\r\n\tIt has been established that energy/nutrient depletion, calcium flux injury, or oxidative stress disrupt endoplasmic reticulum homeostasis and even induce accumulation of misfolded/unfolded proteins leading to endoplasmic reticulum stress. Under endoplasmic reticulum stress conditions, an adaptive mechanism of coordinated signaling pathways, defined unfolded protein response (UPR), is activated to return the endoplasmic reticulum to its healthy functioning state. The aging causes a decrease of the protective adaptive response of the UPR and an increase of the pro-apoptotic pathway together with endoplasmic reticulum ultrastructural injury. Controlling endoplasmic reticulum stress response, maintaining the appropriate endoplasmic reticulum ultrastructure and homeostasis, and retaining mitochondria interplay are crucial aspects for cellular health.
\r\n
\r\n\tThis book presents a comprehensive overview of endoplasmic reticulum, including, but not limited to, endoplasmic reticulum ultrastructural anatomy, MAMs, endoplasmic reticulum stress, and their implication in health and diseases. Additionally, identifying perturbations in the endoplasmic reticulum stress response could lead to early detection of age-related disease and may help develop therapeutic approaches.
",isbn:"978-1-80356-228-5",printIsbn:"978-1-80356-227-8",pdfIsbn:"978-1-80356-229-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"5d7d49bd80f53dad3761f78de4a862c6",bookSignature:"Dr. Gaia Favero",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11674.jpg",keywords:"Metabolism, Aging, Neurodegenerative Diseases, Endoplasmic Reticulum, Microscopy, Metabolic Stress, Ultrastructural Anatomy, Cellular Stress, Contactology, Mitochondria, Cellular Stress, Endoplasmic Reticulum Response",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 9th 2022",dateEndSecondStepPublish:"May 6th 2022",dateEndThirdStepPublish:"July 5th 2022",dateEndFourthStepPublish:"September 23rd 2022",dateEndFifthStepPublish:"November 22nd 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"19 days",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Human anatomy researcher involved in crucial topics on morphology, anatomy, and molecular medicine - working on innovative approaches to aging-related pathopsychological processes at the University of Brescia.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"238047",title:"Dr.",name:"Gaia",middleName:null,surname:"Favero",slug:"gaia-favero",fullName:"Gaia Favero",profilePictureURL:"https://mts.intechopen.com/storage/users/238047/images/system/238047.jpg",biography:'Dr. Gaia Favero is a prominent scientist in the field of life sciences. She is currently engaged as a researcher for the Scientific-Disciplinary Sector BIO/16 Human Anatomy at the Anatomy and Pathophysiology Division, Department of Clinical and Experimental Sciences, University of Brescia (Italy).\r\nDr. Favero focuses on aging-related morphological dysfunctions as the prelude to various pathophysiological processes in her research programs. The central hypothesis is that natural antioxidants and, in particular, melatonin may act as molecular "switches" that modulate cells and tissues by suppressing, at various levels, oxidative stress and inflammatory signalling cascades. These research approaches represent powerful tools for developing innovative preventive strategies and identifying novel prognostic biomarkers for several diseases. 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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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1. Introduction
The management of midfacial fractures includes the treatment of facial fractures, dentoalveolar trauma, and soft-tissue injuries, as well as associated injuries, mainly of the head and neck [1]. The management of fractures of the maxillofacial complex remains a challenge for the oral maxillofacial surgeon, demanding both skill and expertise [2]. The success of treatment and implementation of preventive measures are more specifically dependent on epidemiologic assessments [3].Midfacial fractures can occur in isolation or in combination with other serious injuries, including mandibular, ophthalmologic, cranial, spinal, thoracic, and abdominal trauma, as well as upper and lower orthopedic injuries [4].The epidemiology of facial fractures varies in type, severity, and cause depending on the population studied. Differences among populations in the causes of maxillofacial fractures may be the result of differences in risk and cultural factors among countries, but are more likely to be influenced by the severity of injury [1,5]. The causes of maxillofacial fractures have changed over the past three decades, and they continue to do so. The main causes worldwide are traffic accidents, assaults, falls, sport-related injuries, and warfare [6-8]. Many articles pertaining to the incidence and causes of maxillofacial injuries have been published [1,4,7-10]. In 2003, Motamedi [7] reported the distribution of facial fractures as 72.9% mandibular, 13.9% maxillary, 13.5% zygomatic, 24.0% zygomatico-orbital, 2.1% cranial, 2.1% nasal, and 1.6% frontal injuries [Figure 1].
Figure 1.
Fracture sites are shown for 237 maxillofacial trauma patients according to Motamedi
Causes of these maxillofacial injuries were automobile (30.8%) and motorcycle (23.2%) accidents, altercations (9.7%), sport (6.3%), and warfare (9.7%) [Figure 2].
Figure 2.
The causes of fracture for Motamedi’s assessment of maxillofacial trauma patients
The distribution of maxillary fractures was 54.6% Le Fort II, 24.2% Le Fort I, 12.1% Le Fort III, and 9.1% alveolar [7] [Figure 3].
Figure 3.
Distribution of maxillary fractures in Motamedi’s assessment of maxillofacial trauma patients
According to Cook and Rowe [4], midfacial injuries occur most frequently in individuals aged 21–30 years (43%). The 11–20-year and 31–40-year age groups each account for 20% of these fractures. Most (83.1%) midfacial fractures occur in males, with the remainder (16.9%) occurring in females [4] [Figure 4].
Figure 4.
Age distribution of midfacial fracture patients according to Cook and Rowe.
Thoren [9] noted that injuries are associated with 25.2% of midfacial fractures. These injuries most commonly affect a limb (13.5%), followed by the brain (11.0%), chest (5.5%), spine (2.7%), and abdomen (0.8%) [9].
2. Surgical anatomy
The anatomy of the head is complex; the physical properties of the skin, bone, and brain differ markedly and the facial skeletal components articulate and interdigitate in a complex fashion, with the consequence that a given facial bone is rarely fractured without disrupting its neighbor [10]. The severity and pattern of a fracture depend on the magnitude of the causative force, impact duration, the acceleration imparted by impact to the affected part of the body, and the rate of acceleration change. The surface area of the impact site is also relevant [11,12]. The middle third of the facial skeleton is defined as an area bounded superiorly by a line drawn across the skull from the zygomaticofrontal suture, across the frontonasal and frontomaxillary sutures, to the zygomaticofrontal suture on the opposite side; and inferiorly by the occlusal plane of the maxillary teeth, or, in an edentulous patient, by the maxillary alveolar ridge. It extends posteriorly to the frontal bone in the superior region and the body of the sphenoid in the inferior region, and the pterygoid plates of the sphenoid are usually involved in any severe fracture [13].
