\\n\\n
IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\\n\\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\\n\\nLaunching 2021
\\n\\nArtificial Intelligence, ISSN 2633-1403
\\n\\nVeterinary Medicine and Science, ISSN 2632-0517
\\n\\nBiochemistry, ISSN 2632-0983
\\n\\nBiomedical Engineering, ISSN 2631-5343
\\n\\nInfectious Diseases, ISSN 2631-6188
\\n\\nPhysiology (Coming Soon)
\\n\\nDentistry (Coming Soon)
\\n\\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\\n\\nNote: Edited in October 2021
\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/132"}},components:[{type:"htmlEditorComponent",content:'With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
\n\nDesigned to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
\n\nAfter a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
\n\nOur innovative Book Series format brings you:
\n\nIntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\n\nLaunching 2021
\n\nArtificial Intelligence, ISSN 2633-1403
\n\nVeterinary Medicine and Science, ISSN 2632-0517
\n\nBiochemistry, ISSN 2632-0983
\n\nBiomedical Engineering, ISSN 2631-5343
\n\nInfectious Diseases, ISSN 2631-6188
\n\nPhysiology (Coming Soon)
\n\nDentistry (Coming Soon)
\n\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\n\nNote: Edited in October 2021
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"5960",leadTitle:null,fullTitle:"Liver Cirrhosis - Update and Current Challenges",title:"Liver Cirrhosis",subtitle:"Update and Current Challenges",reviewType:"peer-reviewed",abstract:"Liver cirrhosis represents one of the major challenges for most physicians and surgeons on a global scale. This book provides practicing hepatologists, gastroenterologists and liver surgeons with a valuable tool in their efforts to understand the (molecular) mechanisms involved, be updated regarding the newest and less invasive diagnostic methods, and educate themselves about the challenges involved in the management of liver cirrhosis and its complications. The authors of this book represent a team of true global experts on the topic. In addition to the knowledge shared, the authors provide their personal clinical experience on a variety of different aspects of liver cirrhosis, giving us a well-rounded overview.",isbn:"978-953-51-3310-0",printIsbn:"978-953-51-3309-4",pdfIsbn:"978-953-51-4756-5",doi:"10.5772/66244",price:139,priceEur:155,priceUsd:179,slug:"liver-cirrhosis-update-and-current-challenges",numberOfPages:302,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"df63a0d7ea66a47de3c3e47d5bede328",bookSignature:"Georgios Tsoulfas",publishedDate:"July 5th 2017",coverURL:"https://cdn.intechopen.com/books/images_new/5960.jpg",numberOfDownloads:22978,numberOfWosCitations:11,numberOfCrossrefCitations:12,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:29,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:52,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 9th 2016",dateEndSecondStepPublish:"November 30th 2016",dateEndThirdStepPublish:"February 26th 2017",dateEndFourthStepPublish:"May 27th 2017",dateEndFifthStepPublish:"July 26th 2017",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"57412",title:"Prof.",name:"Georgios",middleName:null,surname:"Tsoulfas",slug:"georgios-tsoulfas",fullName:"Georgios Tsoulfas",profilePictureURL:"https://mts.intechopen.com/storage/users/57412/images/system/57412.png",biography:"Dr. Georgios Tsoulfas received his medical degree from Brown University School of Medicine, Rhode Island, and completed his general surgery residency at the University of Iowa Hospitals and Clinics, as well as a transplant research fellowship at the Starzl Transplant Institute, University of Pittsburgh. He then completed a two-year transplantation surgery fellowship at Massachusetts General Hospital, Harvard Medical School, and then joined the Division of Solid Organ Transplantation and Hepatobiliary Surgery at the University of Rochester Medical Center, New York, as Assistant Professor of Surgery. He has currently moved back to Greece, where he is a Professor of Transplantation Surgery and Chief of the Department of Transplantation Surgery at the Aristotle University School of Medicine. He has published more than 150 papers in peer-reviewed journals and PubMed, as well as 35 book chapters. He is a reviewer for more than forty international journals and serves on the editorial boards of several others.",institutionString:"Aristotle University of Thessaloniki",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"6",totalChapterViews:"0",totalEditedBooks:"8",institution:{name:"Aristotle University of Thessaloniki",institutionURL:null,country:{name:"Greece"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1021",title:"Hepatology",slug:"gastroenterology-hepatology"}],chapters:[{id:"55784",title:"Non-Alcoholic Steatohepatitis, Liver Cirrhosis and Hepatocellular Carcinoma: The Molecular Pathways",doi:"10.5772/intechopen.68771",slug:"non-alcoholic-steatohepatitis-liver-cirrhosis-and-hepatocellular-carcinoma-the-molecular-pathways",totalDownloads:2868,totalCrossrefCites:4,totalDimensionsCites:8,hasAltmetrics:0,abstract:"Non-alcoholic steatohepatitis (NASH) is growing into global problem, mainly due to NASH-induced cirrhosis and hepatocellular carcinoma (HCC), that can develop either subsequently to cirrhosis or preceding it. In addition, NASH-induced cirrhosis constitutes a significant fraction of cases diagnosed as cryptogenic cirrhosis. Thus, there is a need for deeper understanding of the molecular basis, leading to liver steatosis, then—to the associated inflammation seen in NASH, loss of liver architecture and cirrhosis, followed or paralleled by carcinogenesis and HCC. Insulin resistance, increased hepatic iron level, and certain cytokines, including TNF-α and IL-6 derived from extrahepatic adipose tissues, can trigger the chain of events. The imbalance between leptin and adiponectin is important as well. These markers remain important during the whole course from NASH through liver cirrhosis to HCC. The molecular pathogenesis substantiates treatment: hypertriglyceridemia can be lowered by low calorie diet; mTOR complex can become inhibited by physical activity and metformin; cholesterol synthesis, RAF/MAPK1/ERK and p21 pathway by statins; inflammation by pentoxyfillin, and kinases (in HCC) by sorafenib. Bidirectional regulation of telomere attrition, senescence and p21 pathway, restoration of wild-type p53 activity and regulation of miRNA network represent attractive future treatment options. Focusing on relevant molecular pathways allows deeper understanding of NASH pathogenesis, leading to identification of predictive markers and treatment targets.",signatures:"Dzeina Mezale, Ilze Strumfa, Andrejs Vanags, Matiss Mezals, Ilze\nFridrihsone, Boriss Strumfs and Dainis Balodis",downloadPdfUrl:"/chapter/pdf-download/55784",previewPdfUrl:"/chapter/pdf-preview/55784",authors:[{id:"54021",title:"Prof.",name:"Ilze",surname:"Strumfa",slug:"ilze-strumfa",fullName:"Ilze Strumfa"},{id:"174929",title:"Dr.",name:"Andrejs",surname:"Vanags",slug:"andrejs-vanags",fullName:"Andrejs Vanags"},{id:"202253",title:"Dr.",name:"Dainis",surname:"Balodis",slug:"dainis-balodis",fullName:"Dainis Balodis"},{id:"202548",title:"Dr.",name:"Dzeina",surname:"Mezale",slug:"dzeina-mezale",fullName:"Dzeina Mezale"},{id:"203011",title:"Dr.",name:"Matiss",surname:"Mezals",slug:"matiss-mezals",fullName:"Matiss Mezals"},{id:"203012",title:"Dr.",name:"Ilze",surname:"Fridrihsone",slug:"ilze-fridrihsone",fullName:"Ilze Fridrihsone"},{id:"205692",title:"MSc.",name:"Boriss",surname:"Strumfs",slug:"boriss-strumfs",fullName:"Boriss Strumfs"}],corrections:null},{id:"55050",title:"Noninvasive Diagnostic and Prognostic Assessment Tools for Liver Fibrosis and Cirrhosis in Patients with Chronic Liver Disease",doi:"10.5772/intechopen.68317",slug:"noninvasive-diagnostic-and-prognostic-assessment-tools-for-liver-fibrosis-and-cirrhosis-in-patients-",totalDownloads:1962,totalCrossrefCites:2,totalDimensionsCites:5,hasAltmetrics:0,abstract:"Liver fibrosis, that is, excessive accumulation of extracellular matrix protein, occurs and is the wound‐healing response and common final pathway of various chronic liver diseases. Advanced hepatic fibrosis caused by chronic liver inflammation eventually progresses to cirrhosis, and prognosis and management of chronic liver diseases depend on the fibrotic severities. Therefore, the early and precise evaluation of severity and status of liver fibrosis provides useful information for diagnosis as well as treatment planning and treatment efficacy and prognosis. Although invasive liver biopsy is the gold standard to assess the nature and severity of hepatic fibrosis, it has several recognized limitations including sampling error and inter‐observer variability in interpretation and staging. Furthermore, the dynamic process of fibrosis resulting from progression and regression is difficult to capture with biopsy alone. Therefore, alternative, simple, reliable, and noninvasive direct and indirect serum markers able to predict the presence of significant fibrosis or cirrhosis in patients with chronic liver disease with considerable accuracy were needed. The hepatology experts are actively researching noninvasive methods of fibrosis quantification. The aims of this chapter were to review the nature and limitations of the several noninvasive methods for the assessment of presence and severity of liver fibrosis in patients with chronic liver disease.",signatures:"Ju‐Seop Kang and Min‐Ho Lee",downloadPdfUrl:"/chapter/pdf-download/55050",previewPdfUrl:"/chapter/pdf-preview/55050",authors:[{id:"90092",title:"Prof.",name:"Ju-Seop",surname:"Kang",slug:"ju-seop-kang",fullName:"Ju-Seop Kang"},{id:"205417",title:"Prof.",name:"Min-Ho",surname:"Lee",slug:"min-ho-lee",fullName:"Min-Ho Lee"}],corrections:null},{id:"54821",title:"Alternative Diagnostic Tests of Gastroesophageal Varices in Liver Cirrhosis: Recent Advance",doi:"10.5772/intechopen.68418",slug:"alternative-diagnostic-tests-of-gastroesophageal-varices-in-liver-cirrhosis-recent-advance",totalDownloads:1384,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Routine screening for gastroesophageal varices in liver cirrhosis is necessary. At present, upper gastrointestinal endoscopy is the golden diagnostic test of gastroesophageal varices. However, the use of upper gastrointestinal endoscopy is restricted because of its poor compliance and adverse events. In this chapter, we reviewed the recent evidence regarding the value of noninvasive or less invasive tests for the diagnosis of gastroesophageal varices in liver cirrhosis.",signatures:"Xingshun Qi, Qiang Zhu and Ye Tian",downloadPdfUrl:"/chapter/pdf-download/54821",previewPdfUrl:"/chapter/pdf-preview/54821",authors:[{id:"197501",title:"Dr.",name:"Xingshun",surname:"Qi",slug:"xingshun-qi",fullName:"Xingshun Qi"},{id:"204948",title:"Dr.",name:"Qiang",surname:"Zhu",slug:"qiang-zhu",fullName:"Qiang Zhu"},{id:"206215",title:"Dr.",name:"Ye",surname:"Tian",slug:"ye-tian",fullName:"Ye Tian"}],corrections:null},{id:"54952",title:"Correlation Between Transthoracic Contrast-Enhanced Ultrasound and Pulse Oximetry in Hepatopulmonary Syndrome Diagnosis",doi:"10.5772/intechopen.68550",slug:"correlation-between-transthoracic-contrast-enhanced-ultrasound-and-pulse-oximetry-in-hepatopulmonary",totalDownloads:1150,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The prevalence of hepatopulmonary syndrome (HPS) in the setting of cirrhosis ranges between 4 and 47% and its presence increases the mortality rate, especially when hypoxemia is present. Our study aim was to fix whether there is a correlation of results between two simple and non‐invasive procedures such as transthoracic contrast‐enhanced ultrasound (CEUS) and pulse oximetry, used for early detection of HPS in patients with liver cirrhosis, having as endpoint the improvement in their outcome. The rapid lung enhancement and delayed left ventricle enhancement of the saline solution, after at least three systolic beats during CEUS and pulse oximetry showing a SaO2 < 95%, were correlated and considered positive for the diagnosis of HPS. One hundred and sixty‐five (44%) of the total of 375 patients diagnosed with liver cirrhosis enrolled in the current study, with or without respiratory symptoms (dyspnea, clubbing, distal cyanosis, cough and/or spider angioma), showed positive criteria for HPS diagnosis during CEUS. SaO2 < 95% and PaO2 < 70 mmHg were found in 123 patients (33%) during pulse oximetry investigation. Pearson correlation index showed a good correlation between lung and heart CEUS findings and pulse oximetry (r = 0.97) for HPS diagnosis. CEUS and pulse oximetry results correlate and rapidly diagnose HPS, a highly fatal complication of liver cirrhosis (LC), guiding the future treatment by speeding up orthotopic liver transplant OLT recommendations to improve the survival rates.",signatures:"Andra‐Iulia Suceveanu, Adrian‐Paul Suceveanu, Irinel‐Raluca\nParepa, Felix Voinea and Laura Mazilu",downloadPdfUrl:"/chapter/pdf-download/54952",previewPdfUrl:"/chapter/pdf-preview/54952",authors:[{id:"94569",title:"Dr.",name:"Irinel",surname:"Parepa",slug:"irinel-parepa",fullName:"Irinel Parepa"},{id:"165823",title:"Dr.",name:"Andra-Iulia",surname:"Suceveanu",slug:"andra-iulia-suceveanu",fullName:"Andra-Iulia