraoperative arrhythmias.
Pacing is considered in patients with symptomatic bradycardia when a pulse is present but not responded to atropine or second-line drugs (e.g., adrenaline and dopamine) [19]. Temporary cardiac pacing is used in cardiac surgery to increase heart rate, suppress bradycardia dependent tachycardia, overdrive escape rhythms, suppress atrial or ventricular extrasystoles, and terminate re-entrant SVT or atrial flutter. Transcutaneous pacing is used if invasive pacing is not feasible or is impractical.
Cardiac electroversion includes cardioversion (synchronized shocks) or defibrillation (nonsynchronized shocks) of hemodynamically unstable patients, which use high-energy capacitor discharges to simultaneously depolarize all excitable myocardium to terminate arrhythmias. It is highly effective and avoids the potential complications of drug therapy [20]. Defibrillation or unsynchronized cardioversion is indicated in any patients with pulseless ventricular tachycardia or ventricular fibrillation whereas synchronized cardioversion is utilized for the treatment of persistently unstable tachyarrhythmias in patients without loss of pulse. In synchronized cardioversion, the direct current electrical discharge is synchronized with the R or S wave of the QRS complex, avoiding the energy delivery near the apex of T wave, which coincides with a vulnerable period of induction of ventricular fibrillation. The recent use of biphasic cardioversion has shown that less energy is required to convert an arrhythmia to a sinus rhythm. It results in fewer delivered shocks to the patient, less cumulative energy delivered, and less myocardial tissue damage than is found with higher voltage shocks.
6.3 Management of arrhythmias during anesthesia and surgery
Cardiac arrhythmias may not always require treatment. However, the distinction between benign and malignant arrhythmias which carry the risk of sudden death is fundamental [21]. Figure 2 provides an algorithm for the evaluation and management of rhythm disturbances.
Figure 2.
Management of arrhythmias developed during anesthesia and surgery.
Arrhythmias are broadly classified as bradyarrhythmia and tachyarrhythmia (Table 5).
Bradyarrhythmia
Tachyarrhythmia
Sinus arrhythmia
Conduction defects
Sinus arrhythmia
Supraventricular arrhythmias
Ventricular arrhythmias
Sinus bradycardia
AV-blocks
First degree AV-block
Second degree AV-block
Third degree AV-block
Intraventricular blocks
Right bundle branch block (RBBB) or Left bundle branch block (LBBB)
Fascicular block.
Left anterior hemiblock (LAHB)
Left posterior hemiblock (LPHB)
Bifascicular block
Trifascicular block
Sinus tachycardia
Premature atrial contraction
Paroxysmal supraventricular tachycardia
Atrial flutter
Atrial fibrillation
Premature ventricular contractions (PVCs)
Ventricular tachycardia (VT)
Ventricular fibrillation
Torsade de pointes
Table 5.
Classification of bradyarrhythmia and tachyarrhythmia.
Strategies for clinical care of a patient with bradyarrhythmia (Figure 3A) and tachyarrhythmia (Figure 3B).
Figure 3.
Algorithm for (A) bradyarrhythmia. Algorithm for (B) tachyarrhythmias. VT: ventricular tachycardia.
6.4 Bradyarrhythmia
6.4.1 Conduction defects
AV conduction block can occur in the settings of intrinsic cardiac disease, acute myocardial ischemia, general anesthetics, electrolyte abnormalities, and excessive vagal tone. In cardiac surgery, high-grade AV block is not so uncommon complication and thus, a temporary epicardial pacing system is necessary. AV block is classified as first, second, and third-degree (complete). First-degree AV block is generally benign, often needs no treatment apart from careful observation for progression to a higher degree of the block that requires prompt treatment. The second-degree AV block is divided into Mobitz type I and II. In Mobitz type I, the block is often transient and asymptomatic. In Mobitz type II, the block is often symptomatic and has a less favorable prognosis because there is a potential risk of progression to third-degree heart block. Pacing is required if there is severe bradycardia with hemodynamic insufficiency. Third-degree AV block is characterized by electrical instability and may evolve towards asystole. There is no apparent relationship exists between the P waves and QRS complexes. Pacing is typically required because no conduction to ventricles occurs with atrial activity more rapid than ventricular activity (approximately 20–40 beats/min). These bradyarrhythmia (Mobitz type II and third-degree heart block) are not likely to be responsive to atropine and should be treated with transcutaneous pacing or isoproterenol infusion acting as a “chemical pacemaker” while the patient is prepared for transvenous pacing.
Intraventricular conduction defects are generally classified as LBBB, RBBB, or Hemiblock. Intraventricular blocks may be of a His bundle branch block pattern, a fascicular block pattern, or both and result from significant slowing or interruption of conduction. They are frequently seen in those with and without cardiac disease. In the vast majority of cases, RBBB may be a normal variant with little or no impact on cardiovascular prognosis. LBBB is a more serious conduction disturbance and is always associated with significant heart disease. In the presence of LBBB, acute myocardial infarction is difficult to diagnose. When the LBBB occurs in myocardial infarction, a complete heart block may develop. The anatomical or functional block in a fascicle causes a fascicular block. The left anterior hemiblock is common, while the left posterior hemiblock is uncommon. The combination of RBBB with left anterior or posterior hemiblock is called bifascicular block. Trifascicular block refers to a block of both the left and right bundles or to first- or second-degree AV block with additional bifascicular block. Patients with bifascicular and trifascicular blocks are at risk of a slow progression to an advanced or complete AV block.
6.5 Tachyarrhythmia
Tachyarrhythmias are classified into two categories (narrow complex supraventricular tachycardia and wide complex tachycardia), based on the appearance of QRS complex, heart rate, and regularity.
6.5.1 Supraventricular arrhythmias
6.5.1.1 Premature atrial contractions (PACs)
PACs are a common kind of arrhythmia characterized by early (premature) ectopic beats originating in the atria, which may be seen in patients with heart and chronic lung diseases, sepsis, shock, use of volatile agents, sympathetic stimulation, and excessive alcohol, nicotine, or caffeine. PAC is usually hemodynamically insignificant and self-limiting. But when they are in excess or compromise the cardiovascular function, β-blockers, digitalis or calcium channel blockers can be used after excluding the underlying causes.