The middle third of the facial skeleton comprises the following bones [14] [Figure 5]:
Two maxillae
Two zygomatic bones
Two zygomatic processes of the temporal bones
Two palatine bones
Two nasal bones
Two lacrimal bones
The vomer
The ethmoid and attached conchae
Two inferior conchae
The pterygoid plates of the sphenoid
Figure 5.
Bones of the middle third of the facial skeleton
The frontal bone and the sphenoid body and greater and lesser wings are not usually fractured. In fact, they are protected to a considerable extent by the cushioning effect achieved as the fracturing force crushes the comparatively weak bones comprising the middle third of the facial skeleton [13].
3. Initial management of the midfacial trauma patient
The initial assessment and management of a patient’s injuries must be completed in an accurate and systematic manner to quickly establish the extent of any damage to vital life-support systems. Patients are assessed and treatment priorities are established based on patients’ injuries and the stability of their vital signs. Injuries can be divided into three general categories: severe, urgent, and non-urgent. Severe injuries are immediately life threatening and interfere with vital physiologic functions; examples are compromised airway, inadequate breathing, hemorrhage, and circulatory system damage or shock. These injuries constitute approximately 5% of patient injuries but represent more than 50% of injuries associated with all trauma deaths. Urgent injuries make up approximately 10–15% of all injuries and present no immediate threat to life. Patients with this type of injury may present with damage to the abdomen, orofacial structures, chest, or extremities that requires surgical intervention or repair, but their vital signs are stable. Non-urgent injuries account for approximately 80% of all injuries and are not immediately life threatening. Patients with this type of trauma eventually require surgical or medical management, although the exact nature of the injury may not become apparent until significant evaluation and observation are performed. The goal of initial emergency care is to provide life-saving and support measures until definitive care can be initiated. Any trauma victim with altered consciousness must be considered to have a brain injury. The level of consciousness is assessed by serial Glasgow Coma Scale evaluations [15] [Table 1].
\n\n
\n\n
\n\n
\n\n
\n\n Action\n\n
\n\n
\n\n Score\n\n
\n\n
\n\n
\n\n
Eye Opening Spontaneous To speech To pain None Motor Response Obeys Localises pain Withdraws from pain Flexion to pain Extension to pain None Verbal Response Oriented Confused Inappropriate Incomprehensible None
Adapted from Teasdale and Jennett [15]. A patient’s score determines the category of neurologic impairment: 15 = normal, 13 or 14 = mild injury, 9–12 = moderate injury, and 3–8 = severe injury.
Other signs of brain damage include restlessness, convulsions, and cranial nerve dysfunction (e.g. a nonreactive pupil). The classic Cushing triad (hypertension, bradycardia, and respiratory disturbances) is a late and unreliable sign that usually closely precedes brain herniation. Hypotension is rarely due to head injury alone. Patients suspected of sustaining head trauma should not receive any premedication that will alter their mental status (e.g. sedatives or analgesics) or neurologic examination (e.g. anticholinergic-induced pupillary dilation).
3.1. Primary Survey: ABCs
During the primary survey, life-threatening conditions are identified and reversed quickly. This period calls for quick and efficient evaluation of the patient’s injuries and almost simultaneous life-saving intervention. The primary survey progresses in a logical manner based on the ABC pneumonic: airway maintenance with cervical spine control, breathing and adequate ventilation, and circulation with control of hemorrhage. The letters D and E have also been added: a brief neurologic examination to establish the degree of consciousness, and exposure of the patient via complete undressing to avoid overlooking injuries camouflaged by clothing. Maxillofacial injuries may result in airway compromise caused by any of several factors: blood and secretions, a mandibular fracture that allows the tongue to fall against the posterior wall of the pharynx, a midfacial injury that causes the maxilla to fall posteroinferiorly into the nasopharynx, and foreign debris such as avulsed teeth or dentures. A large tonsillar suction tip should be used to clear the oral cavity and pharynx. The establishment of an oral airway assists with tongue position; however, care must always be taken to avoid manipulation of the neck and to provide access to the oral cavity and dentition for the reduction and fixation of any fractures requiring a period of intermaxillary fixation. Neither midfacial fractures nor cerebrospinal rhinorrhea are contraindications to nasal intubation. Care should be taken to pass the tube along the nasal floor into the pharynx, and the tube should be visualised before tracheal intubation. Hypertension or tachycardia during intubation can be attenuated with the intravenous administration of lidocaine or fentanyl. Intubation while the patient is awake causes a precipitous rise in intracranial pressure. Nasal passage of an endotracheal or nasogastric tube in a patient with a basal skull fracture risks cribriform plate perforation and cerebrospinal fluid infection. Slight elevation of the head will improve venous drainage and decrease intracranial pressure.
3.2. Physical examination
The physical examination should begin with an evaluation of soft-tissue injuries. Lacerations should be debrided and examined for disruption of vital structures, such as the facial nerve or parotid duct. The eyelids should be elevated to allow evaluation of the eyes for neurologic and ocular damage. The face should be symmetric, without discolouration or swelling suggestive of bony or soft-tissue injury. The bony landmarks should be palpated, beginning with the supraorbital and lateral orbital rims and followed by the infraorbital rims, malar eminences, zygomatic arches, and nasal bones. Any steps or irregularities along the bony margin are suggestive of a fracture. Numbness over the area of distribution of the trigeminal nerve is usually noted with fractures of the facial skeleton. The oral cavity should be inspected and evaluated for lost teeth, lacerations, and occlusal alterations. Any tooth lost at the time of injury must be accounted for because it may have been aspirated or swallowed. The neck should also be examined for injury. Subcutaneous air may be visualised if massive injury is present; if subtle, it may be detected only by palpation. The presence of air in the soft tissue may be the result of tracheal damage. Any externally expanding edema or hematoma of the neck must be observed closely for continued expansion and airway compromise. Carotid pulses should be assessed. Palpation should be performed to detect abnormalities in the contour of the thyroid cartilage and to confirm the midline position of the trachea in the suprasternal notch.
3.3. Preoperative considerations
Patients with midfacial trauma often pose the greatest airway challenges to the anaesthesiologist. Preoperative airway evaluation must be detailed and thorough. Particular attention should be focused on jaw opening, mask fit, neck mobility, maxillary protrusion, macroglossia, dental pathology, nasal patency, and the existence of any intraoral lesion or debris. If any forewarning sign of problems with mask ventilation or endotracheal intubation is observed, the airway should be secured prior to anaesthesia induction. This process may involve fibre-optic nasal or oral intubation or tracheostomy. Nasal intubation with a preformed or straight tube with a flexible angle connector is usually preferred in dental or oral surgery. The endotracheal tube can then be directed cephalically and connected to breathing tubes passing over the patient’s head.