Suceveanu"},{id:"166631",title:"Dr.",name:"Laura",surname:"Mazilu",slug:"laura-mazilu",fullName:"Laura Mazilu"},{id:"166632",title:"Dr.",name:"Adrian-Paul",surname:"Suceveanu",slug:"adrian-paul-suceveanu",fullName:"Adrian-Paul Suceveanu"},{id:"202493",title:"Dr.",name:"Felix",surname:"Voinea",slug:"felix-voinea",fullName:"Felix Voinea"}],corrections:null},{id:"55444",title:"Pulmonary Complications of Liver Cirrhosis: A Concise Review",doi:"10.5772/intechopen.68620",slug:"pulmonary-complications-of-liver-cirrhosis-a-concise-review",totalDownloads:2061,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Pulmonary complications, in the form of hepatopulmonary syndrome (HPS), portopulmonary hypertension (PPH), and hepatic hydrothorax (HH), are rare occurrences in patients with portal hypertension and liver cirrhosis. These complications are associated with high morbidity and mortality. The only effective therapy is liver transplantation in patients who are suitable. In this chapter, each condition will be outlined in detail from clinical presentations to diagnosis and treatment as well as the challenges that clinicians may have encountered in managing patients with these complications.",signatures:"Nwe Ni Than",downloadPdfUrl:"/chapter/pdf-download/55444",previewPdfUrl:"/chapter/pdf-preview/55444",authors:[{id:"172780",title:"Dr.",name:"Nwe Ni",surname:"Than",slug:"nwe-ni-than",fullName:"Nwe Ni Than"}],corrections:null},{id:"55407",title:"Ascites: Causes, Diagnosis, and Treatment",doi:"10.5772/intechopen.68868",slug:"ascites-causes-diagnosis-and-treatment",totalDownloads:1881,totalCrossrefCites:2,totalDimensionsCites:5,hasAltmetrics:0,abstract:"Ascites is a pathological accumulation of fluid in the peritoneal cavity. Cirrhosis is the most common cause of ascites, representing for 85% of cases. More than one cause may be responsible for the development of ascites (multifactorial). Development of ascites is a poor prognostic event in the natural history of cirrhosis, with approximately 15 and 44% of patients with ascites succumbing in 1 and 5 years, respectively. Patients with cirrhosis need referral for liver transplantation after development of ascites. Proper history and physical examination are important in diagnosing the cause of ascites. Diagnostic paracentesis and abdominal sonogram should be performed during initial evaluation. Low salt diet and diuretic are the initial treatment option, and large volume paracentesis is an option for non‐responder to diuretics. Transjugular intrahepatic portosystemic stent‐shunt (TIPS) is highly valuable in properly selected patients.",signatures:"Mohamed Omar Amer and Hussien Elsiesy",downloadPdfUrl:"/chapter/pdf-download/55407",previewPdfUrl:"/chapter/pdf-preview/55407",authors:[{id:"188636",title:"Dr.",name:"Hussien",surname:"Elsiesy",slug:"hussien-elsiesy",fullName:"Hussien Elsiesy"},{id:"202669",title:"Dr.",name:"Mohamed",surname:"Omar Amer",slug:"mohamed-omar-amer",fullName:"Mohamed Omar Amer"}],corrections:null},{id:"55265",title:"Nutritional Status in Liver Cirrhosis",doi:"10.5772/intechopen.68828",slug:"nutritional-status-in-liver-cirrhosis",totalDownloads:1951,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The metabolism of many nutritional elements (carbohydrate, protein, fat, vitamins, and minerals) is gradually disturbed with progressive chronic liver diseases. In particular, protein‐energy malnutrition (PEM) is known as the most characteristic manifestation of liver cirrhosis (LC) and is closely related to its prognosis. Recently, while sarcopenia (loss of muscle mass and strength or physical performance) has been discussed as an independent factor associated with prognosis in patients with LC, obesity and insulin resistance in patients with LC also contribute to carcinogenesis in LC. Deficiencies of zinc and carnitine are involved in the malnutrition in LC and are associated with hyperammonemia, which is related to the pathogenesis of hepatic encephalopathy. Because the nutritional and metabolic disturbances in LC are fundamentally influenced by many factors, such as the severity of liver damage, the existence of portal‐systemic shunting, and inflammation, proper nutritional assessment is necessary for the nutritional management of patients with LC.",signatures:"Kazuyuki Suzuki, Ryujin Endo and Akinobu Kato",downloadPdfUrl:"/chapter/pdf-download/55265",previewPdfUrl:"/chapter/pdf-preview/55265",authors:[{id:"202978",title:"Prof.",name:"Kazuyuki",surname:"Suzuki",slug:"kazuyuki-suzuki",fullName:"Kazuyuki Suzuki"},{id:"203134",title:"Prof.",name:"Ryujin",surname:"Endo",slug:"ryujin-endo",fullName:"Ryujin Endo"},{id:"203135",title:"Prof.",name:"Yasuhiro",surname:"Takikawa",slug:"yasuhiro-takikawa",fullName:"Yasuhiro Takikawa"}],corrections:null},{id:"55547",title:"Portal Vein Thrombosis in Patients with Liver Cirrhosis",doi:"10.5772/intechopen.68929",slug:"portal-vein-thrombosis-in-patients-with-liver-cirrhosis",totalDownloads:1636,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The myth that patients with liver cirrhosis are “auto‐anticoagulated” is outdated, and evidence shows that these patients frequently experience thrombosis. Portal vein thrombosis (PVT), although considered as rare, it gradually increases complications that are more likely to occur during late‐stage liver cirrhosis. The aim of this chapter is to perform a review of nonmalignant portal vein thrombosis in cirrhosis, in terms of prevalence, pathogenesis, diagnosis, clinical course, and management. Studies were identified by a search strategy using MEDLINE and EMBASE databases. For the MEDLINE search, we used the following terms: (“liver cirrhosis” [MeSH Terms] OR “cirrhosis” [All Fields] OR “cirrhosis” [All Fields]) AND (“portal vein” [MeSH Terms] OR “portal vein” [All Fields]) AND (“Thrombosis” [MeSH Terms]). For the EMBASE search, we used the following terms: (cirrhosis OR phrase liver cirrhosis) AND (phrase thrombosis/OR phrase vein thrombosis/OR phrase thrombosis prevention/OR phrase portal vein thrombosis/OR phrase liver vein thrombosis/OR phrase mesenteric vein thrombosis/OR thrombosis). Studies were considered eligible if they referred to any aspect of prevalence, pathophysiology, clinical presentation, diagnosis and management, or therapy of PVT in cirrhosis. We put forward possible responses to these unsettled issues starting with prevalence, pathogenesis, and treatment options.",signatures:"Anca Trifan, Carol Stanciu and Irina Girleanu",downloadPdfUrl:"/chapter/pdf-download/55547",previewPdfUrl:"/chapter/pdf-preview/55547",authors:[{id:"45442",title:"Dr.",name:"Anca",surname:"Trifan",slug:"anca-trifan",fullName:"Anca Trifan"},{id:"58426",title:"Prof.",name:"Carol",surname:"Stanciu",slug:"carol-stanciu",fullName:"Carol Stanciu"},{id:"202666",title:"Dr.",name:"Irina",surname:"Girleanu",slug:"irina-girleanu",fullName:"Irina Girleanu"}],corrections:null},{id:"55045",title:"Hemodynamic Optimization Strategies in Anesthesia Care for Liver Transplantation",doi:"10.5772/intechopen.68416",slug:"hemodynamic-optimization-strategies-in-anesthesia-care-for-liver-transplantation",totalDownloads:1919,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"In this chapter, aspects of hemodynamic regulation in the end-stage liver disease (ESLD) patient, factors, contributing to the hemodynamic profile, coagulation-related problems, blood products transfusion tactics and problems, and hemodynamic optimization strategies during different stages of liver transplantation procedure—specifically what, when, and how to correct, with special attention to vasoactive agents use, will be discussed.",signatures:"Alexander A. Vitin, Dana Tomescu and Leonard Azamfirei",downloadPdfUrl:"/chapter/pdf-download/55045",previewPdfUrl:"/chapter/pdf-preview/55045",authors:[{id:"201176",title:"Associate Prof.",name:"Alexander",surname:"Vitin",slug:"alexander-vitin",fullName:"Alexander Vitin"},{id:"202442",title:"Dr.",name:"Dana",surname:"Tomescu",slug:"dana-tomescu",fullName:"Dana Tomescu"},{id:"202600",title:"Prof.",name:"Leonard",surname:"Azamfirei",slug:"leonard-azamfirei",fullName:"Leonard Azamfirei"}],corrections:null},{id:"55010",title:"Management of Hepatocellular Carcinoma in the Setting of Liver Cirrhosis",doi:"10.5772/intechopen.68594",slug:"management-of-hepatocellular-carcinoma-in-the-setting-of-liver-cirrhosis",totalDownloads:1175,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Cirrhosis is an increasing cause of morbidity and mortality in more developed countries, being the 14th most common cause of death worldwide. Hepatocellular carcinoma (HCC) consists a significant health issue worldwide, responsible for more than 1 million deaths annually. The incidence and mortality rates vary across different geographical areas. Between 60 and 90% of HCC patients already have liver cirrhosis, attributed mainly to chronic hepatitis B and C, alcohol abuse, and non-alcoholic fatty liver disease (NASH). The surgical management of HCC in the setting of liver cirrhosis with curative intent includes liver resection, ablation or microwave coagulation, and liver transplantation (LT). Liver resection in a cirrhotic liver with HCC is associated with lower survival rates compared with liver transplantation (LT), depending on the diseases’ stage but on the contrary liver resection could be potentially offered in a larger population compared to liver transplantation. One of the biggest limitations of liver resection is the risk of tumor recurrence, which is high, and it may exceed 70% 5 years after the procedure. Liver transplantation is considered the best treatment for hepatocellular carcinoma at early stages because it removes the tumor as well as the underlying cirrhotic liver.",signatures:"Alexander Giakoustidis and Dimitrios E. Giakoustidis",downloadPdfUrl:"/chapter/pdf-download/55010",previewPdfUrl:"/chapter/pdf-preview/55010",authors:[{id:"32192",title:"Dr.",name:"Dimitrios",surname:"Giakoustidis",slug:"dimitrios-giakoustidis",fullName:"Dimitrios Giakoustidis"},{id:"40807",title:"Dr.",name:"Alexandros",surname:"Giakoustidis",slug:"alexandros-giakoustidis",fullName:"Alexandros Giakoustidis"}],corrections:null},{id:"54799",title:"Impact of Glyoxalase-I (Glo-I) and Advanced Glycation End Products (AGEs) in Chronic Liver Disease",doi:"10.5772/intechopen.68417",slug:"impact-of-glyoxalase-i-glo-i-and-advanced-glycation-end-products-ages-in-chronic-liver-disease",totalDownloads:1348,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Inflammation caused by oxidative stress (ROS) is a main driver for development of chronic inflammatory liver disease leading to fibrosis and cirrhosis. An important source of ROS constitutes methylglyoxal (MGO). MGO is formed as a by-product in glycolysis, threonine catabolism, and ketone bodies pathway leading to formation of advanced glycation end products (AGEs). AGEs bind to their receptor for AGEs (RAGE) and activate intracellular transcription factors, such as nuclear factor-κB (NF-κB), resulting in production of pro-inflammatory cytokines and ROS. The enzymes glyoxalase-I (Glo-I) and glyoxalase-II (Glo-II) form the glyoxalase system and are essential for the detoxification of methylglyoxal (MGO). This chapter highlights Glo-I and (R)AGE in chronic liver disease with focus on fibrosis and cirrhosis. AGEs and RAGE have been shown to be upregulated in fibrosis, and silencing of RAGE reduced the latter. In contrast, recent study highlighted reduced expression of Glo-I in cirrhosis with consecutive elevation of MGO and oxidative stress. Interestingly, modulation of Glo-I activity by ethyl pyruvate resulted in reduced activation of hepatic stellate cells and reduced fibrosis in CCl4 model of cirrhosis. In conclusion, Glo-I and R(AGE) are important components in development and progression of chronic liver disease and constitute interesting therapeutic target.",signatures:"Marcus Hollenbach",downloadPdfUrl:"/chapter/pdf-download/54799",previewPdfUrl:"/chapter/pdf-preview/54799",authors:[{id:"204724",title:"Dr.",name:"Marcus",surname:"Hollenbach",slug:"marcus-hollenbach",fullName:"Marcus Hollenbach"}],corrections:null},{id:"55648",title:"Regenerative Medicine in Liver Cirrhosis: Promises and Pitfalls",doi:"10.5772/intechopen.68729",slug:"regenerative-medicine-in-liver-cirrhosis-promises-and-pitfalls",totalDownloads:2016,totalCrossrefCites:1,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Liver cirrhosis is irreversible and mostly ends up with complete loss of liver function/end‐stage liver failure, and the only proven treatment is liver transplantation. Scarcity of donor, high cost, lifelong immunosuppression, and surgical complications are the major issues associated with liver transplantation and these urge to look for alternate therapeutic approaches. Advancements in the field of regenerative medicine are arising hope for the treatment of liver cirrhosis. This chapter deals with the scope of liver regenerative medicine in the treatment of liver cirrhosis. Review of the literature showed that liver regenerative medicine no doubt holds great promises and added a lot of hope to the cure of liver diseases. Primarily, cell‐based therapies had shown great potential to treat liver cirrhosis. Successful clinical human trials further