PSVT is due to the rapid electrical discharge from an ectopic atrial focus, causing regular and consecutive atrial extrasystoles or may be caused by reentry in the AV node by the accessory pathway (AVNRT). It occurs most commonly in normal individuals, who may show no clinical evidence of heart disease. Less common causes of PSVT are rheumatic valvular heart disease, pulmonary embolism, cardiac surgery, thyrotoxicosis, and coronary artery disease. PSVT is characterized by rapid regular atrial rhythm at a rate of 160–220 beats/min, usually with a narrow QRS complex and lacking the P wave. It is typically rapid in onset and conclusion. The majority of patients who develop intraoperative PSVT maintain hemodynamic stability and do not require electrical direct current (DC) cardioversion. For this reason, heart rate control is the mainstay of the therapy that does not require immediate cardioversion [19]. PSVT can be confused with sinus tachycardia, atrial fibrillation, atrial flutter, and ventricular tachycardia. Carotid sinus massage can abruptly terminate the arrhythmia by activation of baroreceptors in the carotid sinus, resulting in increased vagal activity and transient AV nodal conduction block. This aids differentiation between PSVT, atrial flutter, and fibrillation. The Valsalva maneuver can also be used. If these vagal maneuvers are unsuccessful, then rapid intravenous adenosine in a dose of 6–12 mg is the drug of choice for terminating the re-entrant variety of PSVT arrhythmia. Adenosine slows the sinoatrial and AV nodal conduction and prolongs refractoriness, which is very effective in terminating PSVT. Its ultrashort duration of action (10 s) and very rapid onset of action (15–30 s) make it desirable over other intravenous drugs. However, atrial flutter and atrial fibrillation do not respond to adenosine. Other intravenous drugs that are useful for terminating PSVT are verapamil, diltiazem, and β-blockers. Intravenous digoxin is not clinically useful in the acute control of PSVT because of its delayed peak effect and a narrow therapeutic index. DC cardioversion is indicated for PSVT unresponsive to drug therapy or PSVT associated hemodynamic deterioration. Radiofrequency ablation is the preferred approach for patients with persistent symptomatic re-entry PSVT.
6.5.1.3 Atrial flutter
Atrial flutter is due to electrical impulse re-entry into the atria, often giving an atrial rate of 250–350 beats/min with a ventricular rate of 150 beats/min. It is usually associated with varying degrees of AV block, manifesting 2:1–4:1 AV conduction. The rapid P waves create a classic saw tooth appearance on ECG (best seen in leads II, III, aVF, and V1) and are called flutter waves (F waves). Normal T waves are lost in F waves. Atrial flutter often occurs in association with other arrhythmias such as AF. It usually signifies the presence of underlying severe heart disease and exacerbation of a chronic condition such as pulmonary disease, thyrotoxicosis, or after cardiac surgery. In many instances, treatment of the underlying disease process restores sinus rhythm. Intraoperative management of atrial flutter depends on the hemodynamic stability of the patient. Synchronized cardioversion using a low energy current (50–100 J) is the treatment of choice if the hemodynamic deterioration is present. If vital signs are stable, intravenous amiodarone, diltiazem or verapamil may convert the flutter to normal sinus rhythm.
6.5.1.4 Atrial fibrillation (AF)
AF is much commoner than an atrial flutter, and is one of the most common of all arrhythmias, especially in the elderly population [20, 22]. It accounts for more than 90% of supraventricular arrhythmia in the perioperative setting. AF has an irregularly irregular rhythm. The absence of P waves and variable QRS complexes on ECG is diagnostic of AF. AF is due to excessively rapid and disorganized atrial electrical activation without effective atrial contraction at a higher ventricular rate. The loss of atrial contraction may lead to a decrease in cardiac output and blood pressure that is often hemodynamically clinically significant. Other complications of AF include heart failure, pulmonary and systemic thromboembolism, and a significant risk of cerebrovascular events. Patients with ischemic heart disease, rheumatic heart disease, hypertension, thyrotoxicosis, and pneumonia are more prone to develop AF. The immediate intraoperative management of AF should begin with an assessment of hemodynamic status and correction of precipitating factors. The onset of AF or faster rates of chronic AF during the intraoperative period may be precipitated by acid-base and electrolyte abnormalities, hypovolemia, myocardial ischemia, sepsis, and surgical manipulation in the thoracic cavity. The goal of management is directed towards the control of ventricular response rate with pharmacological agents that slow AV node conduction. IV β-blockers or calcium channel blockers produce rapid control of rate. In the acute setting, the usefulness of digoxin is limited due to slow onset and low efficacy in high adrenergic states such as surgery. Amiodarone is a good choice for rate and rhythm control in patients with AF in the operating room. This agent also suppresses atrial ectopy and thus, recurrent AF and improves the success rate of electrical cardioversion. In cardiovascular compromised patients, synchronized DC cardioversion at 100–200 J (biphasic) is the most reliable method of converting AF to sinus rhythm. However, it should not be used in AF of more than 48-h duration without at least 3 weeks of anticoagulation, attempts to restore sinus rhythm may increase the risk of atrial blood clot formation and systemic thromboembolism.
6.5.2 Ventricular arrhythmias
Ventricular arrhythmias during anesthesia are more common in patients with underlying cardiac disease. Their occurrence must be considered life-threatening.
6.5.2.1 Ventricular extrasystole or premature ventricular contractions (PVCs)
PVCs are commonly seen during anesthesia and can be caused by multiple factors such as electrolyte and acid-base disorders, hypoxia, hypercarbia, hypothermia, anesthetic agents, sympathomimetic drugs, and very commonly direct laryngoscopy and tracheal intubation. They are also frequently observed during cardiac and thoracic surgical procedures. PVCs are ectopic beats arising from below the AV node and give rise to a wide and bizarre QRS complex. PVCs can be unifocal, multifocal, or they can alternate with sinus beats in every second (bigeminy) or every third (trigeminy) beat pattern. The management of PVCs should focus on the correction of underlying problems. Asymptomatic or healthy patients generally do not require any treatment. Frequent PVCs, multifocal PVCs, and PVCs occurring on the T wave should be considered a potentially serious event as they can precede runs of life-threatening ventricular tachycardia or fibrillation and require prompt treatment. The immediate availability of a defibrillator is paramount in the event of a deterioration in the rhythm. Lidocaine is the drug of choice. Amiodarone is also helpful. Propanolol, procainamide, and quinidine are other drugs that can be given to abolish PVCs. However, these anti-arrhythmic drugs (classes I and III) may have proarrhythmic effects, particularly in patients with underlying heart disease [23]. Early and continuous vigilance is necessary throughout therapy. It is important to ensure that serum electrolytes (especially potassium) are kept well within the normal range. Cardiac function should be optimized and cardiac ischemia should be managed aggressively. The drugs should be prescribed only if the overall effect is clearly beneficial. Furthermore, the Cardiac Arrhythmia Suppression Trial (CAST) shows that proarrhythmic death can occur even when PVCs are apparently eliminated. Occasionally, PVCs are induced when there is severe bradycardia. Atropine, isoproterenol, or pacing may be effective to abolish the PVCs by speeding up the SA node.