3.4. Intraoperative management
Reconstructive surgery can be associated with substantial blood loss. Strategies to minimise bleeding include a slight head-up position, controlled hypotension, and local infiltration with epinephrine solutions. Because the patient’s arms are typically tucked along the sides of the body, at least two intravenous lines should be established prior to surgery. This step is especially important if one line is used for the delivery of an anaesthetic or hypotensive agent. An arterial line can be helpful in cases of marked blood loss, as a surgeon leaning against the patient’s arm may interfere with non-invasive blood pressure cuff readings. An oropharyngeal pack is often placed to minimize the amount of blood and other debris reaching the larynx and trachea. Due to the proximity of the airway to the surgical field, the anaesthesiologist’s location is more remote than usual. This situation increases the likelihood of serious intraoperative airway problems, such as endotracheal tube kinking, disconnection, or perforation by a surgical instrument. Airway monitoring of end-tidal CO2, peak inspiratory pressures, and esophageal stethoscope breath sounds assumes increased importance in such cases. At the end of the surgery, the oropharyngeal pack must be removed and the pharynx suctioned. Although the presence of some bloody debris during initial suctioning is not unusual, repeated efforts should be less productive. If there is a chance of postoperative edema involving structures that could potentially obstruct the airway (e.g. the tongue), the patient should be left intubated. Otherwise, extubation can be attempted once the patient is fully awake and shows no sign of continued bleeding. Appropriate cutting tools should be placed at the bedside of a patient with intermaxillary fixation (e.g. maxillomandibular wiring), in case of vomiting or other airway emergency.
4. Dentoalveolar fractures
Fracture of the alveolar process is a common injury, comprising 2–8% of all craniofacial injuries. Nearby soft tissues and teeth are often damaged, increasing the severity of the situation [16]. The most common causes of such fractures are falls, motor vehicle accidents, sporting injuries, altercations, child abuse, and playground accidents. Direct or indirect force on a tooth, the latter transmitted most commonly through overlying soft tissues, may cause dentoalveolar injury [17].
4.1. Clinical examination
The practitioner should first ask when, where, and how the injury occurred and whether any treatment has been provided since that time. Answers to these simple questions could provide important clues. The patient’s general health status should be known and his or her current situation examined when any nausea, vomiting, unconsciousness, amnesia, headache, or visual disturbance has occurred after injury. The examination of a patient’s dentoalveolar injuries should assess the condition of the extraoral and intraoral soft tissues, jaws, and alveolar bone; establish the presence of any tooth displacement or mobility; and include tooth percussion and pulp testing [18]. Lacerations, abrasions, and contusions are very common in dentoalveolar injuries. Any vital structure crossing the line of laceration should be noted. The removal of blood clots, saline irrigation, and cleaning of the oral cavity facilitate inspection. Any foreign body within surrounding tissues should be examined carefully because bone or tooth fragments might have penetrated these areas, depending on the mechanism of injury. All fractured or missing teeth and restorations should be assumed to have been swallowed, aspirated, or lodged in adjacent structures. Alveolar segment fractures can be detected readily by visual examination and palpation. However, examination may be difficult because of post-injury pain. Sublingual ecchymosis on the mouth floor is pathognomonic for an underlying mandibular fracture. Step defects, crepitation, malocclusion, and gingival lacerations should raise the suspicion of possible underlying bony defects. The presence of fractured teeth should be noted. The depth of the fracture is very important. Complete mobility of the crown may indicate crown–root fracture. Post-injury occlusion should be checked and any displacement, intrusion, or luxation should be examined carefully. Percussion tests to determine sensitivity and pulp vitality should be performed to rule out periodontal ligament injury and many types of tooth fracture.
4.2. Imaging
Radiographic studies should be performed before intraoral manipulation. Radiography should determine the presence of root or jaw fracture, degree of extrusion or intrusion and its relationship to possible existing tooth germs, extent of root development, and presence of tooth fragments and foreign bodies lodged in soft tissues. The combination of periapical, occlusal, and panoramic radiographs is used most frequently for the detection of damage to underlying tissues. Periapical radiographs provide the most detailed information about root fractures and tooth dislocation. Occlusal radiographs, however, provide larger fields of view and nearly the same level of detail as periapical radiographs; they are also very useful for the detection of foreign bodies. Panoramic radiographs provide useful screening views and visualize fractures of the mandible, maxilla, alveolar ridges, and teeth. Computed tomography (CT) offers insufficient resolution for the diagnosis of dental trauma, but cone-beam CT technology provides sufficient resolution to serve as a valuable tool in the diagnosis of various dental injuries [17,19,20].
4.3. Classification
The most commonly used simple and comprehensive classification of dentoalveolar injuries was developed by Andreasen [21] [Figure 6].
Figure 6.
Diagram of Andreasen’s classification
Dental tissues and pulp
Simple crown infraction (crack in the tooth without loss of tooth substance)
Uncomplicated crown fracture (confined to enamel, or enamel and dentine, with no root exposure)
Complicated crown fracture (pulp exposure)
Uncomplicated crown–root fracture (involving the enamel, dentine, and cementum without pulp exposure)
Complicated crown–root fracture (involving the enamel, dentine, and cementum with pulp exposure)
Root fracture (involving the dentine and cementum with pulp exposure)
Injuries to periodontal tissues
Concussion: injury to the periodontium producing sensitivity to percussion without tooth loosening or displacement
Subluxation: the tooth is loosened but not displaced
Avulsion: tooth displacement without accompanying comminution or fracture of the alveolar socket
Injuries to the supporting bone
Comminution of the alveolar housing, often with intrusive or lateral luxation
Fracture of a single wall of an alveolus
Fracture of the alveolar process en bloc in a dentate patient; the fracture line does not necessarily extend through a tooth socket
Fracture involving the main body of the mandible or maxilla
4.4. Treatment
The aim of dentoalveolar fracture treatment is to re-establish the normal form and function of the masticatory system. The involvement of pulp tissue makes a great difference in the treatment protocol.