strengthen their significance in the field. However, recent trends in liver regenerative medicine are focusing on the development of tissue engineering leading to generation of the whole organ. Despite advantages, liver regenerative medicine has several limitations and sometimes been over‐optimistically interpreted. In conclusion, the current scenario advocates to conduct more preclinical and clinical trials to effectively replace liver transplantation with liver regenerative medicine to treat liver diseases.",signatures:"Asima Tayyeb, Fareeha Azam, Rabia Nisar, Rabia Nawaz, Uzma\nQaisar and Gibran Ali",downloadPdfUrl:"/chapter/pdf-download/55648",previewPdfUrl:"/chapter/pdf-preview/55648",authors:[{id:"202336",title:"Dr.",name:"Asima",surname:"Tayyeb",slug:"asima-tayyeb",fullName:"Asima Tayyeb"}],corrections:null},{id:"55387",title:"The Promising Role of Anti-Fibrotic Agent Halofuginone in Liver Fibrosis/Cirrhosis",doi:"10.5772/intechopen.68641",slug:"the-promising-role-of-anti-fibrotic-agent-halofuginone-in-liver-fibrosis-cirrhosis",totalDownloads:1631,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Liver fibrosis is a complex inflammatory and fibrogenic process that results from chronic liver injury and represents an early step in the progression of cirrhosis. Several cell types [hepatic stellate cells (HSCs), hepatocytes, liver sinusoidal endothelial cells (LSECs), and Kupffer cells (KCs)], cytokines [platelet-derived growth factor (PDGF), transforming growth factor (TGF)-β, tumor necrosis factor (TNF)-α, interferons (IFNs), interleukins (ILs)], oxidative stress, and microRNAs (miRNAs) are involved in the initiation and progression of liver fibrosis/cirrhosis. Generally, liver fibrosis begins with the stimulation of inflammatory immune cells to secrete cytokines, growth factors, and other activator molecules. These chemical mediators direct HSCs to activate and synthesize large amounts of extracellular matrix (ECM) components. Therefore, HSC activation is a pivotal event in the development of fibrosis and a major contributor to collagen (specifically type I) accumulation. The inhibitory effect of halofuginone on collagen type α1(I) synthesis and ECM deposition has been shown in several experimental models of fibrotic diseases. Halofuginone inhibits TGF-β–induced phosphorylation of Smad3, which is a key phenomenon in the fibrogenesis. It also regulates cell growth and differentiation, apoptosis, cell migration, and immune cell function in liver fibrosis/cirrhosis. This review discusses the etiology and mechanisms of liver fibrosis/cirrhosis and the promising role of anti-fibrotic agent halofuginone.",signatures:"Berna Karakoyun",downloadPdfUrl:"/chapter/pdf-download/55387",previewPdfUrl:"/chapter/pdf-preview/55387",authors:[{id:"202061",title:"Associate Prof.",name:"Berna",surname:"Karakoyun Laçin",slug:"berna-karakoyun-lacin",fullName:"Berna Karakoyun Laçin"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"8838",title:"Liver Cirrhosis",subtitle:"Debates and Current Challenges",isOpenForSubmission:!1,hash:"17163eb18a082da0fe70ccc20b7fe69a",slug:"liver-cirrhosis-debates-and-current-challenges",bookSignature:"Georgios Tsoulfas",coverURL:"https://cdn.intechopen.com/books/images_new/8838.jpg",editedByType:"Edited 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To this extent, ergonomics comprises three main fields of research: physical, cognitive, and organizational ergonomics. Physical ergonomics is concerned with the consequences of repetitive motion, materials handling, workplace safety, comfort in the use of portable devices, keyboard design, working postures, and the work environment. Cognitive ergonomics deals with the mental (intellectual and psychological) aspects of the operator-activity relationship: perception, reasoning, memory, stimuli, psycho-motor responses, etc. Organizational ergonomics is concerned with the optimization of sociotechnical systems, including their organizational structures, policies, and processes.
\r\n\r\n\tThis book is designed to provide an extensive literature review, uncover contemporary research, and shed a light on the researchers in all three fields of ergonomics.
",isbn:"978-1-80356-471-5",printIsbn:"978-1-80356-470-8",pdfIsbn:"978-1-80356-472-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"8b7474730a8f1ec6615e66e12a72b4b5",bookSignature:"Dr. Orhan Korhan",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11877.jpg",keywords:"Workplace Safety, Repetitive Strain Injuries, Vibration, Posture, Materials Handling, Work Environment, Cognitive Ergonomics, Communication, Work Design, Community Ergonomics, Telework, Quality Management",numberOfDownloads:16,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 3rd 2022",dateEndSecondStepPublish:"May 6th 2022",dateEndThirdStepPublish:"July 5th 2022",dateEndFourthStepPublish:"September 23rd 2022",dateEndFifthStepPublish:"November 22nd 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"An active researcher and full professor in Industrial Engineering, appointed to be the director of Industry 4.0 Research Center, Vice-Dean of Faculty of Engineering, author of several articles, chapters, and books, and editor of several books in Ergonomics.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"101698",title:"Dr.",name:"Orhan",middleName:null,surname:"Korhan",slug:"orhan-korhan",fullName:"Orhan Korhan",profilePictureURL:"https://mts.intechopen.com/storage/users/101698/images/system/101698.jpeg",biography:"Orhan Korhan graduated with a BS from Eastern Mediterranean University (EMU) in 2000, a MS from the University of Louisville in 2002, and a PhD from EMU in Industrial Engineering in 2010. He has been working at EMU since 2009. He became Assistant Professor in 2010, and Associate Professor in 2014, and a full Professor in 2020. He has been assigned to scientific committee of several international conferences, published several books, book chapters, and papers in various countries. His current research interests include Work-related Musculoskeletal Disorders, Cognitive Ergonomics, Industry 4.0 and Facilities Planning and Design.",institutionString:"Eastern Mediterranean University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"4",institution:{name:"Eastern Mediterranean University",institutionURL:null,country:{name:"Cyprus"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:[{id:"81577",title:"Musculoskeletal Disorders in the Teaching Profession",slug:"musculoskeletal-disorders-in-the-teaching-profession",totalDownloads:16,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"444312",firstName:"Sara",lastName:"Tikel",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/444312/images/20015_n.jpg",email:"sara.t@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"37741",title:"Investigation of the Structure and Properties of PVD and PACVD-Coated Magnesium Die Cast Alloys",doi:"10.5772/48165",slug:"investigation-of-the-structure-and-properties-of-pvd-and-pacvd-coated-magnesium-die-cast-alloys",body:'The development of existing techniques and technologies depends mainly on the used materials. The applied material determines the manufacturing method for the products. Criteria, which are chose by engineers and technologists for a proper material choice are among others: strength, hardness, elongation, density, corrosion resistance, ability for plastic deformation, or even recycling ability [1-9]. At present engineers have in their disposal modern equipment for investigation of the material structure, which allows it to perform a better and more efficient analysis of the mechanisms responsible for specific properties.
In recent years, there is visible an increasing interest on light metals, and especially materials with low density and relatively high strength properties [1-9]. The group of these materials include particular magnesium and its alloys. Mechanical properties of pure magnesium are relatively low and depends on its purity. In as cast state the tensile strength Rm is in the range of 80 - 120 MPa, yield strength Re = 20 MPa, elongation A = 4 - 6%, and hardness is equal 30 HB. Magnesium is recognised in the periodic table of elements in the group of earth alkali metals and is therefore not to found in nature in the basic form, but only in the form of chemical compounds. As a pure element magnesium has not found wide application possibilities, but as an alloy in combination with other elements such as aluminium, zinc, manganese, silicon, zirconium, thorium, lithium, calcium and rare earth metals, magnesium forms alloys with unique properties, which are used for production of diverse devices and machine- and construction elements. Magnesium alloys are characterised with the lowest density among all non-ferrous metals, as well with a favourable strength to density ratio, which means, that with a lower weight magnesium can hold similar static and dynamic loads compared to aluminium alloys, or even iron alloys. Moreover, these metals have a high vibration damping capacity and good casting properties, similar to these of aluminium cast alloys. Magnesium alloys are used for production of different types of car accessories such as steering wheels, pedals, wheels, seat frames, inlet manifolds, gear housings and other elements (Table 1) [1-9].
the abundance of natural resources together with the cost effective primary processes contribute to a stable supply that can rapidly grow to meet future demand | |
magnesium is the lightest structural metal. It is lighter than aluminum by 35 percent and lighter than zinc by 73 percent. Its excellent strength-to-weight ratio significantly decreases the weight and cost of magnesium components | |
magnesium is a durable metal with excellent capacity for damping vibrations | |
magnesium is the easiest metal to machine, which leads to rapid processing and the cost effective production of finished parts | |
in the die casting process magnesium can be formed into very complicated and thin-walled parts with a high degree of precision | |
magnesium alloys, due to their excellent conductivity, shield against harmful electromagnetic radiation and are an ideal material to be used in electronic equipment, where electromagnetic radiation is an issue | |
the increase in the use of magnesium applications is approximately 15-20 percent annually |
Increasingly, they find their application in the sports industry. They are also used for production of bicycle frames, ski and other sports equipment, etc. Beside the automotive and sport industry these alloys are used for construction elements, machinery and equipment, industrial automation, electronics, also in the military industry, and in the electrical branches (Table 1). Magnesium alloys are recognized as materials with high potential application possibilities, what is increasingly reflected in its increasing popularity and usage in production. Thanks to innovatory technologies, it is possible to perform castings from a few grams to several kilograms in weight. These alloys due to the number of its benefits will soon become an indispensable standard in the automotive, sports and aviation industry [1-9]. The growing trends in the production of magnesium alloys point at the increased necessity of their application in the world constructional industry, and the magnesium alloys will become one of the most frequent materials used in the following decades.
Optimization of chemical composition and technological conditions, production, casting and heat treatment of light metal alloys, due to the excellent set of mechanical properties and corrosion resistance based on the analysed precipitation- and phase transitions processes occurring in the investigated alloys during their cooling process is just one of the existing possibilities applicable for the enhancement of mechanical properties. Taking into account, that some properties are of interest only for the surface of the material, investigations were carried out concerning surface treatment of the magnesium alloys by applying of the physical vapour deposition processes. Due to insufficient stiffness of the substrate material a dual coating system was applied with a variable coating hardness, consisting of a soft ground - transition gradient layer - and a hard, wear-resistant outer layer. Thin hard PVD coatings on a soft surface, seams to be a preferred combination from the tribological point of view. Such coatings have found its special application for components working tribo-corrosive environment [10-16].
The aim of this research work is to determine the nature and properties of two-layer coating in a gradient like and hard wear resistant layer configuration, produced using the PVD and PACVD process on magnesium alloy substrate. Taking into account the optimisation of chemical composition and the development of optimal production conditions for achieving highest possible mechanical properties, corrosion resistance and functional properties compared to the existing standard surface layers.
The investigations have been carried out on test pieces of MCMgAl12Zn1 (Table 2, No. 1), MCMgAl9Zn (Table 2, No.2), MCMgAl6Zn (Table 2, No. 3), MCMgAl3Zn1 (Table 2, No. 4) magnesium alloys in as-cast and after heat treatment states. The chemical composition of the investigated materials is given in Table 2.