6.5.2.2 Ventricular tachycardia (VT)
VT is a severe, potentially life-threatening arrhythmia as the rhythm can degenerate into ventricular fibrillation, requiring emergent treatment. The ECG shows a rapid ventricular rhythm with broad abnormal QRS complexes. The ratio of P and QRS has no fixed relationship because of atrioventricular dissociation. Like other forms of arrhythmias, the correction of precipitating factors assumes great importance. It can be categorized into non-sustained and sustained ventricular tachycardia [24].
Non-sustained VT (NSVT) is defined as 3 or more PVCs that occur at a rate of more than 120 beats/min and lasting less than 30s without hemodynamic compromise. These arrhythmias are routinely seen in the absence of cardiac disease and may not require drug therapy. However, NSVT should be monitored carefully, as it can generate into a non-perfusing rhythm.
Sustained VT presents with a broad QRS complex that may be monomorphic or polymorphic. Timely termination of VT is desirable even if it is well-tolerated. Amiodarone is the first-line recommended therapy for patients with VT. The alternative pharmacological therapy includes lidocaine and procainamide. Patients may show signs of inadequate perfusion with or without a pulse. Pulseless VT should be treated immediately with defibrillation and initiation of cardiopulmonary resuscitation according to Advanced Cardiac Life Support (ACLS) algorithm, whereas VT with a pulse should be treated with synchronized cardioversion.
6.5.2.3 Ventricular fibrillation (VF)
This arrhythmia is characterized by very rapid, chaotic, grossly irregular, and disorganized broad complexes on the ECG with no mechanical effect, resulting either from rapid discharges of impulses from one or more ventricular foci or from multiple wandering re-enters circuits in the ventricles. On the ECG, the QRS is absent. It is a serious, life-threatening rhythm due to lack or no cardiac output during the arrhythmia. Clinically, pulses will be impalpable and there will be an acute drop in oxygen saturation on pulse oximetry.
VF during anesthesia and surgery is a critical event. The common causes are myocardial ischemia, hypoxia, hypothermia, metabolic electrolyte imbalance, and drug effects. Management includes prompt initiation of cardiopulmonary resuscitation. External defibrillation is the only effective method to convert VF to a viable rhythm. The most important factor affecting survival in patients experiencing VF is time to defibrillation. Survival is best if defibrillation occurs within 3–5 min of cardiac arrest.
As with any pulseless arrest, contributing factors must be investigated and addressed. When VF is refractory to electrical treatment, IV administration of adrenaline 1 mg or amiodarone 150–300 mg may improve the response to electrical defibrillation. Adjunctive therapy with amiodarone, lidocaine, or magnesium may be indicated. A precordial thump is occasionally effective in the termination of VF but should only be attempted if a defibrillator is not immediately available [25]. Standard ACLS algorithms should be followed for electrical, pharmacological, and adjunct therapy.
6.5.2.4 Torsades de pointes (TdP)
It is an atypical polymorphic form of VT characterized by a constantly changing/twisting QRS axis around the baseline. A non-uniform delay in repolarization is the underlying electrophysiological derangement, manifested as prolonged QT interval on ECG. Tdp is usually short in duration and spontaneously reverts to sinus rhythm. However, rapidly recurring episodes may degenerate into VF and cardiac arrest [26]. The management of Tdp depends on hemodynamic stability and is initially aimed at correction of the precipitating factors and use of intravenous magnesium as cellular membrane stabilizer:
Single episode and hemodynamically stable: intravenous magnesium sulfate is the first-line therapy and helps to prevent recurrent arrhythmias.
Multiple self-terminating episodes and hemodynamically stable: intravenous magnesium and consider temporary transvenous overdrive atrial pacing and/or intravenous isoproterenol infusion, to reduce the RR interval and repolarization time.
Hemodynamic instability: prompt synchronized electrical cardioversion, and intravenous magnesium.
Pulseless arrhythmia: Follow VF treatment approach. Intravenous magnesium should be administered. Avoid amiodarone since it has a proarrhythmic effect because of the additional prolongation of the QTc interval but administer intravenous lidocaine instead.
Lidocaine is the preferred antiarrhythmic drug for TdP, though there is a lack of evidence to support its use. Other antiarrhythmic drugs such as amiodarone, procainamide, beta-blockers further prolong the QT interval and therefore worsen the condition. β-blockers will slow down the heart rate, increasing the risk of TdP.
6.5.2.5 Pulseless electrical activity (PEA)
PEA, previously known as electromechanical dissociation, is a life-threatening, non-shockable cardiac rhythm. It occurs when the electrical activity of the heart persists but does not usually follow sufficient ventricular response to produce a sufficient cardiac output to generate a pulse and supply blood to the organs in the body. While the absence of a pulse confirms a clinical diagnosis of cardiac arrest, PEA can only be differentiated from other causes of cardiac arrest by ECG. This means that PEA includes any pulseless waveform except for VF, VT, or asystole. PEA is often caused by a profound cardiovascular insult which weakens the cardiac contraction and is usually exacerbated by worsening acidosis, hypoxia, and increasing vagal tone (Table 6). Further compromise of the inotropic state of the cardiac muscle leads to inadequate mechanical activity, despite the presence of electrical activity and ultimately causing degeneration of the rhythm and death of the patient. Overall, the prognosis of PEA patients is poor and still shows a high mortality rate despite optimum CPR.
4Hs
4Ts
Hypoxia
Toxicity
Hypovolemia
Tamponade (cardiac)
Hypothermia/hyperthermia
Tension pneumothorax
Hypokalemia/hyperkalemia (electrolyte disorders) and hydrogen ions (acidosis)
Thromboembolism (coronary or pulmonary)
Table 6.
Factors contributing to the etiology of PEA that is widely thought as 4Hs and 4Ts include as following.