4.4.1. Dental tissues and pulp
Simple crown infractions do not require treatment. Multiple cracks can be sealed with restorative materials to prevent staining. For uncomplicated crown fractures affecting only the enamel, grinding of the sharp edges is one possible solution. In cases of extensive enamel loss, a composite restoration may be used for recontouring. If a considerable amount of dentine is exposed, it should be covered with glass ionomer as an emergency treatment, and permanent composite restoration with bonding agents can be performed immediately or at a later stage. If the missing fragment is found, bonding to the tooth can be attempted with dentine bonding agents. Periodic follow-up visits should be scheduled to monitor pulp vitality. The management of complicated crown fractures is more challenging. If the exposed pulp tissue is vital, pulp capping or pulpotomy should be performed in cases without extensive crown loss. In cases of severe loss of crown substance or a lengthy interval between injury and treatment, pulp extirpation should be performed via Ca(OH)2 application in the root canal. Permanent root canal filling is carried out later in such cases. If the exposed pulp tissue is already necrotic, Ca(OH)2 should be applied immediately after canal debridement. The course of treatment for uncomplicated crown–root fractures depends on the fracture location. An intact coronal fragment must be removed and inspected carefully to determine whether restoration of the remaining fragment is possible. If the fracture does not extend too far apically, the remaining fragment is suitable for restoration, and the pulp has not been exposed, the treatment protocol is the same as described above for crown fractures. Gingivectomy, ostectomy, or orthodontic extrusion might be required later for tooth restoration. In complicated crown–root fractures, pulp extirpation and Ca(OH)2 application are recommended during the emergency stage, followed by the permanent restoration of the remaining tooth fragment after root canal filling. Surgical extrusion is an option for such fractures because the pulp tissue cannot be devitalised as in uncomplicated crown–root fractures. When no combination of procedures successfully renders the remaining fragment restorable, extraction of the tooth is necessary. When root fractures are located above or close to the gingival crevice, the whole tooth should be extracted; when the remaining tissue allows tooth restoration, only the coronal fragment should be removed for root canal therapy and post and core restoration. Fractures between the middle and apical thirds of the tooth have a good prognosis for pulp survival and the joining of root fragments to one another during healing. A displaced or mobile fragment should be repositioned correctly and the tooth should be splinted for 2–3 months. During this time, the fragments usually calcify. The tooth should be inspected for signs of pulp necrosis during follow-up visits and root canal therapy should be performed if necessary.
4.4.2. Injuries to periodontal tissues
Concussed teeth present only tenderness to percussion in the horizontal and vertical directions. Removing the tooth from occlusion is the only accepted treatment option in such cases. Subluxated teeth show no clinical or radiographic displacement, but damage to the periodontal ligament tissue is present. Periodontal tissue rupture can cause bleeding from the gingival margin crevice. Treatment in these cases is the same as described for concussion, and follow-up monitoring of pulp vitality is necessary. Extrusive luxation is characterized by neurovascular and periodontal ligament rupture with mobility and bleeding from the gingival margin. Pulp necrosis and external root resorption may be seen in later stages. The tooth should be positioned properly and splinted to uninjured adjacent teeth with an acid-etch/resin splint for 3 weeks. Other methods of splinting used routinely in oral and maxillofacial surgery are not recommended. If pulp necrosis occurs, endodontic therapy should be performed. Lateral extrusions often involve the alveolar bone, and may be characterized by complex gingival lacerations and step deformities. The goal of treatment is to properly reposition the alveolar bone and tooth, which can be accomplished with the application of an acid-etch/resin splint for 4–8 weeks. Intrusive luxation is characterized by obvious tooth displacement and comminution and fracture of the alveolus. The risks of pulpal necrosis and inflammatory root resorption are higher in such cases than in other dentoalveolar injuries. Affected teeth with complete root development and closed apices should be repositioned and stabilized with a non-rigid splint. Endodontic therapy within 10–14 days after injury, including canal filling with Ca(OH)2, is recommended to retard or inhibit the inflammatory or replacement resorption process. Intrusion of an incompletely developed tooth is discussed in the ‘Midfacial Fractures in Children’ section below. The fate of an avulsed tooth depends on the cellular viability of the periodontal fibres that remain attached to the root surface prior to reimplantation. Important factors determining the success of treatment measures are the length of time that the tooth has been out of the socket, the state of the tooth and periodontal tissues, and the manner in which the tooth has been preserved before replantation. Avulsed teeth should be stored temporarily in milk, saliva, saline, or Hank’s solution. More than 15 min of extraoral exposure of a periodontal ligament will deplete most cell metabolites in the dental tissue. Teeth in poor hygienic condition and those with moderate to severe periodontal disease, gross caries involving the pulp, apical abscess, infection at the replanting site, and bony defects and/or alveolar injuries involving the loss of supporting bone are generally not replanted. For individuals with avulsed teeth with mature or closed apices who present within 2 h after injury, the tooth is placed in Hank’s solution for about 30 min, then in doxycycline (1 mg/20 mL saline) to inhibit bacterial growth and aid pulpal revascularization; replantation and splinting with an acid-etch/resin splint for 7–10 days are then performed. Endodontic cleansing and shaping of the canal should be performed, and Ca(OH)2 filling should be applied immediately prior to splint removal. The use of final gutta-percha obturation 6–12 months later is contingent on the resolution of canal and/or root pathology. To optimise the success of treatment, avulsed teeth should be replanted and stabilized within 2 h, before periodontal ligament cells become irreversibly necrotic. Teeth with apical openings >1 mm in diameter have a much better prognosis than do those with more mature or closed apices; however, when the extraoral period exceeds 2 h, apical root morphology has little effect on the treatment success rate.
4.4.3. Injuries to the supporting bone
Most alveolar fractures occur in the premolar and incisor regions. The treatment of these fractures involves proper reduction and rapid stabilization. Manipulation by pressure and rigid stabilization of the fragments are accepted closed-reduction techniques. Major displacement or difficulty with closed reduction may necessitate open reduction. Alignment of the involved teeth, edema of the segments, restoration of proper occlusion, and edema of the teeth in the fractured segment are important. The removal of teeth with no bony support may be considered, but should not be performed before the fractured bony segments have healed, even if the teeth are considered to be unsalvageable. Segment edema can be performed with acrylic or metal cap splints, orthodontic bands, fibreglass splints, transosseous wires, small or mini cortical plates, or transgingival lag screws; these materials should be applied for at least 4 weeks.