The mass concentration of main elements, % | |||||||
No. | Al | Zn | Mn | Si | Fe | Mg | Rest |
1 | 12.1 | 0.62 | 0.17 | 0.047 | 0.013 | 86.96 | 0.0985 |
2 | 9.09 | 0.77 | 0.21 | 0.037 | 0.011 | 89.79 | 0.0915 |
3 | 5.92 | 0.49 | 0.15 | 0.037 | 0.007 | 93.33 | 0.0613 |
4 | 2.96 | 0.23 | 0.09 | 0.029 | 0.006 | 96.65 | 0.0361 |
Chemical composition of investigated alloys, %
The coating deposition process of the coatings: Ti/TiCN/TiAlN and Cr/CrN/CrN was made in a device based on the cathodic arc evaporation method in an Ar, N2 and C2H2 atmosphere moreover the DLC coating were deposited using acetylene (C2H2) as precursor and was produced by PACVD process (Table 3). Cathodes containing pure metals (Cr, Ti) and the TiAl (50:50 at. %) were used for deposition of the coatings. The diameter of the used cathodes was 65 mm. After pumping the chamber the base pressure was 5x10-3 Pa (Table 3).
The temperature was controlled by thermocouples. Then the substrates were cleaned by argon ion at the pressure 2 Pa for 20 min. To improve the adhesion of coatings, a transition Cr or Ti interlayer was deposited. The working pressure during the deposition process was 2-4 Pa depending of the coatings type. The distance between each of the cathodes and the deposited substrates was 120 mm.
The examinations of thin foils microstructure and phase identification were made on the JEOL 3010CX transmission electron microscope (TEM), at the accelerating voltage of 300 kV using selected area diffraction method (SAD) for phase investigations. The diffraction patterns from the TEM were solved using a special computer program “Eldyf” software supplied by the Institute of Material Science o the University of Silesia. TEM specimens were prepared by cutting thin plates from the material. The specimens were ground down to foils with a maximum thickness of 80 μm before 3 mm diameter discs were punched from the specimens. The disks were further thinned by ion milling method with the Precision Ion Polishing System (PIPS™), used the ion milling device model 691 supplied by Gatan until one or more holes appeared. The ion milling was done with argon ions, accelerated by a voltage of 15 kV, energy and angle are presented in Table 4.
Process parameters | Coating type | ||
Ti/TiCN-gradient/TiAlN | Cr/CrN-gradient/CrN | Ti/DLC/DLC | |
Base pressure [Pa] | 510-3 | 510-3 | 1x10-3 |
Working pressure [Pa] | 9.010-1/1.1÷1.9/2.8 | 1.0/1.4÷2.3/2.2 | 2 |
Argon flow rate measurement [sccm] | 80* | 80* | 80* |
10** | 80** | - | |
10*** | 20*** | - | |
Nitrogen flow rate measurement [sccm] | 0225** | 0250** | - |
350*** | 250*** | - | |
Acetylene flow rate measurement [sccm] | 1400** | - | 230 |
Substrate bias voltage [V] | 70* | 60* | 500 |
70** | 60** | ||
70*** | 60*** | ||
Target current [A] | 60 | 60 | - |
Process temperature [ºC] | <150 | <150 | <180 |
Deposition parameters of the investigated coatings*during metallic layers deposition, **during gradient layers deposition, *** during ceramic layers deposition
Angle [°] | Energy [KeV] | Time [min] |
6 | 3.8 | 180 |
3 | 3.2 | 15 |
Ion milling parameters using for polishing
Microstructure investigation was performed using scanning electron microscope (SEM) ZEISS Supra 25 with a magnification between 10000 and 35000 times. For microstructure evaluation the Secondary Electrons (SE) detection was used, with the accelerating voltage of 5÷25 KV. For a complex metallographic analysis of the fractures of the investigated samples, the material with the coated layer was initially cut, and before braking cooled down in liquid nitrogen. Qualitative and quantitative chemical composition analysis in micro-areas of the investigated coatings was performed using the X-Ray microanalysis (EDS) by mind of the spectrometer EDS LINK ISIS supplied by Oxrord. This device is attached to the electron scanning microscope Zeiss Supra 35. The investigations were performed by an accelerating voltage of 20 kV.
The analysis of phase composition of the substrates and of the obtained coatings was carried out using the X-ray diffraction method (XRD) on the X-ray apparatus X’Pert of the Panalytical Company using the filtered radiation of a cobalt lamp. For the reason of put on diffraction pattern coming from the substrate material and coating ones as well as their intensity, and also convergence of the Miller indexes for different coating types to achieve a more accurate information from the surface layer and decrease of the substrate influence on the diffraction pattern in the future investigations a diffraction technique was applied with a constant angle of incidence of the primary X-Ray beam using parallel beam collimator placed before the proportional detector. Diffraction pattern of gradient- and multilayer coatings were achieved by different angle of incidence of the primary beam. The effective depth of measurement was chosen experimentally on the basis of preliminary investigations of different angles of incidence.
The specimens were tested on Raman spectroscope from Renishaw, type inVia Raman Microscope, coupled with light microscope; for observation has been used laser with wavelength 514nm and full power equal to 30mW; after precise alignment of the laser spot the data was obtained in single spectral acquisition with use of 20x long working distance plan objective lens.
The cross-sectional atomic composition of the samples (coating and substrate) was obtained by using a glow discharge optical spectrometer, GDOS-750 QDP from Leco Instruments. The following operation conditions of the spectrometer Grimm lamp were fixed during the tests:
lamp inner diameter – 4 mm;
lamp supply voltage – 700 V;
lamp current – 20 mA;
working pressure – 100 Pa.
Wear resistance investigations were performed using the ball-on-disk method in dry friction conditions in horizontal settlement of the rotation axis of the disk. As the counterpart there was used a tungsten carbide ball with a diameter of 3 mm. The tests were performed at room temperature by a defined time using the following test conditions:
load, Fn-5N,
rotation of the disk 200 turns/min,
wear radius of 2.5 mm,
shift rate of -0, 05 m/s.
The measurement of roughness of the surface of the obtained coatings was carried out using the profilographometer Diavite Compact of Asmeo Ag Company. The measurement length of Lc=0.8 mm and measurement accuracy of ±0.02 μm. The parameter Ra acc. the Standard PN-EN ISO 4287:1999 was assumed as the quantity describing the roughness. On each investigated sample there was performed 6 measurements and we determined the average.
Results of diffraction method investigations achieved by the high resolution transmission electron microscope allow to identify the TiAlN, CrN, graphit phase occurred in the surface layer (Fig. 1-12). For all investigated alloys a nanocrystalline microstructure of the surface layer in investigated area was detected. On figure 1, 2, there are showed the microstructures of the layer TiAlN phase, using the dark field technique the size of the subgrains or crystallites can be determined, as ca. 15 nm in diameter. For phase determination of the structure of the surface layer diffraction pattern analysis of the investigated areas has allow it to identify the (Ti,Al)N phase as a cubic phase of the 225-Fm3m space group with the d-spacing of a=b=c=0,424173 nm. The CrN phase was determined as a cubic phase of the 225-Fm3m space group with the d-spacing of a=b=c=0.414 nm. Investigations performed using particularly the dark field technique on the transmission electron microscope have confirmed that the size of the CrN crystallites, in the majority of the cases does not exceed the limit of ~ 20 nm (Fig. 5,6). Also a globular bulk shaped morphology and homogeneity of these crystallites was found, as well a low statistical dispersion in the range between 10 to 20 nm.
Structure of the thin foil from TiAlN surface layer (Ti/TiCN/TiAlN coating), bright field, TEM
Structure of the thin foil from TiAlN surface layer (Ti/TiCN/TiAlN coating), dark field, TEM
Diffraction pattern of the thin foil from TiAlN surface layer (Ti/TiCN/TiAlN coating) presented on
Solution of the diffraction pattern presented on
Structure of the thin foil from CrN surface layer (Cr/CrN/CrN coating), bright field, TEM
Structure of the thin foil from CrN surface layer (Cr/CrN/CrN coating), bright field, TEM
Diffraction pattern of the thin foil from CrN surface layer (Cr/CrN/CrN coating) presented on
Solution of the diffraction pattern presented on
The graphite phase was determined as a hexagonal phase of the 186-P63mc space group with the lattice parameters of a=b=0.2, c=0.679 nm (Fig. 9,10). Investigations performed using particularly the dark field technique on the transmission electron microscope have confirmed, that the size of the graphite crystallites, which the Ti/DLC/DLC coating is constant, is in the range up to 30 nm and with irregular shape.
Investigations of the fractures of the magnesium alloys coated with the Ti/TiCN/TiAlN, Cr/CrN/CrN, Ti/DLC/DLC layers show an occurrence of sharp transition zone between the substrate and coating (Fig. 13-18). It was found out, as a result of the microstructure investigations on scanning electron microscope, that there are no pores or cracks in the produced coating and no defects and failures occurring spontaneously in this single layer are of significant importance for the properties of the whole layer (Fig. 13-18). The thickness of the Ti/TiCN/TiAlN layer is in the range up to 3.3 µm, Cr/CrN/CrN layer is in the range up to 1.9 µm, and Ti/DLC/DLC layer is in the range up to 2,5 microns.
In the case of the Ti/TiCN/TiAlN layer it was also found that the examined layers were not uniform and consisted of three sub-layers, with a clearly visible transition zone between the gradient layer and the wear resistant coating achieved using separate metals evaporation sources, where the upper one had a thickness of ca. 0.6 µm (Fig. 13, 14). Coating thickness was measured using a scanning electron microscope. Fracture morphology of the investigated coatings is characterised by a lack of columnar structure (Fig. 13-18). On the basis of the performed observations on scanning electron microscope the coating of the Ti/TiCN/TiAlN type show an increasing non-homogeneity compared to the Cr/CrN/CrN and Ti/DLC/DLC coatings what is connected with the presence of numerous droplet-shaped microparticles (their number depends on the type of the target) and should that fore significantly influence mechanical properties and resistance of the investigated surfaces (Fig. 13-20). The droplets observed in SEM are noticeably different in terms of size and shape (regular and irregular shape, slightly flat). There were also some hollows formed probably when the solidified droplets break off after the used process has been completed (Fig. 19,20).
Structure of the thin foil from DLC surface layer (Ti/DLC/DLC coating), bright field, TEM
Structure of the thin foil from DLC surface layer (Ti/DLC/DLC coating), dark field, TEM
Diffraction pattern of the thin foil from DLC surface layer (Ti/DLC/DLC coating) presented on
Solution of the diffraction pattern presented on
Cross-section SEM images of the Ti/TiCN/TiAlN coating deposited onto the AZ91 substrate
Cross-section SEM images of the Ti/TiCN/TiAlN coating deposited onto the AZ91 substrate
Cross-section SEM images of the Cr/CrN/CrN coating deposited onto the AZ121 substrate
Cross-section SEM images of the Cr/CrN/CrN coating deposited onto the AZ61 substrate
As a result of the performed X-ray microanalysis using the qualitative energy spectrometer EDS it was confirmed the presence of major alloying elements Mg, Al, Zn, N, Cr, as compounds of the investigated alloys as well of the coatings (in this case Cr/CrN/CrN coating) (Fig. 21). Moreover qualitative analysis of the chemical elements distribution performed on the cross-section of the investigated sample clearly confirms increase of the concentration of the elements at grain boundaries of the produced coatings (Fig. 21).
Cross-section SEM images of the Ti/DLC/DLC coating deposited onto the AZ121 substrate
Cross-section SEM images of the Ti/DLC/DLC coating deposited onto the AZ61 substrate
Surface topography of the Ti/TiCN/TiAlN coating deposited onto AZ61 substrate
Surface topography of the Cr/CrN/CrN coating deposited onto AZ91 substrate
Based on the results obtained by the quantitative X-ray microanalysis using the energy dispersed X-ray EDS spectrometer it was confirmed the presence of Mg, Al, Zn, Ti, C as major alloying elements of the cast magnesium alloys as well the obtained coatings (Fig. 22, Table 5). Due to the fact, that the EDS analysis in case of measurement of so called light element concentrations, for which the energy <1 keV (C) has a relatively large measurement error because of strong absorption. For this reason the described values should be seen as estimated values only. But the measurement error in case of mass concentration measurement - in the range from 5 to 20 % - is about 2%.
Chemical element | The mass and atomic concentration of main elements, % | |||
mass | atomic | |||
Analysis 1 (point 1) | ||||
C | 92.85 | 96.92 | ||
Mg | 04.33 | 02.24 | ||
Al | 00.52 | 00.24 | ||
Ti | 02.29 | 00.60 | ||
Matrix | Correction | ZAF | ||
Analysis 2 (point 2) | ||||
C | 76.59 | 89.31 | ||
Zn | 00.84 | 00.18 | ||
Mg | 12.56 | 07.23 | ||
Al | 01.55 | 00.81 | ||
Ti | 08.46 | 02.47 | ||
Matrix | Correction | ZAF | ||
Analysis 2 (point 3) | ||||
Zn | 05.67 | 02.25 | ||
Mg | 67.38 | 71.85 | ||
Al | 26.95 | 25.90 | ||
Matrix | Correction | ZAF |
The results of quantitative chemical analysis from third 1, 2, 3 areas of coating Ti/DLC/DLC deposited onto substrate from AZ91 alloy marked in Fig. 22
The area analysis of chemical elements of the Cr/CrN/CrN coating and the magnesium (AZ61) substrate: image of the secondary electrons (A) and maps of elements’ distribution
Cross-section SEM images of the Ti/DLC/DLC coating deposited onto the AZ91 substrate
Changes of coating component concentration and substrate material made in GDOS were presented in Figs. 23, 24. The tests carried out with the use of GDOS indicate the occurrence of a transition zone between the substrate material and the coating, which results in the improved adhesion between the coatings and the substrate. In the transition zone between the coatings and the substrate, the concentration of the elements of the substrate increases with simultaneous rapid decrease in concentration of elements contained in the coatings. The existence of the transition zone should be connected with high-energy ion action that caused mixing of the elements in the interface zone.