Prompt and good quality CPR according to ACLS guidelines to maintain cardiac output until the PEA can be corrected is the first step in the management of PEA, while potential underlying causes are identified and addressed [27]. Once a diagnosis is made, specific therapy to treat the cause should be commenced immediately. This process may involve the decompression of pneumothorax, pericardial drain for tamponade, fluids infusion for hypovolemia, correction of body temperature for hypothermia, administration of thrombolytics pulmonary embolism, and early coronary angiography with percutaneous coronary intervention (PCI) in patients with myocardial infarction. Where it is not possible to determine and/or reverse the underlying cause of PEA, the treatment of PEA is similar to that of asystole. The mainstay of drug therapy for PEA arrest is intravenous adrenaline 1 mg every 3–5 min. The routine use of sodium bicarbonate is not recommended, except in special situations (e.g., severe metabolic acidosis or hyperkalemia). Atropine is generally no longer recommended for PEA as it has not been shown to have a therapeutic benefit. Defibrillators cannot be used to correct this rhythm, as the problem lies in the response of the myocardial tissue to electrical impulses. Although PEA and asystole are often considered fatal arrhythmias, PEA has a slightly better outcome than asystole. Previous data by the National Registry of Cardiopulmonary Resuscitation in 2003 revealed that 10% of hospital patients whose initial rhythm is PEA survive with good neurological outcomes [28].
7. Post resuscitation care
Resuscitation of an intraoperative cardiac arrest victim does not end with ROSC and must be tailored to the needs of the individual patient.
Following ROSC after cardiac arrest, many patients suffer from post-cardiac arrest syndrome, which is a high inflammatory state characterized by brain injury, myocardial dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathology [29]. The severity of this syndrome varies according to the duration and cause of cardiac arrest. Management of these patients is challenging and requires a structured approach including restoration of adequate hemodynamics and organ perfusion, optimizing ventilation, treatment of electrolyte abnormalities, glycemic control targeted temperature management, and multimodal prognostication to improve outcomes. Specific therapy is determined by the etiology of arrest and initiating treatment to prevent recurrence [30].
The flow diagram is designed as a step-by-step guide to critical arrhythmias management in the operating room, as shown in Figure 4 [26, 31].
Figure 4.
Summary of management of critical arrhythmias at any time in the operating room [26, 29]. CPR: cardiopulmonary resuscitation; OR: operating room; ROSC: return of spontaneous circulation.
8. Conclusions
Cardiac arrhythmias can occur in all stages of anesthesia and surgical procedures. They are relatively frequent and continue to be an important source of morbidity and mortality among surgical patients. Most arrhythmias are benign, but some can progress to malignant arrhythmias and necessitate an urgent response. A thorough understanding of the arrhythmias, timely diagnosis as well as performing an early intervention with appropriate therapy enables a proactive approach to patient management and is life-saving for patients.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"arrhythmias, anesthesia, surgery, life-threatening, intraoperatively",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/79449.pdf",chapterXML:"https://mts.intechopen.com/source/xml/79449.xml",downloadPdfUrl:"/chapter/pdf-download/79449",previewPdfUrl:"/chapter/pdf-preview/79449",totalDownloads:156,totalViews:0,totalCrossrefCites:0,dateSubmitted:"July 4th 2021",dateReviewed:"October 24th 2021",datePrePublished:"November 25th 2021",datePublished:"March 9th 2022",dateFinished:"November 25th 2021",readingETA:"0",abstract:"Life-threatening arrhythmias are frequently encountered during anesthesia for cardiac or non-cardiac surgery. They result in a significant cause of morbidity and mortality, particularly in elderly patients. Predisposing factors like electrolytes abnormalities, pre-existing cardiac disease, intubation procedure, anesthetic medications, and various surgical stimulation need to be determined. Early diagnosis and commencement of an appropriate treatment protocol may be lifesaving. Treatment usually involves correction of the underlying causes, cardiac electroversion, and the use of one or more antiarrhythmic agents. Although ventricular tachycardia, ventricular fibrillation, torsade de pointes, and pulseless electrical activity are considered malignant arrhythmias that can lead to cardiac arrest, other types of Brady and tachyarrhythmias are also included in this chapter to enable adopting a more objective approach in the management of arrhythmias intraoperatively, avoiding risks of inappropriate management strategies.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/79449",risUrl:"/chapter/ris/79449",signatures:"Zuraini Md. Noor",book:{id:"10704",type:"book",title:"Cardiac Arrhythmias",subtitle:"Translational Approach from Pathophysiology to Advanced Care",fullTitle:"Cardiac Arrhythmias - Translational Approach from Pathophysiology to Advanced Care",slug:"cardiac-arrhythmias-translational-approach-from-pathophysiology-to-advanced-care",publishedDate:"March 9th 2022",bookSignature:"Endre Zima",coverURL:"https://cdn.intechopen.com/books/images_new/10704.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83969-506-3",printIsbn:"978-1-83969-505-6",pdfIsbn:"978-1-83969-507-0",isAvailableForWebshopOrdering:!0,editors:[{id:"201263",title:"Dr.",name:"Endre",middleName:null,surname:"Zima",slug:"endre-zima",fullName:"Endre Zima"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"353513",title:"Dr.",name:"Zuraini",middleName:null,surname:"Md. Noor",fullName:"Zuraini Md. Noor",slug:"zuraini-md.