4.4.4. Complications
Pulp canal obliteration is characterized by the deposition of hard tissue within the root canal space and dark-yellow discolouration of the clinical crown. This complication is seen most frequently after tooth luxation or horizontal root fracture. A tooth with pulpal canal obliteration does not require treatment unless the pulp tissue becomes necrotic and develops periradicular radiolucency. Pulp necrosis is the most likely complication of dentoalveolar injury. Its incidence depends on the type and severity of injury and the extent of root development; teeth with fully formed roots are affected more often. If pulp necrosis is detected, root canal therapy should be initiated immediately to prevent inflammatory root resorption. Internal root resorption can be an issue after most dentoalveolar injuries. This process is usually detected radiographically; if it is identified at an early stage, root canal therapy has an excellent prognosis. The risk of tooth fracture after endodontic therapy is increased in cases of large defects. Follow-up radiography is useful for the detection of internal root resorption. If necrotic pulp is not removed, inflammation of the root surface may occur and the tooth root will be resorbed. Inflammatory root resorption can be detected radiographically and treated by Ca(OH)2 dressing after canal debridement. Ankylosis can occur following damage to large areas of the periodontal membrane, as a primary result of trauma, or as a result of inflammatory root resorption. Osseous replacement proceeds slowly in adults; the tooth may serve for several years, but will loosen eventually.
5. Le Fort fractures
Rene Le Fort famously characterized the types of midfacial fracture caused by anteriorly directed forces [22-24] [Figure7-9]. Most Le Fort fractures are caused by motor vehicle accidents, and this type of trauma is often associated with other facial fractures and orthopaedic and neurologic injuries.
5.1. Clinical Examination
5.1.1. Le Fort I fractures (Guerin fracture)
In Le Fort I fractures, a horizontal fracture line separates the inferior portion of the maxilla, the horizontal plates of the palatal bones, and the inferior one-third of the sphenoid pterygoid processes from the superior two-thirds of the face, which remain associated with the skull. The entire maxillary dental arch may be mobile or wedged in a pathologic position. The patient may have an anterior open bite. Step deformities can be palpated intraorally if edema allows. Hematomas in the upper vestibule (Guerin’s sign) and epistaxis may occur. Le Fort I fractures can be detected readily by orthopantomography, and CT provides a superior level of detail. [Figure 7].
Figure 7.
Le Fort I Fracture (Figure adapted from www.radiologytutorials.com)
5.1.2. Le Fort II fractures
In Le Fort II fractures, the pyramidal mid-face is separated from the rest of the facial skeleton and skull base. The fracture begins inferior to the nasofrontal suture and extends across the nasal bones and along the maxilla to the zygomaticomaxillary suture, including the inferomedial third of the orbit. The fracture then continues along the zygomaticomaxillary suture to and through the pterygoid plates. [Figure 8].
Figure 8.
Le Fort II Fracture (Figure adapted from www.radiologytutorials.com)
5.1.3. Le Fort III fractures
In Le Fort III fractures, the face is essentially separated along the base of the skull due to force directed at the level of the orbit. The fracture line runs from the nasofrontal region along the medial orbit, through the superior and inferior orbital fissures, and then along the lateral orbital wall through the frontozygomatic suture. It then extends through the zygomaticotemporal suture and inferiorly through the sphenoid and the pterygomaxillary suture. In the past, Water’s and lateral views were used to identify Le Fort fractures. CT and three-dimensional CT are now used most frequently, and axial and coronal scans are most useful for identifying midfacial fractures. Pterygoid plate fractures are found in all types of Le Fort fracture. Le Fort I fractures can be seen through the lateral aspect of the piriform aperture. Fractures of the infraorbital rim and zygomaticomaxillary buttress are unique to Le Fort II fractures. Only Le Fort III fractures involve the lateral orbital wall and zygomatic arch, and cerebrospinal fluid leakage can be a matter of concern. [Figure 9].
Figure 9.
Le Fort III Fracture (Figure adapted from www.radiologytutorials.com)
5.1.4. Treatment
The basic principle employed in the treatment of Le Fort fractures is fixation of the maxilla to the next highest stable structure, which differs with Le Fort fracture level. At the Le Fort I level, fixation is performed along the vertical buttresses of the maxilla at the piriform and zygomatic buttress. At higher Le Fort levels, fixation to the nasal bones, orbital rims, or zygomaticofrontal sutures may be necessary. The restoration of proper occlusion is a main goal of treatment. Reconstruction and fixation of the paranasal and zygomaticoalveolar buttresses are often sufficient to re-establish the proper position of the maxilla in Le Fort I fractures. Fractures with minimal or no displacement can heal spontaneously. Bleeding from the nasal wall or septal cracks is common and can be managed by various types of nasal packing. Tamponades can be used at other bleeding sites, such as those with lacerations or abrasions. Intermaxillary fixation with arch bars should be performed after reduction of the maxilla, followed by internal fixation of the maxillary vertical buttresses with plates and screws. Le Fort I fractures can generally be approached via maxillary vestibular incisions. Reduction of the maxilla can be challenging because of impaction, telescoping, or a significant interval of time between injury and treatment. If resistance is encountered during mobilisation of the maxilla, Rowe or Hayton–Williams disimpaction forceps may be used to help reduce the fracture [Figure 10,11].
Figure 10.
Rowe disimpaction forceps
Figure 11.
Hayton Williams forceps
Incomplete fractures may make maxillary mobilisation difficult; in such cases, completion of the fracture with osteotomies can facilitate reduction. In cases of severe comminution, inadequate dentition, periodontal disease, or edentulous arches (Gunning splints), fabricated occlusal or palatal splints can be applied to establish intermaxillary fixation.
Le Fort II fractures can be reduced with Rowe impaction forceps and intermaxillary fixation. A maxillary buccal vestibule incision and any of various approaches to the orbital rim can be used if open reduction is necessary. Bilateral Lynch incisions are to expose the nasofrontal suture [Figure 12].
Figure 12.
Lynch incision line
Le Fort III fractures rarely occur in isolation and are usually components of panfacial fractures. Bicoronal incisions can be used to expose the naso-orbito-ethmoidal region, frontozygomatic sutures, and lateral orbital rims. Pre-auricular, lower lid, and maxillary vestibular incisions can be performed when necessary.
5.1.5. Complications
Patients who have undergone intermaxillary fixation may experience breathing problems, which can be resolved by opening the nasopharyngeal airways. Hemorrhage of the posterior superior alveolar artery should be suspected when perfuse bleeding occurs following any fracture of the posterior alveolar wall. Rapid decreases in blood pressure, hemoglobin, and hematocrit are other signs of fatal hemorrhage. If the artery cannot be ligated, embolization is indicated after the identification of the bleeding source via angiography. Some forms of trauma cause paranasal sinus fractures. Sinus complications, such as chronic sinusitis, polyps, mucocele formation, and acute sinus infection may occur in such cases. Proper anatomic reduction of the sinuses can restore normal sinus function. Vision-related complications can be an issue before or after the reduction of a fracture, especially a high Le Fort fracture. Blindness, enophthalmos, and diplopia can occur due to intraorbital or retrobulbar hemorrhage or damage to the optic nerve caused by bone fragments. Improper rigid fixation of fracture segments will result in malocclusion; this complication usually occurs in patients with anterior open bites and/or class III fracture patterns. Improper rigid fixation may also cause numbness of the area innervated by the infraorbital nerve due to impingement of this nerve. A second surgical procedure is required to correct such complications. Malunion of maxillary fractures can obstruct the nasolacrimal ducts. Non-union of the segments may result in an inadequate blood supply, malpositioning, or infection. Foreign bodies, fractured teeth, and hematomas may cause infection.