Changes of constituent concentration of the Cr/CrN/CrN and the AZ61 substrate materials
Changes of constituent concentration of the Ti/TiCN/TiAlN and the AZ61 substrate materials
On Figs. 25 a and b there are presented the X-ray diffractions of the investigated magnesium alloys in state after heat treatment. Using the of qualitative X-ray phase analysis methods it was confirmed, that in the investigated materials occurs the γ (Mg17Al12) phase as well the α-Mg phase which is the alloy matrix. A too small volume fraction of other phases present in the material does not allow it to perform an unambiguous identification of the obtained X-ray diffractions. Because of the overlapping reflections of the substrate and the coating material, as well the relatively small thickness of each layer, there were difficulties with identification of the phases. It was also confirmed the presence of reflexes coming from the phases present in the substrate, e.g. α and γ (Fig. 25 c,d). Very small volume fraction of other phases present in the substrate material does not allow it to perform an unambiguous identification of the recorded X-ray spectrum. The presence of substrate reflexes was confirmed on every achieved X-Ray diffraction collected from the coating, due to the thickness of the obtained coatings <3.5 μm, smaller than the X-ray penetration depth. Using the technique of fixed incidence angle (GIXRD method) there are collected only reflexes from the thin surface layers (Fig. 25 e,f).
The morphology of the deposited films, particulary DLC coating was characterized also by Raman spectroscopy. This spectroscopy method was used to determine the microstructure and chemical composition of the deposited DLC films. The shape of the achieving Raman spectrum is characteristic for carbon materials with a low level of structure order. The obtained spectrum can be presented in form of two Gaussian curves, respectively for the Raman shift values equal ca 1500 cm -1 (D band) and 1300 cm -1 (G band). The ratio of their height can be presented as a ordering level of the carbon structure of the material analyzed. The analyzed layer is composed of amorphous carbon - or more precisely- composed of poorly structured carbon material, including small crystallites.
X-ray diffraction pattern of: a) AZ31 substrate, b) AZ121 substrate, c) Ti/TiCN/TiAlN coating deposited on the AZ91 magnesium alloys, d) Cr/CrN/CrN coating deposited on the AZ91 magnesium alloys obtained by Bragg-Brentano method, e) Ti/TiCN/TiAlN coating deposited on the AZ61 magnesium cast alloy obtained by GIXRD method (α=4º), f) Cr/CrN/CrN coating deposited on the AZ61 magnesium cast alloy obtained by GIXRD method (α=4º)
Raman spectra of the DLC films deposited on AZ91 magnesium alloys.
The highest value of surface roughness equal 0.3 mm was measured for the coating of the Ti/TiCN/TiAlN type which is likely caused by the occurrence of numerous microparticles in the shape of droplets in the structure (Table 6, Figure 13, 14, 19). The observed high homogeneity of the Cr/CrN/CrN surface coating is characterized by a smaller amount of crystallised droplets of liquid metal (Table 6, Figure 20), what responses to a smaller surface roughness within the range from 0.12 to 0.15 mm. The Ti/DLC/DLC coating has a surface roughness of ~ 0.25 mm. The performed investigations of the surface of the cast magnesium alloy, with coated layers confirm a lack of significant effect of the substrate type on the surface roughness (Table 6).
To determine the tribological properties of the investigated coating deposited on the magnesium alloys substrate, an abrasion test under dry slide friction conditions was carried out by the ball-on-disk method. Table 6 and Fig. 27 presents the friction coefficient and sliding distance results for each type of the investigated substrate. Under technically dry friction conditions, after the wearing-in period, the friction coefficient recorded for the associations tested is stabilized in the range 0.08-0.38 μm depending on the used substrate and coatings. All friction coefficient diagrams which were collected depending on the rotation rate or friction path length have similar characteristics and can be divided into two parts (Fig. 27). In the first part, there occurs a sharp increase of the friction coefficient together with increasing friction path length. It was assumed, that this is a transient state of the friction process. The second part of the graph has already a stable state. Rapid changes of the friction coefficient value are caused by the occurrence of pollutants in form of sample counterface spalling products (balls are made from WC), which disturb the measurement of the friction coefficient. Comparing the friction coefficient results with the friction path length, it was found that the best wear resistance is characteristic for materials coated with DLC carbon. According to the applied load of 5 N, the average friction coefficients for the DLC coatings with the sliding rate of 0.05 m / s is in the range of 0.08-0.15 mm, which is ten times lower compared to the friction coefficient values of other examined coatings. However, the results of the friction path length for the DLC coatings were at a level exceeding even 70 times the results of the friction path length achieved for the Cr/CrN/CrN coatings. This is characteristic for DLC coatings, because they are composed of poorly ordered graphite, which is probably formed by a friction-assisted phase transformation of the surface layer of the DLC matrix and acts as a lubricant at the surface [17]. Accordingly, the high hardness of DLC together with this transfer layer is responsible for the low friction coefficient of the DLC film in comparison with magnesium alloys coated other investigated coatings. At high sliding speed, the transfer layer is more easily formed due to the accumulation of heat, resulting in a lower friction coefficient.
0.13 | 0.24-0.27 | 8 | |
0.28 | 0.19-0.22 | 59.4 | |
0.24 | 0.09-0.16 | 550 | |
0.12 | 0.25-0.38 | 7.8 | |
0.27 | 0.18-0.25 | 57.6 | |
0.25 | 0.1-0.17 | 540 | |
0.15 | 0.22-0.28 | 22 | |
0.30 | 0.17-0.22 | 77.7 | |
0.25 | 0.09-0.19 | 630 | |
0.12 | 0.2-0.29 | 13 | |
0.28 | 0.15-0.22 | 66 | |
0.26 | 0.08-0.15 | 605 |
The characteristics of the tested coatings
Dependence of friction coefficient on sliding distance during the wear test for: a) Ti/DLC/DLC coating deposited on the AZ61, b) Ti/DLC/DLC coating deposited on the AZ31, c) Ti/TiCN/TiAlN coating deposited on the AZ121, d) Ti/TiCN/TiAlN coating deposited on the AZ91
Due to the character of the investigated material (magnesium alloys) and its relatively low melting point, the whole technological PVD and PACVD processes were performed at temperatures up to 150 °C for Cr/CrN/CrN coatings and Ti/TiCN/TiAlN coatings, and up to 180° C for Ti/DLC/DLC coatings. Results of diffraction method investigations achieved by the high resolution transmission electron microscope allow to identify the TiAlN, CrN, graphit phase occurred in the surface layer. It was found out, as a result of the microstructure investigations on scanning electron microscope, that there are no pores or cracks in the produced coating and no defects and failures occurring spontaneously in this single layer are of significant importance for the properties of the whole layer. Coating thickness was measured using a scanning electron microscope. The thickness of the Ti/TiCN/TiAlN layer is in the range up to 3.3 µm, Cr/CrN/CrN layer is in the range up to 1.9 µm, and Ti/DLC/DLC layer is in the range up to 2.5 microns. The tests carried out with the use of GDOS indicate the occurrence of a transition zone between the substrate material and the coating, which results in the improved adhesion between the coatings and the substrate. Using the technique of fixed incidence angle (GIXRD method) there are collected only reflexes from the thin surface layers. The highest wear resistance was obtained for the of Ti/DLC/DLC coating.
The Portuguese health system is mainly described as a National Health Service (NHS), following the Beveridge tradition, with universal coverage and mandatory participation. In parallel with the NHS, there are some Bismarkean features, such as those arising from the existence of occupation-based health insurance, which are also mandatory or quasi-mandatory. On top of these two layers of health insurance coverage, there is a market for private health insurance on a voluntary basis. This insurance is both supplementary and complementary to the NHS. People may be interested in buying a health insurance policy because it gives them faster access to health care, lets them choose the provider and enjoy a better experience when admitted to a hospital, and have access to services not included in the NHS, such as dental care [1].
Over the last 6 years, health care expenditure on private VHI in Portugal as a percentage of GDP has been less than 0.5% and it has been about 5% of current health expenditure [2]. Despite this trend, voluntary private health insurance in Portugal grew by about 3.5% between 2012 and 2015 [3].
The insurance market is characterized by asymmetric information [4, 5] expressed by moral hazard [6] and by adverse selection [7]. A moral hazard happens after the insurance contract has been signed and it refers to the situation where the insured person uses more health care services than they would need. On the other hand, adverse selection happens before the insurance contract has been signed, when the insurance company cannot assess the risk type of individual purchasing the insurance. This individual may be a low health risk, so they will be mainly healthy and generate low health care spending, or they may be high risk and will generate high health care spending. If the adverse selection does not take place, then low-risk individuals might prefer to buy the insurance and this is called advantageous or propitious selection [8], which is beneficial to insurance companies. This situation is often explained by a person’s risk preferences. Healthy people tend to be risk-averse and so they choose to buy VHI [9, 10].
Older people are often considered as high health risk individuals, who are very likely to have more health problems than younger individuals, have higher medical expenditures, and raise the claims paid by insurance companies [11]. Not only do these people have more health problems, but insurance companies face moral hazards and adverse selection issues that result in the overuse of health care and the payment of excessive claims. For these reasons, older people are not usually the customers desired by insurance companies.
The Portuguese health insurance market is not as highly regulated as it is in other countries, because health insurance is voluntary and the NHS has universal coverage. So, insurance companies can adopt several strategies to prevent or mitigate moral hazard and adverse selection [12] and to reduce paying out excessive claims. One strategy could involve the eligibility requirements excluding people older than 65. Even though this cream-skimming strategy discriminates against older people, there is a small health insurance market for older people in Portugal. In the last available National Health Survey, conducted in 2014, of the 5,701 people older than 65 interviewed, 5.8% of them stated they had a voluntary health insurance policy.
The purpose of this work is to estimate the main determinants for older people in Portugal to take out private health insurance since no previous studies have been published and there may be differences across European countries [13, 14]. We use data collected by the 2014 National Health Survey and we estimate a multivariate probit. We also compute the marginal effects associated with the most important variables. This analysis provides insights for designing health and social policies that will reduce the inequality in health care access that may be generated by differences in health insurance coverage.
The factors explaining the demand for VHI are well discussed in the literature. While Outreville [15] focused on the demand for insurance in general, [16, 17] have looked at the demand for VHI and reviewed the determinants for buying it; [1] outlined these determinants for the EU countries. The explanatory factors include the demographic and economic determinants (also referred to as socioeconomic status), that is, gender, age, education, income, marital status, employment status, and other characteristics [11, 13, 16, 17, 18, 19]. In general, we can say that the likelihood of purchasing VPHI increases with age, income, education, being employed, and living in urban areas. The results are not conclusive for determinants, such as gender, family composition, and being a pensioner.
In Europe, where health systems tend to be mandatory and offer universal coverage, the determinants for holding a private VHI differ between countries [13, 14]. Regarding Portugal, an empirical study performed almost 20 years ago [20], concluded that the VHI buyers were most likely young, self-employed, living in urban areas, and receiving a middle to high income, thus leaving out older people.
The focus on the demand for private VHI by older people has been much less studied because it is known that as we age, the likelihood of having this type of insurance decreases [21]. Four empirical works should be mentioned that are concerned exclusively with older people and use the data collected by SHARE – Survey of Health, Aging, and Retirement in Europe [18, 13, 14, 19]. In general, being female, having had a good education, and receiving a higher income increases the demand for private VHI by older people.
Special attention is often given to the role of the health status and health behavior since there are proxies for the individual healthrisk type [22]. Health status can be measured by self-assessed health and the presence (or the number) of chronic diseases [18, 23], while health behavior can be proxied by body mass index or being overweight [24], and by smoking decisions [25].
The theory predicts that high-risk individuals are more likely to have health insurance, that is, adverse selection exists in health insurance. However, there are no conclusive empirical results regarding the relationship between individual risk variables and having a VHI policy [16]. This means that advantageous selection is a possibility, where low-risk type people choose to buy health insurance [23, 26].
The empirical results regarding indicators of health status and health-related behavior are mixed. Some studies have found that people reporting better health are more likely to have voluntary health insurance, supporting the hypothesis of advantageous selection [11, 12, 14, 18, 23, 27, 28, 29]; other authors found no significant correlation [27, 30]; and still, others found that healthy people tend to have VHI less often, as predicted by adverse selection hypothesis [11, 12, 14, 19].