-noor",email:"drzuraini@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_1_2",title:"1.1 Definition of cardiac arrhythmias",level:"2"},{id:"sec_3",title:"2. Mechanism of intraoperative arrhythmias",level:"1"},{id:"sec_4",title:"3. Contributing factors and causes of arrhythmias during anesthesia for surgery",level:"1"},{id:"sec_5",title:"4. Anesthetic agents and adjuvants related to arrhythmias",level:"1"},{id:"sec_6",title:"5. Diagnostic evaluation",level:"1"},{id:"sec_7",title:"6. Specific intra-operative arrhythmias",level:"1"},{id:"sec_7_2",title:"6.1 Antiarrhythmic drugs",level:"2"},{id:"sec_8_2",title:"6.2 Pacing and cardiac electroversion",level:"2"},{id:"sec_9_2",title:"6.3 Management of arrhythmias during anesthesia and surgery",level:"2"},{id:"sec_10_2",title:"6.4 Bradyarrhythmia",level:"2"},{id:"sec_10_3",title:"6.4.1 Conduction defects",level:"3"},{id:"sec_12_2",title:"6.5 Tachyarrhythmia",level:"2"},{id:"sec_12_3",title:"6.5.1 Supraventricular arrhythmias",level:"3"},{id:"sec_12_4",title:"6.5.1.1 Premature atrial contractions (PACs)",level:"4"},{id:"sec_13_4",title:"6.5.1.2 Paroxysmal supraventricular tachycardia (PSVT)",level:"4"},{id:"sec_14_4",title:"6.5.1.3 Atrial flutter",level:"4"},{id:"sec_15_4",title:"6.5.1.4 Atrial fibrillation (AF)",level:"4"},{id:"sec_17_3",title:"Table 6.",level:"3"},{id:"sec_17_4",title:"6.5.2.1 Ventricular extrasystole or premature ventricular contractions (PVCs)",level:"4"},{id:"sec_18_4",title:"6.5.2.2 Ventricular tachycardia (VT)",level:"4"},{id:"sec_19_4",title:"6.5.2.3 Ventricular fibrillation (VF)",level:"4"},{id:"sec_20_4",title:"6.5.2.4 Torsades de pointes (TdP)",level:"4"},{id:"sec_21_4",title:"Table 6.",level:"4"},{id:"sec_25",title:"7. Post resuscitation care",level:"1"},{id:"sec_26",title:"8. Conclusions",level:"1"},{id:"sec_30",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Forrest JB, Cahalan MK, Rehder K, Goldsmith CH, Levy WJ, Strunin L, et al. Multicenter study of general anaesthesia II. Results. Anesthesiology. 1990;72:262-268'},{id:"B2",body:'Forrest J, Rehder K, Cahalan M, Goldsmith C. Multicenter study of general anaesthesia III. Predictors of severe perioperative adverse outcomes. Anesthesiology. 1992;76:3-15'},{id:"B3",body:'Katz R, Bigger T. Cardiac arrhythmias during anaesthesia and operation. Anesthesiology. 1970;33(2):193-194'},{id:"B4",body:'Dua N, Kumra VP. Management of perioperative arrhythmias. Indian Journal of Anaesthesia. 2007;51(4):310-323'},{id:"B5",body:'Altinbas A, Tas N, Bektas O. Perioperative arrhythmias. Middle Black Sea Journal of Health Science. 2017;3(3):41-48. 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Drugs to be avoided in patients with long QT syndrome: Focus on the anaesthesiologist management. World Journal of Cardiology. 2013;5(4):87-93. DOI: 10.4330/wjc.v5.i4.87'},{id:"B16",body:'Kabade S, Shankar B, Venkatesh Y. Perioperative cardiac arrhythmias: An approach. Journal of Evolution of Medical and Dental Sciences. 2014;37(3):9633-9647. DOI: 10.14260/jemds/2014/3247'},{id:"B17",body:'Kwon CH, Kim S-H. Intraoperative management of critical arrhythmia. Korean Journal of Anaesthesiology. 2017;70(2):120-126. DOI: 10.4097/kjae.2017.70.2.120'},{id:"B18",body:'Part 5:Electrical therapies. Automated external defibrillators, defibrillation, cardioversion and pacing. Circulation American Heart Association. 2005;112:IV-35-IV-46. DOI: 10.1161/CIRCULATIONAHA.105.166554'},{id:"B19",body:'Stewart A, Greaves K, Bromilow J. Supraventricular tacharrhythmias and their management in the perioperative period. Continuing Education in Anaesthesia, Critical Care & Pain. 2015;15(2):90-97. 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Antiarrhythmic drugs-clinical use and clinical decision making: A consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology (ESC) Working Group on Cardiovascular Pharmacology, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and International Society of Cardiovascular Pharmacotherapy. European Society of Cardiology (ESC). 2018;20:731-732. DOI: 10.1093/europace/eux373'},{id:"B24",body:'Lorentz MN, Vianna B. Cardiac dysrhythmias and anaesthesia. Revista Brasileira de Anestesiologia. 2011;61(6):798-813'},{id:"B25",body:'Hines R, Marschall K. Stoelting’s. Abnormalities of cardiac conduction and cardiac rhythm. Anaesthesia and Co-existing Disease. 7th ed. Philadelphia, PA: Elsevier; 2018. pp. 151-200'},{id:"B26",body:'Hutchins D. Perioperative Cardiac Arrhythmias: Part Two. Ventricular Dysrhythmias. Anaesthesia Tutorial of the Week 285. 2013. Available from: https://resources.wfsahq.org/atotw/peri-operative-cardiac-arrhythmias-part-two-ventricular-dysrhythmias-anaesthesia-tutorial-of-the-week-285/'},{id:"B27",body:'Myerburg R, Halperin H, Egan D, Boineau R, Chugh S, Gillis A, et al. Pulseless electrical activity: Definition, causes, mechanisms, management, and research priorities for the next decade: Report From a National Heart, Lung, and Blood Institute Workshop. Circulation AHA. 2013;128(23):2532-2541. DOI: 10.1161/CIRCULATIONAHA.113.004490'},{id:"B28",body:'Peberdy MA, Kaye W, Ornato J, Larkin G, Nadkarni V, Elizabeth M, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation Journal. 2003;58:297-308'},{id:"B29",body:'Walker A, Johnson N. Critical care of the post-cardiac arrest patient. Cardiology Clinics. 2018;36(3):419-428. DOI: 10.1016/j.ccl.2018.03.009'},{id:"B30",body:'Ben-Jacob TK, Moitra VK, O’Connor MF. Intraoperative advanced cardiac life support (ACLS) [Uptodate.com]. 2021. Available from: https://www.uptodate.com/contents/intraoperative-advanced-cardiac-life-support [Accessed: September 18, 2021]'},{id:"B31",body:'Horvath B. Malignant arrhythmia and cardiac arrest in the operating room. [Internet]. 2021. Available from: https://emedicine.medscape.com/article/2500081-overview [Accessed: August 24, 2021]'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Zuraini Md. Noor",address:"drzuraini@gmail.com",affiliation:'
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Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"May 18th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:27,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"14",title:"Cell and Molecular Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",isOpenForSubmission:!0,editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",slug:"rosa-maria-martinez-espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",biography:"Dr. Rosa María Martínez-Espinosa has been a Spanish Full Professor since 2020 (Biochemistry and Molecular Biology) and is currently Vice-President of International Relations and Cooperation development and leader of the research group 'Applied Biochemistry” (University of Alicante, Spain). Other positions she has held at the university include Vice-Dean of Master Programs, Vice-Dean of the Degree in Biology and Vice-Dean for Mobility and Enterprise and Engagement at the Faculty of Science (University of Alicante). She received her Bachelor in Biology in 1998 (University of Alicante) and her PhD in 2003 (Biochemistry, University of Alicante). She undertook post-doctoral research at the University of East Anglia (Norwich, U.K. 2004-2005; 2007-2008).\nHer multidisciplinary research focuses on investigating archaea and their potential applications in biotechnology. She has an H-index of 21. She has authored one patent and has published more than 70 indexed papers and around 60 book chapters.\nShe has contributed to more than 150 national and international meetings during the last 15 years. Her research interests include archaea metabolism, enzymes purification and characterization, gene regulation, carotenoids and bioplastics production, antioxidant\ncompounds, waste water treatments, and brines bioremediation.