6. Fractures of the zygomatic bone
Zygomatic bone fracture is the second most common midfacial injury, following nasal fracture. A zygomatic complex fracture is characterized by separation of the zygoma from its four articulations (frontal, sphenoidal, temporal, and maxillary). An independent fracture of the zygomatic arch is termed an isolated zygomatic arch fracture [Figure 13,14].
Figure 13.
Zygomatic complex fracture
Figure 14.
Isolated Zygomatic Arch fracture
6.1. Clinical examination
The face is inspected and palpated to identify asymmetry caused by displaced fragments of the facial skeleton. Pain, ecchymosis, and periorbital edema with subconjunctival hemorrhage are the earliest clinical signs of a non-displaced zygomatic bone injury. Displaced fractures generally cause depression of the malar eminence and infraorbital rim. Damage to the zygomaticotemporal and infraorbital nerves may cause paraesthesia or anaesthesia in the cheek, lateral nose, upper lip, and maxillary anterior teeth. Epistaxis and diplopia are common in zygomatic bone fractures. Limitation of motion in the extraocular muscles and enophthalmos or exophthalmos should be noted, as they can be signs of fracture of the orbital floor or medial or lateral orbital walls. In such cases, ophthalmologic consultation should be considered before surgical intervention. An isolated zygomatic arch fracture typically has an M-shaped pattern, with two fragments collapsed medially and often impinging on the masseter muscle or even the muscular process of the mandible. Medial displacement of the zygomatic arch may cause mandibular trismus as a result of masseter muscle spasm or mechanical impingement of the coronoid process against the displaced segments. Direct lateral force causes an isolated zygomatic arch fracture or an inferomedially displaced zygomatic complex fracture; frontal force usually produces an inferoposteriorly displaced fragment. Extraoral step deformities of the zygomatic arch and inferior and superolateral orbital margins, as well as intraoral step deformities of the zygomaticomaxillary buttress, may be palpable if the region is free of edema. Axial and coronal CT images inhibit visualisation of the buttress of the midfacial skeleton. Three-dimensional images may be used to obtain additional information about the relationships of displaced and rotated fractured segments to surrounding bony structures. Plain radiography employing Waters’ and Caldwell’s views can also be used to detect zygomatic complex fractures. The submentovertex view is very helpful for the evaluation of the zygomatic arch and malar projection.
6.2. Treatment
The management of zygomatic bone fractures depends on the degree of displacement and the resultant aesthetic and functional deficits. Surgery can be delayed until the majority of facial edema is gone. Isolated zygomatic arch and zygomatic complex fractures with minimal or no displacement are not managed surgically. A soft diet restriction can help to avoid secondary fracture displacement. When displacement and minimal comminution are present, the Gillies technique is the standard reduction treatment for isolated zygomatic arch fractures [Figure 15]. In the Gillies approach, a 2-cm-long temporal incision is made behind the hairline, and the subcutaneous and superficial temporal fascia are dissected to the level of the temporalis muscle to reach the underlying temporal surface of the zygomatic bone; a zygomatic elevator is then used to reduce the arch fracture [25]. The use of a J-shaped hook elevator through a periauricular incision made anterior to the articular eminence and inferior to the zygomatic arch is an alternative approach for reducing zygomatic arch fractures. This approach is faster than the Gillies approach, but it can easily cause damage to the frontal branches of the facial nerve. Fixation of zygomatic arch fractures can be performed by packing the temporal fossa or using transcutaneous circumzygomatic arch wires while providing support with metal or aluminium finger splints. Open reduction is rarely performed in highly comminuted zygomatic arch fractures because it requires a time-consuming coronal incision.
Figure 15.
Gillies approach to zygomatic arch (Figure adapted from www.aofoundation.org)
Displaced zygomatic complex fractures require open reduction and internal fixation. Miniplates and microplates provide the best results with minimal complications. A useful option for displaced zygomatic fractures is the application of a transcutaneous Carroll–Girard screw in the malar region [Figure 16].
Figure 16.
Useof Carroll-Girard screw (Figure adapted from www.aofoundation.org)
This technique enables excellent manipulation of the fractured segment for reduction. Reduction of the frontozygomatic suture, zygomaticomaxillary buttress, and inferior orbital rim should be the main goal of the treatment protocol. The perfect reduction of these three points of reference allows proper positioning of the fractured segment. The location and number of fixation sites depend on the fracture pattern, location, direction of displacement, and degree of instability. In more severe fractures, perfect reduction can be achieved with the use of the zygomatic arch as a fourth reference point. The zygomaticomaxillary buttress should be reduced first via an intraoral approach, while this structure is easy to reach; this technique leaves no scar and may achieve reduction of the entire fractured segment. The zygomaticomaxillary buttress is approached surgically through a 3–5-mm-long incision in the maxillary vestibule above the mucogingival junction, extending from the canine region to first molar region. The protocol for minimally comminuted and displaced fractures should be temporary edema of the zygomaticofrontal suture with wires, reduction of the zygomaticomaxillary buttress and inferior orbital rim, and then replacement of the temporary zygomaticofrontal edema with a plate. The zygomaticofrontal suture is approached surgically through a lateral eyebrow incision, and the inferior orbital rim is approached via subciliary and transconjunctival incisions [Figure 17-19].
Figure 17.
Lateral eyebrow incision line
Figure 18.
Transconjuctival incision line
Figure 19.
Subciliary incision line
In complex and highly comminuted fractures, the zygomatic arch should be reconstructed first; a coronal flap is usually used to gain access to this structure.
6.3. Complications
Restoration of the natural contour of the zygoma is the key to restoring facial projection in patients with displaced and comminuted fractures. Inadequate flattening the zygomatic arch and failure to achieve optimal rotation of the zygomaticomaxillary complex result in malar eminence flattening, asymmetry, and widening of the face. Inadequate reduction or edema of segments may cause malunion.