In most studies, indicators of chronic diseases are found to be insignificant when explaining the demand for VHI [29, 31, 32]. Few works have reported a positive correlation between suffering from chronic diseases and having private health insurance [18, 23].
The relationship between health-related behaviors and private VHI coverage has been studied less and the results are mixed [14]. While some studies find that smokers are less likely to have VHI [27, 33], others find the opposite [18]. The results are similarly mixed for overweight people. It may be found that being overweight is associated with lower odds of taking out VHI or more likely [24].
The Portuguese Health System, created in 1979, is defined as a National Health Service; it is mainly financed through taxes and is a universal coverage system. This means it covers all residents and most medical services.
In parallel with the NHS, there are occupation-based health insurance schemes. These include the public insurance schemes that cover civil servants (called ADSE), the armed forces (called ADM), and also private insurance that covers bank employees (called SAMS), among others. There are other, smaller, occupation-based health insurance plans. All the social contributions under these professional insurance policies are income based.
The Portuguese health system comprises conventional private health insurance and it is non-compulsory. Voluntary health insurance (VHI) provides faster access to appointments and treatments, which are also provided by the NHS, or provides access to services not covered by the NHS, such as dental care.
According to NHS rules, people should be registered with an NHS general practitioner, for primary care, and access to specialists in the NHS is controlled by general practitioner gatekeeping. However, people covered by insurance have direct access to specialists (provided by the private sector) according to the rules of the insurance, and private physicians can refer patients to NHS hospitals. So, having an insurance policy on top of NHS coverage has some advantages when it comes to accessing health care services [3]. These reasons for health care access and quality might justify the demand for private VHI by older people in Portugal.
We use data collected by the National Health Survey, which are representative of the Portuguese Population [34]. It is harmonized and regulated at the European level (EU regulation no 141/2013). It includes 18,204 individuals and our sample considers those aged over 65, that is, 5,701 individuals.
The dependent variable is given by the question if the individual has voluntary health insurance. This is a binary variable that takes value 1 if the respondent has private health insurance and 0 otherwise.
Independent variables are grouped into five categories—demographic, socioeconomic, marital status, health status, related behavior, and insurance status. These variables are described in Table 1.
Group of variables | Independent variables | Description |
---|---|---|
Demographic | Male | Dummy variable. Takes value 1 is male, 0 otherwise |
Age | Ordinal variable. Age is grouped into 15 classes. The first class takes value 1 and comprises ages 15–19; the last class takes value 15 and includes people older than 85. The variable is taken as continuous. | |
Socio-economic | Education | Ordinal variable. Education is grouped into five levels of education. First level 0 is those without schooling; fifth and last level is 5 and includes people with a college education. The variable is taken as continuous. |
Income | Ordinal variable. Income is grouped into five classes that represent the quantile of net monthly income per equivalent adult. The first value of income corresponds to the first quantile of income. The variable is taken as continuous. | |
Urban | Dummy variable. Takes value 1 if the area is densely inhabited, 0 otherwise. | |
Rural | Dummy variable. Takes value 1 if the area is sparsely inhabited, 0 otherwise. | |
Moderate urban | Reference category. | |
Marital status | Single | Dummy variable. Takes value 1 if person is single; 0 otherwise. |
Married | Dummy variable. Takes value 1 if person is married; 0 otherwise. | |
Divorced | Dummy variable. Takes value 1 if person is divorced; 0 otherwise. | |
Widow | Reference category. | |
Health status and related behavior | SAH | Ordinal variable. Measures self-assessed health and ranges 1–5, where 1 means “very bad” and 5 “very good” health. The variable is taken as continuous. |
Chronic diseases | Dummy variable. Takes value 1 if person suffers from at least one chronic disease; 0 otherwise. | |
Smoking | Dummy variable. Takes value 1 if person smokes; 0 otherwise. | |
BMI | Body Mass Index. | |
Insurance status | ADSE | Dummy variable. Takes value 1 if person is covered through ADSE insurance; 0 otherwise. |
SAMS | Dummy variable. Takes value 1 if person is covered through SAMS insurance; 0 otherwise. | |
Other insurance | Dummy variable. Takes value 1 if person has another occupational-based health insurance on top of NHS; 0 otherwise. | |
NHS | Reference category. This is the case where respondents do not hold any occupational-based health insurance. |
Description of independent variables.
The model to be estimated in this analysis is written as follows:
where VHI* is the latent dependent variable, VHI is the observable dependent variable, βi’s are the coefficients to be estimated, Xi’s are the independent variables, and εi is the residual.
The dependent variable expresses whether the respondent has voluntary health insurance. The binary nature of this variable implies that the econometric method of estimation is a probit. The estimated coefficients provide the direction of the relation between independent and dependent variables. The computation of the marginal effects allows the comparison of the intensity of the estimated coefficients. The marginal effects provide information on how the probability of having VHI changes when there is a unit change in the independent variable.
The results are obtained using Stata 15 econometric software.
The sample comprises 5,701 respondents older than 65, of whom 85.4% are retired. Only 332 respondents say that they have private voluntary health insurance, the large majority (about 94%) do not. Most of them are not entitled to any other insurance coverage apart from the NHS, and only about 10% are covered by ADSE, the occupation-based insurance plan for public workers (Table 2).
Group of variables | Independent variables | Descriptive statistics | |
---|---|---|---|
Number | % | ||
Demographic | Male | ||
Male | 2,215 | 38.85 | |
Female | 3,486 | 61.15 | |
Age | |||
65–69 | 1,533 | 26.89 | |
70–74 | 1,319 | 23.14 | |
75–79 | 1,259 | 22.08 | |
80–84 | 979 | 17.17 | |
+85 | 611 | 10.72 | |
Socio-economic status | Education (years) | ||
0 | 1,942 | 34.06 | |
6 | 2,938 | 51.53 | |
9 | 353 | 6.19 | |
12 | 189 | 3.32 | |
15 | 14 | 0.25 | |
17 | 265 | 4.65 | |
Income (quantile) | |||
Q1 | 1,368 | 24.00 | |
Q2 | 1.534 | 26.91 | |
Q3 | 1.174 | 20.59 | |
Q4 | 867 | 15.21 | |
Q5 | 758 | 13.30 | |
Level of urbanization | |||
Urban | 1,563 | 27.42 | |
Median | 1,689 | 29.63 | |
Rural | 2,449 | 42.96 | |
Retired | |||
Yes | 4,869 | 85.4 | |
Other status | 832 | 14.6 | |
Marital status | Marital status | ||
Single | 363 | 6.37 | |
Married | 2,913 | 51.10 | |
Widow(er) | 2,132 | 37.40 | |
Divorce | 293 | 5.14 | |
Health status and related behavior | SAH | ||
1. Very bad | 542 | 9.51 | |
2. Bad | 1,443 | 25.33 | |
3. Fair | 2,817 | 49.45 | |
4. Good | 787 | 13.81 | |
5. Very good | 108 | 1.90 | |
Chronic diseases | |||
None | 778 | 13.65 | |
At least one | 4,992 | 86.35 | |
Smoker | |||
Yes | 266 | 4.7 | |
No | 5,433 | 95.3 | |
BMI | |||
Average | 27.0 | ||
Insurance status | Insurance | ||
None (only NHS) | 4,836 | 84.83 | |
ADSE | 566 | 9.93 | |
SAMS | 83 | 1.46 | |
Other insurance | 216 | 3.78 |
Descriptive statistics.
The remaining descriptive statistics for the independent variables are also shown in Table 2. The majority of the people in the sample are women (
Finally, regarding their health status, the majority of older Portuguese assess their health status below the median level and about 86% of them report suffering from at least one chronic disease.
Other descriptive statistics regarding the distribution of respondents with private health insurance across income, education, and self-assessed health are shown in Table 3. Considering those individuals who said they had private health insurance (332 people), their distribution across income shows that a larger share of respondents has a high-income level. The distribution of people with health insurance across levels of education has two peaks, one at 6 years of schooling and the other at 17 years of schooling. The distribution of the health status of people having an insurance policy shows that most people with health insurance report a health status better than fair.
Income | ||||||
Quantile | Q1 | Q2 | Q3 | Q4 | Q5 | |
number | 21 | 31 | 50 | 66 | 164 | |
% | 6.3 | 9.3 | 15.1 | 19.9 | 49.4 | |
Education | ||||||
years | 0 | 6 | 9 | 12 | 15 | 17 |
number | 30 | 120 | 63 | 42 | 3 | 74 |
% | 9.1 | 36.1 | 19.0 | 12.7 | 0.0 | 22.3 |
SAH | ||||||
levels | 1 | 2 | 3 | 4 | 5 | |
number | 10 | 43 | 172 | 90 | 17 | |
% | 3.0 | 13.0 | 51.8 | 27.1 | 5.1 |
Distribution of respondents with voluntary health insurance.
To finish the description of the variables, we now report the correlation between health risk indicators. The pairwise correlation between SAH and suffering from chronic diseases is equal to −0.364 and between SAH and smoking it is equal to 0.107, both for a statistical significance of less than 0.001. The tetrachoric correlation between smoking and suffering from a chronic disease is equal to −0.257 for an identical statistically significant level. So, there is no strong correlation that could prevent the joint utilization of these variables in a regression analysis.
The results obtained with the estimation of the probit for having voluntary health insurance are presented in Table 4. The statistically significant coefficients at 5% are marked with *.
Coef. | Std. Err. | P > z | ||
---|---|---|---|---|
Demographic | Male | 0,061 | 0,068 | 0,370 |
Age group | ||||
70–74 | −0.132 | 0.077 | 0.085 | |
75–79 | −0.226* | 0.089 | 0.011 | |
80–84 | −0.497* | 0.120 | 0.000 | |
+85 | −0.469* | 0.148 | 0.002 | |
Socio-Economic | Education | 0.073* | 0.009 | 0.000 |
Income | ||||
Q2 | 0.051 | 0.121 | 0.672 | |
Q3 | 0.353* | 0.116 | 0.002 | |
Q4 | 0.542* | 0.117 | 0.000 | |
Q5 | 0.988* | 0.122 | 0.000 | |
Urban | 0.112 | 0.077 | 0.146 | |
Rural | 0.042 | 0.077 | 0.588 | |
Retired | −0.073 | 0.087 | 0.399 | |
Marital status | Single | −0.367* | 0.181 | 0.043 |
Married | −0.039 | 0.118 | 0.738 | |
Widow(er) | −0.193 | 0.131 | 0.141 | |
Insurance | ADSE | −0.647* | 0.108 | 0.000 |
SAMS | −0.200 | 0.179 | 0.265 | |
Other insurance | −0.410* | 0.149 | 0.006 | |
Health status and health behavior | SAH | |||
2 | 0.128 | 0.160 | 0.424 | |
3 | 0.212 | 0.150 | 0.159 | |
4 | 0.330* | 0.164 | 0.044 | |
5 | 0.392 | 0.226 | 0.083 | |
Chronic diseases | 0.180* | 0.091 | 0.047 | |
BMI | −0.006 | 0.008 | 0.405 | |
Smoking | −0.277* | 0.135 | 0.041 | |
_cons | −2.285 | 0.318 | 0.000 | |
Number of obs5,509 | ||||
LR chi2(26)518.92 | ||||
Prob > chi20.000 | ||||
Pseudo R20.207 | ||||
Log likelihood−994.916 |
Probit results.
Note: * Significant at less than 5%.
The estimated coefficients show that as someone gets old or is single, the probability of having private health insurance decreases, while for higher income or education levels that probability increases.
Regarding the insurance status of people, being a beneficiary of ADSE or another occupation-based insurance decreases the odds of having private VHI. Lastly, the results for health status and health-related behavior are mixed. On the one hand, higher levels of SAH may be related to having VHI, but on the other hand, suffering from a chronic disease is also positively related to having VHI; additionally, the observable behavior of smoking results in a lower likelihood of benefiting from VHI coverage.
The marginal effects associated with the most important and statistically significant coefficients are presented in Table 5.
dy/dx | Std.Err. | P > z | |
---|---|---|---|
Age group | |||
70–74 | −0.015 | 0.008 | 0.083 |
75–79 | −0.024 | 0.009 | 0.009 |
80–84 | −0.044 | 0.009 | 0.000 |
+85 | −0.042 | 0.011 | 0.000 |
Income | |||
Q2 | 0.003 | 0.006 | 0.670 |
Q3 | 0.025 | 0.008 | 0.002 |
Q4 | 0.045 | 0.010 | 0.000 |
Q5 | 0.117 | 0.016 | 0.000 |
Education | 0.007 | 0.001 | 0.000 |
ADSE | −0.063 | 0.011 | 0.000 |
SAMS | −0.019 | 0.017 | 0.265 |
SAH | |||
2 | 0.010 | 0.012 | 0.402 |
3 | 0.018 | 0.011 | 0.112 |
4 | 0.030 | 0.014 | 0.026 |
5 | 0.038 | 0.024 | 0.109 |
Chronic diseases | 0.017 | 0.009 | 0.047 |
Smoking | −0.027 | 0.013 | 0.041 |
Marginal effects.