\nRosa María’s other roles include editorial board member for several journals related\nto biochemistry, reviewer for more than 60 journals (biochemistry, molecular biology, biotechnology, chemistry and microbiology) and president of several organizing committees in international meetings related to the N-cycle or respiratory processes.",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"15",title:"Chemical Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",isOpenForSubmission:!0,editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",slug:"sukru-beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",biography:"Dr. Şükrü Beydemir obtained a BSc in Chemistry in 1995 from Yüzüncü Yıl University, MSc in Biochemistry in 1998, and PhD in Biochemistry in 2002 from Atatürk University, Turkey. He performed post-doctoral studies at Max-Planck Institute, Germany, and University of Florence, Italy in addition to making several scientific visits abroad. He currently works as a Full Professor of Biochemistry in the Faculty of Pharmacy, Anadolu University, Turkey. Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. Dr. Beydemir is also Rector of Bilecik Şeyh Edebali University, Turkey.",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",slug:"deniz-ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",biography:"Dr. Deniz Ekinci obtained a BSc in Chemistry in 2004, MSc in Biochemistry in 2006, and PhD in Biochemistry in 2009 from Atatürk University, Turkey. He studied at Stetson University, USA, in 2007-2008 and at the Max Planck Institute of Molecular Cell Biology and Genetics, Germany, in 2009-2010. Dr. Ekinci currently works as a Full Professor of Biochemistry in the Faculty of Agriculture and is the Head of the Enzyme and Microbial Biotechnology Division, Ondokuz Mayıs University, Turkey. He is a member of the Turkish Biochemical Society, American Chemical Society, and German Genetics society. Dr. Ekinci published around ninety scientific papers, reviews and book chapters, and presented several conferences to scientists. He has received numerous publication awards from several scientific councils. Dr. Ekinci serves as the Editor in Chief of four international books and is involved in the Editorial Board of several international journals.",institutionString:null,institution:{name:"Ondokuz Mayıs University",institutionURL:null,country:{name:"Turkey"}}},editorThree:null},{id:"17",title:"Metabolism",coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",isOpenForSubmission:!0,editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",slug:"yannis-karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",biography:"Yannis Karamanos, born in Greece in 1953, completed his pre-graduate studies at the Université Pierre et Marie Curie, Paris, then his Masters and Doctoral degree at the Université de Lille (1983). He was associate professor at the University of Limoges (1987) before becoming full professor of biochemistry at the Université d’Artois (1996). He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. His teaching areas are energy metabolism and regulation, integration and organ specialization and metabolic adaptation.",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null},{id:"18",title:"Proteomics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",isOpenForSubmission:!0,editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",slug:"paolo-iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",biography:"Paolo Iadarola graduated with a degree in Chemistry from the University of Pavia (Italy) in July 1972. He then worked as an Assistant Professor at the Faculty of Science of the same University until 1984. In 1985, Prof. Iadarola became Associate Professor at the Department of Biology and Biotechnologies of the University of Pavia and retired in October 2017. Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. He is a Consultant Reviewer for several journals, including the Journal of Chromatography A, Journal of Chromatography B, Plos ONE, Proteomes, International Journal of Molecular Science, Biotech, Electrophoresis, and others. He is also Associate Editor of Biotech.",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",slug:"simona-viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",biography:"Simona Viglio is an Associate Professor of Biochemistry at the Department of Molecular Medicine at the University of Pavia. She has been working since 1995 on the determination of proteolytic enzymes involved in the degradation process of connective tissue matrix and on the identification of biological markers of lung diseases. She gained considerable experience in developing and validating new methodologies whose applications allowed her to determine both the amount of biomarkers (Desmosine and Isodesmosine) in the urine of patients affected by COPD, and the activity of proteolytic enzymes (HNE, Cathepsin G, Pseudomonas aeruginosa elastase) in the sputa of these patients. Simona Viglio was also involved in research dealing with the supplementation of amino acids in patients with brain injury and chronic heart failure. She is presently engaged in the development of 2-DE and LC-MS techniques for the study of proteomics in biological fluids. The aim of this research is the identification of potential biomarkers of lung diseases. She is an author of about 90 publications (According to Scopus: H-Index: 23; According to WOS: H-Index: 20) on peer-reviewed journals, a member of the “Società Italiana di Biochimica e Biologia Molecolare,“ and a Consultant Reviewer for International Journal of Molecular Science, Journal of Chromatography A, COPD, Plos ONE and Nutritional Neuroscience.",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null}]},overviewPageOFChapters:{paginationCount:49,paginationItems:[{id:"80495",title:"Iron in Cell Metabolism and Disease",doi:"10.5772/intechopen.101908",signatures:"Eeka Prabhakar",slug:"iron-in-cell-metabolism-and-disease",totalDownloads:1,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Iron Metabolism - Iron a Double‐Edged Sword",coverURL:"https://cdn.intechopen.com/books/images_new/10842.jpg",subseries:{id:"17",title:"Metabolism"}}},{id:"81799",title:"Cross Talk of Purinergic and Immune Signaling: Implication in Inflammatory and Pathogenic Diseases",doi:"10.5772/intechopen.104978",signatures:"Richa Rai",slug:"cross-talk-of-purinergic-and-immune-signaling-implication-in-inflammatory-and-pathogenic-diseases",totalDownloads:7,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Purinergic System",coverURL:"https://cdn.intechopen.com/books/images_new/10801.jpg",subseries:{id:"17",title:"Metabolism"}}},{id:"81764",title:"Involvement of the Purinergic System in Cell Death in Models of Retinopathies",doi:"10.5772/intechopen.103935",signatures:"Douglas Penaforte Cruz, Marinna Garcia Repossi and Lucianne Fragel