Poor or excessive reconstruction of the orbital rim should be avoided because an increase in orbital volume can cause enophthalmos and a decrease can cause exophthalmos. Diplopia can be caused by edema, hematoma, injury to cranial nerves 3, 4, or 6, and damage to extraocular muscles, and may heal spontaneously except in the latter case.
Although damage to the zygomaticomaxillary and zygomaticofacial nerves is less common, zygomaticomaxillary complex fractures often cause damage to the infraorbital foramen. Anaesthesia of the lower eyelid and malar and upper lip areas is common in infraorbital nerve injuries. Proper reduction of the fractured segments usually minimizes the risk of permanent symptoms. Blindness immediately after surgery may indicate impingement of the orbital apex contents by a bony fragment. Retrobulbar hematomas rarely develop, but compression of the central retinal artery causing disruption of the retinal circulation may lead to irreversible ischaemia of the optic nerve and permanent blindness.
Patients with zygomatic fractures may suffer from trismus, which may be caused by impingement of the zygomatic bone on the coronoid process of the mandible or ankylosis of the coronoid process to the zygomatic arch. If a previous zygomatic bone or arch fracture has been reduced improperly, the zygomatic bone should be repositioned via osteotomy; otherwise, coronoidectomy is the most common solution.
7. Orbital fractures
Isolated orbital fracture is not a common type of midfacial fracture, but the incidence of midfacial fractures involving the orbit is high because all Le Fort II and III fractures and those of the naso-orbito-ethmoidal and zygomaticomaxillary complexes involve orbital injury. Orbital fractures may affect the internal and/or external orbital frame. Thus, fractures of the orbital region can be discussed in the context of zygomaticomaxillary complex, naso-orbito-ethmoidal complex, and isolated orbital fractures.
7.1. Clinical examination
As discussed above, zygomaticomaxillary complex fracture is the most common fracture type with orbital involvement. Like naso-orbito-ethmoidal fractures (discussed below), zygomaticomaxillary complex fractures are caused by blunt force applied directly to the bone. Isolated fractures of the orbit often occur as a result of direct force to the globe of the eye. A sudden increase in intraorbital pressure creates an outward force that causes fracture of the weakest bony structures in internal orbital walls. Isolated orbital fractures can be classified as ‘blow-out’ or ‘blow-in’. Most blow-out fractures affect the anteroinferomedial aspect of the orbital cavity and displace the orbital globe posteromedially and inferiorly. A significant increase in the volume of the orbital cavity results in enophthalmos of the globe. Herniation of the orbital roof and globe to the maxillary sinus occurs in such fractures. When an isolated fracture is caused by low-energy force, linear fracture of the orbit may be detected. Linear fractures retain periosteal attachments and do not cause orbital globe herniation to the maxillary sinus or complete perforation of the maxillary sinus roof. More severe trauma causes a complex fracture involving two or more orbital walls. In complex internal orbital fractures, the globe is often displaced posteriorly and the optic canal may be involved. Blow-in fractures affect the orbital roof and may be diagnosed after severe injury of the anterior skull base. Rupture of the orbital roof reduces the orbital volume and often causes anteroinferior globe displacement.
The affected region should be inspected carefully to identify the presence of edema, chemosis, ecchymosis, lacerations, ptosis, asymmetric lid drape, canalicular injury, and/or canthal tendon disruption. Any step deformity or mobility around the orbital rim should be palpated before edema develops in surrounding tissues. Neurosensation of the infraorbital and supraorbital nerves should be tested. Ophthalmologic consultation is very important and necessary. Limitation of ocular movements can be caused by mechanical entrapment or neurologic injury. Three-dimensional CT and magnetic resonance imaging are preferred for the evaluation of orbital fractures. Waters’ projection is the most useful plain radiographic modality because it enables visualisation of the orbital floor and roof. Ophthalmic ultrasonography and color Doppler imaging can provide additional information.
7.2. Treatment
Subciliary and transconjunctival incisions are the most aesthetically acceptable approaches to the orbital floor. Linear injuries of the orbital floor require no intervention unless they show signs of soft-tissue entrapment in fractured but self-reduced sites. In patients with blow-out or blow-in fractures, soft- and hard-tissue reduction and reconstruction are necessary. Grafting of the injured site with autografts, allografts, or alloplastic materials may be necessary to achieve proper anatomic reduction and stability and to prevent soft-tissue contraction. The iliac crest and nasal septal cartilage are the best donor sites for autografts, and the use of alloplastic titanium mesh can be successful in cases requiring extra support.
7.3. Complications
Most internal orbital fractures cause volumetric contraction or expansion of the orbital cavity, which may lead to diplopia, enophthalmos, exophthalmos, proptosis, and/or extraocular muscle imbalance. Extraocular muscle imbalance and diplopia can be the result of extraocular muscle entrapment or neuropathy of the 3rd to 5th cranial nerves. An increase in orbital volume causes enophthalmos, which may occur weeks or months after injury.
For some challenging fractures of the orbital floor, the transconjunctival approach may be safer than other methods. The placement of a transconjunctival incision at the conjunctival fornix appears to minimize the risk of eyelid malposition. A transantral endoscopic approach is an alternative method that avoids potential damage caused by lower-lid incisions.
8. Naso-orbito-ethmoidal fractures
Naso-orbito-ethmoidal facture can occur either in isolation or in association with other midfacial fractures. Most associated injuries affect the cervical spine and ocular and intracranial regions. This fracture type is caused by focused high-energy transfer to the intercanthal area. Because the naso-orbito-ethmoidal area contains several types of tissue (bone, cartilage, tendons, ocular tissue) restoration is challenging.
8.1. Clinical examination
Naso-orbito-ethmoidal fractures are characterized by three major post-injury symptoms: increased intercanthal distance, diminished nasal projection, and impaired nasofrontal and lacrimal drainage.
Markowitz et al. [26] developed the most widely used classification system for naso-orbito-ethmoidal fractures, which distinguishes three fracture types [Figure 20]:
Type I: the medial canthal tendon is attached to a single, large central fragment
Type II: the medial canthal tendon is attached to a comminuted but manageable central fragment; the canthal tendon remains attached to a fragment that is sufficiently large to allow osteosynthesis
Type III: the medial canthal tendon is attached to a comminuted and unmanageable central fragment; the fragments are either too small to allow osteosynthesis or completely detached.
Figure 20.