These effects represent the change in the probability of having a VHI policy after the discrete change from the base level of the independent variable. In this way, the change to the oldest age groups implies a decrease of about 4% in the probability of having VHI, while the change from the lowest income quintile to the highest expresses an increase of 11% in the probability of being covered by VHI. Being a member of ADSE results in a 6% less chance of having VHI, and finally, the change from poor health status to a better one increases the likelihood of benefiting from a VHI; for instance, it increases almost 4% for people reporting very good health.
In Europe, health systems tend to be mandatory and offer universal coverage. Despite this major trend, there is a market for voluntary private health insurance. Portugal is characterized by having a National Health Service of universal coverage with distinctive features of mandatory occupation-based insurance. Because the health insurance market suffers from asymmetric information, insurance companies adopt cream-skimming strategies to minimize adverse selection and moral hazards. One such strategy is to set the eligibility requirement for buying an insurance health policy is having to be under 65. In this way, most older people are unable to buy a health insurance policy. However, there is a small market and about 5% of Portuguese older people report having voluntary private health insurance of some kind.
Our aim in this work was to find the main determinants of the demand for private health insurance by older people in Portugal and contribute to the literature on voluntary health insurance schemes in different European countries, as there is no study for Portugal. We used data collected by the 2014 National Health Survey and estimated a probit for people over 65 having private health insurance.
The main results are aligned with previous studies concerning the importance of income and education [11, 16, 17, 18, 19]. The higher the income and the better educated the individuals, the greater the probability of having private health insurance.
Concerning age and health insurance, we found that as they get older, they are less likely to have private voluntary health insurance [23, 35, 36]. The results show that only a minority of individuals, about 332 people, have a voluntary private health insurance policy. These people tend to have a high income and a high level of education, which is uncommon among people older than 65. Most older people in Portugal receive small pensions and have a low level of formal education, which deters them from taking out health insurance. The lack of schooling is the origin of illiteracy, both financial and health-related, which precludes people from making wiser choices on how to make better use of their savings and reduce future out-of-pocket expenditures. One major concern relates to dental care and the (high) associated cost. This aspect of health care is usually neglected by older people because it is not covered by the NHS and because they do not have a complementary private health insurance policy to cover it [37, 38].
Regarding the role of health status and behavior in explaining the demand for private health insurance, our results are mixed. On the one hand, there is some evidence of advantageous selection because better health status and no smoking are associated with taking out health insurance. On the other, reported suffering from chronic diseases is also associated with health insurance, this time reflecting adverse selection.
It could be that insurance companies are discriminating based on observable traits, such as smoking. Or, related to high health risks, such as suffering from a chronic disease, it may be the case that people fail to report them. Perhaps insurance companies do not “cream skim” based on these conditions, either because they lack sufficient reliable information, or because they may calculate the probability that a person suffers from a certain disease at a certain age, or even because the insurance company can control claims associated with those health conditions by cost-sharing.
Another explanation of the mixed results found when relating health risk to health insurance is based on the demand side of the market. Maybe there is heterogeneity in the risk preferences of older people. In some countries, healthier individuals might be more risk-averse [14, 16] and so they are more prone to take out voluntary health insurance. Maybe this is the case with Portugal as it was with the UK [39]. On the other hand, people suffering from chronic diseases have a default health status that they consider to be a reference status in the sense proposed by the prospect theory [40]. These people may thus tend to be risk-averse with reference to their health status, and consequently, they are also more prone to have a private health insurance policy.
Finally, regarding the existence of parallel occupation-based insurance plans, our results indicate that people benefiting from ADSE, the largest occupation-based insurance for public servants, or from any other form of private or public health insurance (public health insurance is for the armed forces; private insurance includes bank workers, Portugal – Telecom workers, and postal CTT workers) are less likely to have VHI. This is expected to happen because occupation-based insurances provide a second layer of health coverage on top of the universal provided by the NHS. People benefiting from occupation-based insurance policies pay taxes to finance the NHS and pay a percentage of their income to finance occupation-based insurance. Therefore, this double financing by people deters them from looking for additional private health insurance coverage. In fact, these people do not need private health insurance because their health care needs are covered either by the NHS or by their occupation-based insurance.
The organization of the Portuguese health system creates inequity in access to health care. In the first place, people with double coverage have easier access to health care, and then people with high incomes can afford to buy private health insurance coverage. On top of this, inequality is aggravated by a tax system that gives some benefits to wealthier people for buying private health insurance or for spending on private health care [1]. The findings reported in this work confirm the existence of this sort of inequality, especially among older people.
One limitation of this work is that it is not possible to analyze the type of coverage provided to older people by voluntary private health insurance. This sort of information would show us what health care services older people want, and what could be lacking in the supply of NHS.
The results found in our analysis provide some insights into what makes older people decide to take out voluntary private health insurance. We have concluded that income is a determinant factor for taking out private health insurance, but it is also a factor for generating inequality in health care access. Older people can find it hard to access dental care or simple eye care because it is not covered by the NHS, or because the NHS waiting lists are too long. But the difficulty of complementing NHS coverage with private health insurance increases health care access inequity. Health and social policies may aim to narrow the gap either by providing health care in the NHS or by subsidizing the purchase of private health insurance for low-income older people. The first approach to this has already been put into place. The instrument called “dentist-check” for older people, created by the Ministry of Health attempts to mitigate the inequality in access to dental care, but it needs to be assessed.
small share of older people buy voluntary private health insurance
higher income and higher education increase the likelihood of holding voluntary private health insurance
benefiting from occupation-based insurance schemes reduce that likelihood
voluntary private health insurance reflects inequity in healthcare access
The author declares no conflict of interest.
The author received no financial support for the research, authorship, and/or publication of this article.
The author declares this work does not require any human/animal subjects to acquire ethical approval.
I13; D81; C3
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Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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It is also the time that lasts the development of the follicle in the ovary, until rupture occurs and ovulation takes place, which coincides with the appearance of estrus. This chapter will describe the physiological and endocrinological bases of estrus in the goat. Likewise, factors affecting the presence of estrus and ovulation will be described. At another point, synchronization of estrus and ovulation, factors affecting the presence of estrus and external symptoms of estrus, will be described. To achieve synchronization of estrus or induction of ovulation within or outside the breeding season, it may be necessary to manage light hours, male effect, and/or use of hormones. The importance of artificial insemination is described, as well as the current situation of this technique worldwide. Currently, the techniques of artificial insemination in goats have been limited worldwide, due to the lack of resources of producers and trained technicians. The techniques of artificial insemination with estrous synchronization programs and ovulation with current research results will be described.",book:{id:"5987",slug:"goat-science",title:"Goat Science",fullTitle:"Goat Science"},signatures:"Fernando Sánchez Dávila, Alejandro Sergio del Bosque González\nand Hugo Bernal Barragán",authors:[{id:"201830",title:"Dr.",name:"Fernando",middleName:"Sanchez",surname:"Davila",slug:"fernando-davila",fullName:"Fernando Davila"},{id:"206127",title:"Dr.",name:"Alejandro Sergio",middleName:null,surname:"Del Bosque-Gonzalez",slug:"alejandro-sergio-del-bosque-gonzalez",fullName:"Alejandro Sergio Del Bosque-Gonzalez"},{id:"206128",title:"Dr.",name:"Hugo",middleName:null,surname:"Bernal-Barragán",slug:"hugo-bernal-barragan",fullName:"Hugo Bernal-Barragán"}]},{id:"58095",title:"The Innovative Techniques in Animal Husbandry",slug:"the-innovative-techniques-in-animal-husbandry",totalDownloads:3766,totalCrossrefCites:4,totalDimensionsCites:8,abstract:"Technology is developing rapidly. In this development, the transfer of computer systems and software to the application has made an important contribution. Technologic instruments made farmers can work more comfortable and increased animal production efficiency and profitability. Therefore, technologic developments are the main research area for animal productivity and sustainability. Many technologic equipment and tools made animal husbandry easier and comfortable. Especially management decisions and applications are effected highly ratio with this rapid development. In animal husbandry management decisions that need to be done daily are configured according to the correctness of the decisions to be made. At this point, smart systems give many opportunities to farmers. Milking, feeding, environmental control, reproductive performance constitute everyday jobs most affected by correct management decisions. Human errors in this works and decisions made big effect on last product quality and profitability are not able to be risked. This chapter deal with valuable information on the latest challenges and key innovations affecting the animal husbandry. Also, innovative approaches and applications for animal husbandry are tried to be summarized with detail latest research results.",book:{id:"6384",slug:"animal-husbandry-and-nutrition",title:"Animal Husbandry and Nutrition",fullTitle:"Animal Husbandry and Nutrition"},signatures:"Serap Göncü and Cahit Güngör",authors:[{id:"215579",title:"Prof.",name:"Serap",middleName:null,surname:"Goncu",slug:"serap-goncu",fullName:"Serap Goncu"},{id:"218971",title:"Dr.",name:"Cahit",middleName:null,surname:"Güngör",slug:"cahit-gungor",fullName:"Cahit Güngör"}]},{id:"58486",title:"Quality of Chicken Meat",slug:"quality-of-chicken-meat",totalDownloads:3290,totalCrossrefCites:18,totalDimensionsCites:26,abstract:"Chicken meat is considered as an easily available source of high-quality protein and other nutrients that are necessary for proper body functioning. In order to meet the consumers’ growing demands for high-quality protein, the poultry industry focused on selection of fast-growing broilers, which reach a body mass of about 2.5 kg within 6-week-intensive fattening. Relatively low sales prices of chicken meat, in comparison to other types of meat, speak in favor of the increased chicken meat consumption. In addition, chicken meat is known by its nutritional quality, as it contains significant amount of high-quality and easily digestible protein and a low portion of saturated fat. Therefore, chicken meat is recommended for consumption by all age groups. The technological parameters of chicken meat quality are related to various factors (keeping conditions, feeding treatment, feed composition, transport, stress before slaughter, etc.). Composition of chicken meat can be influenced through modification of chicken feed composition (addition of different types of oils, vitamins, microelements and amino acids), to produce meat enriched with functional ingredients (n-3 PUFA, carnosine, selenium and vitamin E). By this way, chicken meat becomes a foodstuff with added value, which, in addition to high-quality nutritional composition, also contains ingredients that are beneficial to human health.",book:{id:"6384",slug:"animal-husbandry-and-nutrition",title:"Animal Husbandry and Nutrition",fullTitle:"Animal Husbandry and Nutrition"},signatures:"Gordana Kralik, Zlata Kralik, Manuela Grčević and Danica Hanžek",authors:[{id:"207236",title:"Dr.",name:"Gordana",middleName:null,surname:"Kralik",slug:"gordana-kralik",fullName:"Gordana Kralik"},{id:"227281",title:"Prof.",name:"Zlata",middleName:null,surname:"Kralik",slug:"zlata-kralik",fullName:"Zlata Kralik"},{id:"227283",title:"Dr.",name:"Manuela",middleName:null,surname:"Grčević",slug:"manuela-grcevic",fullName:"Manuela Grčević"},{id:"227284",title:"BSc.",name:"Danica",middleName:null,surname:"Hanžek",slug:"danica-hanzek",fullName:"Danica Hanžek"}]},{id:"56453",title:"Goat System Productions: Advantages and Disadvantages to the Animal, Environment and Farmer",slug:"goat-system-productions-advantages-and-disadvantages-to-the-animal-environment-and-farmer",totalDownloads:4328,totalCrossrefCites:5,totalDimensionsCites:21,abstract:"Goats have always been considered very useful animals. Goats success is related to its excellent adaptability to the difficult mountain conditions, extreme weather and low value feed acceptance, versatile habits and high production considering their size. These are some reasons because goats are among the first animals to be domesticated. In terms of evolution, goats could be separated by their dispersion area in three large groups: the European, the Asian, and the African. Global goat populations, mainly in Africa and in Asia, have increased for centuries but very strongly in the past decades, well above the world population growth. They are also used for