Madeira",slug:"involvement-of-the-purinergic-system-in-cell-death-in-models-of-retinopathies",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Purinergic System",coverURL:"https://cdn.intechopen.com/books/images_new/10801.jpg",subseries:{id:"17",title:"Metabolism"}}},{id:"81756",title:"Alteration of Cytokines Level and Oxidative Stress Parameters in COVID-19",doi:"10.5772/intechopen.104950",signatures:"Marija Petrusevska, Emilija Atanasovska, Dragica Zendelovska, Aleksandar Eftimov and Katerina Spasovska",slug:"alteration-of-cytokines-level-and-oxidative-stress-parameters-in-covid-19",totalDownloads:8,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Chemokines Updates",coverURL:"https://cdn.intechopen.com/books/images_new/11672.jpg",subseries:{id:"18",title:"Proteomics"}}}]},overviewPagePublishedBooks:{paginationCount:27,paginationItems:[{type:"book",id:"7006",title:"Biochemistry and Health Benefits of Fatty Acids",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7006.jpg",slug:"biochemistry-and-health-benefits-of-fatty-acids",publishedDate:"December 19th 2018",editedByType:"Edited by",bookSignature:"Viduranga Waisundara",hash:"c93a00abd68b5eba67e5e719f67fd20b",volumeInSeries:1,fullTitle:"Biochemistry and Health Benefits of Fatty Acids",editors:[{id:"194281",title:"Dr.",name:"Viduranga Y.",middleName:null,surname:"Waisundara",slug:"viduranga-y.-waisundara",fullName:"Viduranga Y. Waisundara",profilePictureURL:"https://mts.intechopen.com/storage/users/194281/images/system/194281.jpg",biography:"Dr. Viduranga Waisundara obtained her Ph.D. in Food Science and Technology from the Department of Chemistry, National University of Singapore, in 2010. She was a lecturer at Temasek Polytechnic, Singapore from July 2009 to March 2013. She relocated to her motherland of Sri Lanka and spearheaded the Functional Food Product Development Project at the National Institute of Fundamental Studies from April 2013 to October 2016. She was a senior lecturer on a temporary basis at the Department of Food Technology, Faculty of Technology, Rajarata University of Sri Lanka. She is currently Deputy Principal of the Australian College of Business and Technology – Kandy Campus, Sri Lanka. She is also the Global Harmonization Initiative (GHI) Ambassador to Sri Lanka.",institutionString:"Australian College of Business & Technology",institution:null}]},{type:"book",id:"6820",title:"Keratin",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6820.jpg",slug:"keratin",publishedDate:"December 19th 2018",editedByType:"Edited by",bookSignature:"Miroslav Blumenberg",hash:"6def75cd4b6b5324a02b6dc0359896d0",volumeInSeries:2,fullTitle:"Keratin",editors:[{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}}]},{type:"book",id:"7978",title:"Vitamin A",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7978.jpg",slug:"vitamin-a",publishedDate:"May 15th 2019",editedByType:"Edited by",bookSignature:"Leila Queiroz Zepka, Veridiana Vera de Rosso and Eduardo Jacob-Lopes",hash:"dad04a658ab9e3d851d23705980a688b",volumeInSeries:3,fullTitle:"Vitamin A",editors:[{id:"261969",title:"Dr.",name:"Leila",middleName:null,surname:"Queiroz Zepka",slug:"leila-queiroz-zepka",fullName:"Leila Queiroz Zepka",profilePictureURL:"https://mts.intechopen.com/storage/users/261969/images/system/261969.png",biography:"Prof. Dr. Leila Queiroz Zepka is currently an associate professor in the Department of Food Technology and Science, Federal University of Santa Maria, Brazil. She has more than fifteen years of teaching and research experience. She has published more than 550 scientific publications/communications, including 15 books, 50 book chapters, 100 original research papers, 380 research communications in national and international conferences, and 12 patents. She is a member of the editorial board of five journals and acts as a reviewer for several national and international journals. Her research interests include microalgal biotechnology with an emphasis on microalgae-based products.",institutionString:"Universidade Federal de Santa Maria",institution:{name:"Universidade Federal de Santa Maria",institutionURL:null,country:{name:"Brazil"}}}]},{type:"book",id:"7953",title:"Bioluminescence",subtitle:"Analytical Applications and Basic Biology",coverURL:"https://cdn.intechopen.com/books/images_new/7953.jpg",slug:"bioluminescence-analytical-applications-and-basic-biology",publishedDate:"September 25th 2019",editedByType:"Edited by",bookSignature:"Hirobumi Suzuki",hash:"3a8efa00b71abea11bf01973dc589979",volumeInSeries:4,fullTitle:"Bioluminescence - Analytical Applications and Basic Biology",editors:[{id:"185746",title:"Dr.",name:"Hirobumi",middleName:null,surname:"Suzuki",slug:"hirobumi-suzuki",fullName:"Hirobumi Suzuki",profilePictureURL:"https://mts.intechopen.com/storage/users/185746/images/system/185746.png",biography:"Dr. Hirobumi Suzuki received his Ph.D. in 1997 from Tokyo Metropolitan University, Japan, where he studied firefly phylogeny and the evolution of mating systems. He is especially interested in the genetic differentiation pattern and speciation process that correlate to the flashing pattern and mating behavior of some fireflies in Japan. He then worked for Olympus Corporation, a Japanese manufacturer of optics and imaging products, where he was involved in the development of luminescence technology and produced a bioluminescence microscope that is currently being used for gene expression analysis in chronobiology, neurobiology, and developmental biology. Dr. Suzuki currently serves as a visiting researcher at Kogakuin University, Japan, and also a vice president of the Japan Firefly Society.",institutionString:"Kogakuin University",institution:null}]}]},openForSubmissionBooks:{},onlineFirstChapters:{},subseriesFiltersForOFChapters:[],publishedBooks:{},subseriesFiltersForPublishedBooks:[],publicationYearFilters:[],authors:{paginationCount:148,paginationItems:[{id:"165328",title:"Dr.",name:"Vahid",middleName:null,surname:"Asadpour",slug:"vahid-asadpour",fullName:"Vahid Asadpour",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/165328/images/system/165328.jpg",biography:"Vahid Asadpour, MS, Ph.D., is currently with the Department of Research and Evaluation, Kaiser Permanente Southern California. He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. He has also designed medical devices, including a laser Doppler monitoring system.",institutionString:"Kaiser Permanente Southern California",institution:null},{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169608/images/system/169608.png",biography:"Prof. Dr. Marian Gaiceanu graduated from the Naval and Electrical Engineering Faculty, Dunarea de Jos University of Galati, Romania, in 1997. He received a Ph.D. (Magna Cum Laude) in Electrical Engineering in 2002. Since 2017, Dr. Gaiceanu has been a Ph.D. supervisor for students in Electrical Engineering. He has been employed at Dunarea de Jos University of Galati since 1996, where he is currently a professor. Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:null},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:"Polytechnic University of Timişoara",institution:{name:"Polytechnic University of Timişoara",country:{name:"Romania"}}},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:null},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"357085",title:"Mr.",name:"P. Mohan",middleName:null,surname:"Anand",slug:"p.-mohan-anand",fullName:"P. Mohan Anand",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356696",title:"Ph.D. Student",name:"P.V.",middleName:null,surname:"Sai Charan",slug:"p.v.-sai-charan",fullName:"P.V. Sai Charan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"357086",title:"Prof.",name:"Sandeep K.",middleName:null,surname:"Shukla",slug:"sandeep-k.-shukla",fullName:"Sandeep K. Shukla",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356823",title:"MSc.",name:"Seonghee",middleName:null,surname:"Min",slug:"seonghee-min",fullName:"Seonghee Min",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Daegu University",country:{name:"Korea, South"}}},{id:"353307",title:"Prof.",name:"Yoosoo",middleName:null,surname:"Oh",slug:"yoosoo-oh",fullName:"Yoosoo Oh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:"Yoosoo Oh received his Bachelor's degree in the Department of Electronics and Engineering from Kyungpook National University in 2002. He obtained his Master’s degree in the Department of Information and Communications from Gwangju Institute of Science and Technology (GIST) in 2003. In 2010, he received his Ph.D. degree in the School of Information and Mechatronics from GIST. In the meantime, he was an executed team leader at Culture Technology Institute, GIST, 2010-2012. In 2011, he worked at Lancaster University, the UK as a visiting scholar. In September 2012, he joined Daegu University, where he is currently an associate professor in the School of ICT Conver, Daegu University. Also, he served as the Board of Directors of KSIIS since 2019, and HCI Korea since 2016. From 2017~2019, he worked as a center director of the Mixed Reality Convergence Research Center at Daegu University. From 2015-2017, He worked as a director in the Enterprise Supporting Office of LINC Project Group, Daegu University. His research interests include Activity Fusion & Reasoning, Machine Learning, Context-aware Middleware, Human-Computer Interaction, etc.",institutionString:null,institution:{name:"Daegu Gyeongbuk Institute of Science and Technology",country:{name:"Korea, South"}}},{id:"262719",title:"Dr.",name:"Esma",middleName:null,surname:"Ergüner Özkoç",slug:"esma-erguner-ozkoc",fullName:"Esma Ergüner Özkoç",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Başkent University",country:{name:"Turkey"}}},{id:"346530",title:"Dr.",name:"Ibrahim",middleName:null,surname:"Kaya",slug:"ibrahim-kaya",fullName:"Ibrahim Kaya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"419199",title:"Dr.",name:"Qun",middleName:null,surname:"Yang",slug:"qun-yang",fullName:"Qun Yang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Auckland",country:{name:"New Zealand"}}},{id:"351158",title:"Prof.",name:"David W.",middleName:null,surname:"Anderson",slug:"david-w.-anderson",fullName:"David W. Anderson",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Calgary",country:{name:"Canada"}}}]}},subseries:{item:{id:"5",type:"subseries",title:"Parasitic Infectious Diseases",keywords:"Blood Borne Parasites, Intestinal Parasites, Protozoa, Helminths, Arthropods, Water Born Parasites, Epidemiology, Molecular Biology, Systematics, Genomics, Proteomics, Ecology",scope:"Parasitic diseases have evolved alongside their human hosts. In many cases, these diseases have adapted so well that they have developed efficient resilience methods in the human host and can live in the host for years. Others, particularly some blood parasites, can cause very acute diseases and are responsible for millions of deaths yearly. Many parasitic diseases are classified as neglected tropical diseases because they have received minimal funding over recent years and, in many cases, are under-reported despite the critical role they play in morbidity and mortality among human and animal hosts. The current topic, Parasitic Infectious Diseases, in the Infectious Diseases Series aims to publish studies on the systematics, epidemiology, molecular biology, genomics, pathogenesis, genetics, and clinical significance of parasitic diseases from blood borne to intestinal parasites as well as zoonotic parasites. We hope to cover all aspects of parasitic diseases to provide current and relevant research data on these very important diseases. In the current atmosphere of the Coronavirus pandemic, communities around the world, particularly those in different underdeveloped areas, are faced with the growing challenges of the high burden of parasitic diseases. At the same time, they are faced with the Covid-19 pandemic leading to what some authors have called potential syndemics that might worsen the outcome of such infections. Therefore, it is important to conduct studies that examine parasitic infections in the context of the coronavirus pandemic for the benefit of all communities to help foster more informed decisions for the betterment of human and animal health.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/5.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11401,editor:{id:"67907",title:"Dr.",name:"Amidou",middleName:null,surname:"Samie",slug:"amidou-samie",fullName:"Amidou Samie",profilePictureURL:"https://mts.intechopen.com/storage/users/67907/images/system/67907.jpg",biography:"Dr. Amidou Samie is an Associate Professor of Microbiology at the University of Venda, in South Africa, where he graduated for his PhD in May 2008. He joined the Department of Microbiology the same year and has been giving lectures on topics covering parasitology, immunology, molecular biology and industrial microbiology. He is currently a rated researcher by the National Research Foundation of South Africa at category C2. He has published widely in the field of infectious diseases and has overseen several MSc’s and PhDs. His research activities mostly cover topics on infectious diseases from epidemiology to control. His particular interest lies in the study of intestinal protozoan parasites and opportunistic infections among HIV patients as well as the potential impact of childhood diarrhoea on growth and child development. He also conducts research on water-borne diseases and water quality and is involved in the evaluation of point-of-use water treatment technologies using silver and copper nanoparticles in collaboration with the University of Virginia, USA. 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