forest grazing, an integrated and alternative production system, very useful to control weed growth reducing fire risk. Despite some exceptions, no large‐scale effort to professionalize this industry has been made so far. There are consumers for goat dairy products and there is enough global production, but misses a professional network between both. Regarding goat meat, the world leadership also stays in Africa and Asia, namely in China, and there is a new phenomenon, the spreading of goat meat tradition through Europe due to migrants from Africa and other places with strong goat meat consumption.",book:{id:"5987",slug:"goat-science",title:"Goat Science",fullTitle:"Goat Science"},signatures:"António Monteiro, José Manuel Costa and Maria João Lima",authors:[{id:"190314",title:"Prof.",name:"António",middleName:"Cardoso",surname:"Monteiro",slug:"antonio-monteiro",fullName:"António Monteiro"},{id:"203680",title:"Prof.",name:"Maria João",middleName:null,surname:"Lima",slug:"maria-joao-lima",fullName:"Maria João Lima"},{id:"203683",title:"MSc.",name:"José Manuel",middleName:null,surname:"Costa",slug:"jose-manuel-costa",fullName:"José Manuel Costa"}]},{id:"70760",title:"Induction and Synchronization of Estrus",slug:"induction-and-synchronization-of-estrus",totalDownloads:1716,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"Estrus cycle is a rhythmic change that occur in the reproductive system of females starting from one estrus phase to another. The normal duration of estrus cycle is 21 days in cow, sow, and mare, 17 days in ewe, and 20 days in doe. The species which exhibit a single estrus cycle are known as monstrous and species which come into estrus twice or more are termed polyestrous animals. Among them some species have estrus cycles in a particular season and defined as seasonal polyestrous. It includes goats, sheep, and horses. On the other hand, cattle undergo estrus throughout the year. The estrus inducers can grossly be divided into two parts, that is, non-hormonal and hormonal. Non-hormonal treatments include plant-derived heat inducers, mineral supplementation, uterine and ovarian massage, and use of Lugol’s iodine. The hormones that are used in estrus induction are estrogen, progesterone, GnRH, prostaglandin, insulin, and anti-prolactin-based treatment. Synchronization can shorten the breeding period to less than 5 days, instead of females being bred over a 21-day period, depending on the treatment regimen. The combination of GnRH with the prostaglandin F2α (PGF2α)- and progesterone-based synchronization program has shown a novel direction in the estrus synchronization of cattle with the follicular development manipulation.",book:{id:"8545",slug:"animal-reproduction-in-veterinary-medicine",title:"Animal Reproduction in Veterinary Medicine",fullTitle:"Animal Reproduction in Veterinary Medicine"},signatures:"Prasanna Pal and Mohammad Rayees Dar",authors:[{id:"299126",title:"Dr.",name:"Mohammad Rayees",middleName:null,surname:"Dar",slug:"mohammad-rayees-dar",fullName:"Mohammad Rayees Dar"},{id:"311663",title:"Dr.",name:"Prasanna",middleName:null,surname:"Pal",slug:"prasanna-pal",fullName:"Prasanna Pal"}]}],onlineFirstChaptersFilter:{topicId:"25",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82457",title:"Canine Hearing Management",slug:"canine-hearing-management",totalDownloads:6,totalDimensionsCites:0,doi:"10.5772/intechopen.105515",abstract:"The United States military employs multipurpose canines as force multipliers. A newly developed baseline audiology program applicable to noise effects on the hearing threshold for these dogs has just been developed by the University of Cincinnati FETCHLAB using brainstem auditory evoked potentials to detect estimated threshold shifts in this population. Dogs that are routinely deployed are subject to consistent exposure to noise in the field. Few investigations have focused on the effects of transport noise on the auditory system in multipurpose dogs. The consequence of these dogs having a significant hearing threshold shift is a failure of the dog to properly respond to voice commands and to miss critical acoustic cues while on target. This chapter specifically discusses the baseline protocol for audiological testing of special operations’ multipurpose canines related to helicopter transport.",book:{id:"11580",title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg"},signatures:"Peter M. Skip Scheifele, Devan Marshall, Stephen Lee, Paul Reid, Thomas McCreery and David Byrne"},{id:"82285",title:"Parvovirus Vectors: The Future of Gene Therapy",slug:"parvovirus-vectors-the-future-of-gene-therapy",totalDownloads:6,totalDimensionsCites:0,doi:"10.5772/intechopen.105085",abstract:"The unique diversity of parvoviral vectors with innate antioncogenic properties, autonomous replication, ease of recombinant vector production and stable transgene expression in target cells makes them an attractive choice as viral vectors for gene therapy protocols. Amongst various parvoviruses that have been identified so far, recombinant vectors originating from adeno-associated virus, minute virus of mice (MVM), LuIII and parvovirus H1 have shown promising results in many preclinical models of human diseases including cancer. The adeno-associated virus (AAV), a non-pathogenic human parvovirus, has gained attention as a potentially useful vector. The improved understanding of the metabolism of vector genomes and the mechanism of transduction by AAV vectors is leading to advancement in the development of more sophisticated AAV vectors. The in-depth studies of AAV vector biology is opening avenues for more robust design of AAV vectors that have potentially increased transduction efficiency, increased specificity in cellular targeting, and an increased payload capacity. This chapter gives an overview of the application of autonomous parvoviral vectors and AAV vectors, based on our current understanding of viral biology and the state of the platform.",book:{id:"11580",title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg"},signatures:"Megha Gupta"},{id:"82170",title:"Equine Stress: Neuroendocrine Physiology and Pathophysiology",slug:"equine-stress-neuroendocrine-physiology-and-pathophysiology",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.105045",abstract:"This review presents new aspects to understanding the neuroendocrine regulation of equine stress responses, and their influences on the physiological, pathophysiological, and behavioral processes. Horse management, in essence, is more frequently confirmed by external and internal stress factors, than in other domestic animals. Regardless of the nature of the stimulus, the equine stress response is an effective and highly conservative set of interconnected relationships designed to maintain physiological integrity even in the most challenging circumstances (e.g., orthopedic injuries, abdominal pain, transport, competitions, weaning, surgery, and inflammation). The equine stress response is commonly a complementary homeostatic mechanism that provides protection (not an adaptation) when the body is disturbed or threatened. It activates numerous neural and hormonal networks to optimize metabolic, cardiovascular, musculoskeletal, and immunological functions. This review looks into the various mechanisms involved in stress responses, stress-related diseases, and assessment, prevention or control, and management of these diseases and stress. Stress-related diseases can not only be identified and assessed better, given the latest research and techniques but also prevented or controlled.",book:{id:"10665",title:"Updates on Veterinary Anatomy and Physiology",coverURL:"https://cdn.intechopen.com/books/images_new/10665.jpg"},signatures:"Milomir Kovac, Tatiana Vladimirovna Ippolitova, Sergey Pozyabin, Ruslan Aliev, Viktoria Lobanova, Nevena Drakul and Catrin S. Rutland"},{id:"81793",title:"Canine parvovirus-2: An Emerging Threat to Young Pets",slug:"canine-parvovirus-2-an-emerging-threat-to-young-pets",totalDownloads:19,totalDimensionsCites:0,doi:"10.5772/intechopen.104846",abstract:"Canine parvovirus-2 (CPV-2) is a highly contagious and key enteropathogen affecting the canine population around the globe by causing canine parvoviral enteritis (CPVE) and vomition. CPVE is one of the the leading causes of morbidity and mortality in puppies and young dogs. Over the years, five distinct antigenic variants of CPV-2, namely CPV-2a, CPV-2b, new CPV-2a, new CPV-2b, and CPV-2c, have emerged throughout the world. CPV-2 infects a diverse range of wild animals, and the newer variants of CPV-2 have expanded their host range to include felines. Despite the availability of highly specific diagnostics and efficacious vaccines, CPV-2 outbreaks have been reported globally due to the emergence of newer antigenic variants, expansion of the viral host range, and vaccination failures. The present chapter describes the latest information pertaining to virus properties and replication, disease manifestations in animals, and an additional recent updates on diagnostic, prevention and control strategies of CPV-2.",book:{id:"11580",title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg"},signatures:"Mithilesh Singh, Rajendran Manikandan, Ujjwal Kumar De, Vishal Chander, Babul Rudra Paul, Saravanan Ramakrishnan and Darshini Maramreddy"},{id:"81271",title:"The Diversity of Parvovirus Telomeres",slug:"the-diversity-of-parvovirus-telomeres",totalDownloads:38,totalDimensionsCites:0,doi:"10.5772/intechopen.102684",abstract:"Parvoviridae are small viruses composed of a 4–6 kb linear single-stranded DNA protected by an icosahedral capsid. The viral genes coding non-structural (NS), capsid, and accessory proteins are flanked by intriguing sequences, namely the telomeres. Telomeres are essential for parvovirus genome replication, encapsidation, and integration. Similar (homotelomeric) or different (heterotelomeric) at the two ends, they all contain imperfect palindromes that fold into hairpin structures. Up to 550 nucleotides in length, they harbor a wide variety of motifs and structures known to be recognized by host cell factors. Our study aims to comprehensively analyze parvovirus ends to better understand the role of these particular sequences in the virus life cycle. Forty Parvoviridae terminal repeats (TR) were publicly available in databases. The folding and specific DNA secondary structures, such as G4 and triplex, were systematically analyzed. A principal component analysis was carried out from the prediction data to determine variables signing parvovirus groups. A special focus will be put on adeno-associated virus (AAV) inverted terminal repeats (ITR), a member of the genus Dependoparvovirus used as vectors for gene therapy. This chapter highlights the diversity of the Parvoviridae telomeres regarding shape and secondary structures, providing information that could be relevant for virus-host interactions studies.",book:{id:"11580",title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg"},signatures:"Marianne Laugel, Emilie Lecomte, Eduard Ayuso, Oumeya Adjali, Mathieu Mével and Magalie Penaud-Budloo"},{id:"79209",title:"Virtual Physiology: A Tool for the 21st Century",slug:"virtual-physiology-a-tool-for-the-21st-century",totalDownloads:153,totalDimensionsCites:0,doi:"10.5772/intechopen.99671",abstract:"Veterinary physiology is a basic curricular unit for every course within the veterinary field. It is mandatory to understand how the animal body works, and what to expect of a healthy body, in order to recognize any misfunction, and to be able to treat it. Classic physiology teaching involves wet labs, much equipment, many reagents, some animals, and a lot of time. But times are changing. In the 21st century, it is expected that the teaching and learning process can be more active and attractive, motivating students to learn better. It is necessary to understand what students like, and to introduce novelties into the school routine. The use of a game-based learning, using “new” technologies, creating virtual experiences and labs, reducing the costs of reagents, equipment, and especially reducing the use of animals, will be the future for physiology teaching.",book:{id:"10665",title:"Updates on Veterinary Anatomy and Physiology",coverURL:"https://cdn.intechopen.com/books/images_new/10665.jpg"},signatures:"Carmen Nóbrega, Maria Aires Pereira, Catarina Coelho, Isabel Brás, Ana Cristina Mega, Carla Santos, Fernando Esteves, Rita Cruz, Ana I. Faustino-Rocha, Paula A. Oliveira, João Mesquita and Helena Vala"}],onlineFirstChaptersTotal:14},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:320,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:133,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:17,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"6",title:"Infectious Diseases",doi:"10.5772/intechopen.71852",issn:"2631-6188",scope:"This series will provide a comprehensive overview of recent research trends in various Infectious Diseases (as per the most recent Baltimore classification). Topics will include general overviews of infections, immunopathology, diagnosis, treatment, epidemiology, etiology, and current clinical recommendations for managing infectious diseases. Ongoing issues, recent advances, and future diagnostic approaches and therapeutic strategies will also be discussed. This book series will focus on various aspects and properties of infectious diseases whose deep understanding is essential for safeguarding the human race from losing resources and economies due to pathogens.",coverUrl:"https://cdn.intechopen.com/series/covers/6.jpg",latestPublicationDate:"June 25th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:13,editor:{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"3",title:"Bacterial Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/3.jpg",isOpenForSubmission:!1,editor:null,editorTwo:null,editorThree:null},{id:"4",title:"Fungal Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/4.jpg",isOpenForSubmission:!0,editor:{id:"174134",title:"Dr.",name:"Yuping",middleName:null,surname:"Ran",slug:"yuping-ran",fullName:"Yuping Ran",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9d6QAC/Profile_Picture_1630330675373",biography:"Dr. Yuping Ran, Professor, Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China. Completed the Course Medical Mycology, the Centraalbureau voor Schimmelcultures (CBS), Fungal Biodiversity Centre, Netherlands (2006). International Union of Microbiological Societies (IUMS) Fellow, and International Emerging Infectious Diseases (IEID) Fellow, Centers for Diseases Control and Prevention (CDC), Atlanta, USA. Diploma of Dermatological Scientist, Japanese Society for Investigative Dermatology. Ph.D. of Juntendo University, Japan. Bachelor’s and Master’s degree, Medicine, West China University of Medical Sciences. Chair of Sichuan Medical Association Dermatology Committee. General Secretary of The 19th Annual Meeting of Chinese Society of Dermatology and the Asia Pacific Society for Medical Mycology (2013). In charge of the Annual Medical Mycology Course over 20-years authorized by National Continue Medical Education Committee of China. Member of the board of directors of the Asia-Pacific Society for Medical Mycology (APSMM). Associate editor of Mycopathologia. 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