Classification of Nasoorbitoethmoidal fractures
Periorbital ecchymosis, subconjunctival hemorrhage, and pain are the most common signs and symptoms of naso-orbito-ethmoidal fractures. Other signs and symptoms include skin and mucosal lacerations, epistaxis, nasal obstruction, edema, telecanthus, and increased canthal angles. Depression of the bony segment causes internal and external nasal cosmetic deformities. Edema may obscure such depression for up to 5 days, and most surgeons recommend the postponement of surgery until the edema has resolved. The impaction of bony segments to the orbit may cause exophthalmos, proptosis, or ptosis. Fractures of cribriform plate and posterior wall of the frontal sinus may cause cerebrospinal fluid leakage. Nasal bone mobility, traumatic telecanthus, crepitus, and depressibility of the area are the clinical digital-examination findings for naso-orbito-ethmoidal fractures.
Increased intercanthal distance, termed telecanthus, is a key deformity resulting from naso-orbito-ethmoidal injury. Normal intercanthal distances are 29–36 mm in males and 29–34 mm in females; a distance exceeding 40 mm is classified as telecanthus and may indicate that surgical treatment is required.The medial canthal tendon is a very important anatomic factor in naso-orbito-ethmoidal injuries resulting in telecanthus. The pretarsal portions of the orbicularis oculi muscle in the upper and lower lids unite at the canthus to form the medial canthal tendon. The superficial portion of this tendon provides support to the eyelids and maintains the integrity of the palpebral fissure. Restoration of this component after canthal detachment is critical for maintaining proper eyelid appearance. The deeper portion, also called Horner’s muscle, attaches to the posterior lacrimal crest and assists in the movement of fluid through the lacrimal system. Disruption of the medial canthal tendon causes contraction of the orbicularis oculi muscle, increasing the intercanthal distance and laterally displacing the rounded contour of the medial palpebral fissure. The ‘bowstring test’ is a useful method of assessing the status of the medial canthal tendon’s attachment to the bone. This test involves lateral pulling of the lid while palpating the tendon area to detect movement of fracture segments [27] [Figure 21].
Figure 21.
Bowstring test
Two- and three-dimensional CT using axial and coronal views are the most valuable imaging methods for the diagnosis of naso-orbito-ethmoidal fractures. The use of conventional imaging techniques is not recommended because these modalities do not provide adequate information.
8.2. Treatment
The goals of naso-orbito-ethmoidal fracture treatment are the resolution of the three major issues described above: Establishment of proper nasal projection, narrowing of the intercanthal distance, and establishment of the nasofrontal and lacrimal fluid route. The surgeon should seek to achieve satisfactory results in a single surgery because corrective secondary surgery may cause scarring and fibrosis. For this reason, most authors have advocated the postponement of surgery for 3–7 days to allow for the recession of edema. For naso-orbito-ethmoidal fractures involving a single fragment (type I), treatment can be attempted with closed reduction and the provision of intranasal packing support. If the fragment cannot be reduced satisfactorily by closed reduction, the operation should be converted immediately to an open reduction to avoid the need for secondary surgery. In most cases, a transoral approach is sufficient to reach the injured area without an additional incision.
Proper restoration of types II and III naso-orbito-ethmoidal fractures usually require wide access, which can be provided only by a coronal flap. Wide exposure of the nasal bones and medial orbital walls can be achieved readily. When necessary, a transoral approach can be used to access the paranasal areas and a transconjunctival approach can be used to expose the inferior orbital rim or inferomedial wall. Existing lacerations can also be used to access the injured area. Transcutaneous approaches are not considered to be acceptable because they cause facial scarring.
In severe naso-orbito-ethmoidal injuries, nasal dorsal strut grafting is often required to re-establish support for the entire nose. This graft is cantilevered from the stable frontal bone and placed in the subcutaneous plane, extending inferiorly to the nasal tip.
When the medial canthal tendon is detached completely or attached to an unusable bone fragment, its proper position must be secured immediately using medial canthopexy. The medial canthal tendon should be reduced into a position slightly posterosuperior to the posterior lacrimal crest. The tendon is then sutured with a wire passing transnasally to a cantilevered miniplate on the opposing (undamaged) side. The canthopexy should be positioned sufficiently deep in the orbit to achieve the proper shape of the palpebral fissure and lower lid, as the superficial portion of the medial canthal tendon secures the position of the lower lid and contour of the palpebral fissure. Proper positioning of the medial canthal tendon will achieve correct lacrimal fluid drainage, which is aided by the deep portion of the tendon. When nasofrontal obstruction is a concern, endoscopic frontal sinus surgery can be indicated to re-establish nasofrontal drainage. The medial canthal tendon should be slightly over-reduced in canthopexy procedures to compensate for remodelling of related tissues.
8.3. Complications
Cosmetic deformities are foreseeable after nasal and naso-orbito-ethmoidal injuries. Postoperative septal hematoma, septal abscess, and/or destructive fracture of the septal cartilage/bone are the postoperative causes of nasal deformity. Massive comminution of the naso-orbito-ethmoidal complex is classically associated with saddle nose deformity. Bone grafting is required in most patients to establish proper nasal projection, symmetry, and contour. However, even bone grafts can be associated with potential resorption problems in the long term. Depending on the fracture level, cartilage or bone grafts and nasal implants can be used to improve the appearance of these deformities.
Septal deviation due to inadequate closed reduction often results in external nasal asymmetry. Direct septal visualisation via the open rhinoplasty approach is preferred for the correction of this defect.
After naso-orbito-ethmoidal injury, scar contracture results in cosmetic and functional deformities. Thus, secondary surgery should be avoided because it may result in scarring.
Open reduction and internal fixation procedures often damage the medial canthal tendon or nasolacrimal apparatus. As a result, epiphora related to nasolacrimal duct obstruction can be an issue. Intubation or stenting of the lacrimal duct may be necessary in such cases.
9. Midfacial fractures in children
Midfacial fractures are not common in children; they account for only 1–8% of pediatric fractures [28-31] and usually affect the mandible. This low incidence is related to the protection provided by the mandible and cranium, which absorb most of the traumatic impact, and to the elastic nature of midfacial bones and flexibility of osseous suture lines [32]. Children form a distinct patient group in maxillofacial surgery due to significant differences between the facial skeletons of children and adults. Depending on the patient’s age, these differences include small bone size, small paranasal sinus volume, growth potential, the presence of tooth germs in alveoli during primary and mixed dentition stages, a more rapid healing process compared with adults, and difficulty with cooperation resulting in the need for general anaesthesia in more cases than in adults [33]. The proportion of children in whom midfacial fractures are identified has increased over time, probably due to the increased use of adequate imaging modalities [34]. CT has largely supplanted standard radiography as the preferred imaging method for pediatric facial trauma.
The presence of tooth germs in alveoli potentially creates zones of weakness in the jaws and limits the placement of certain plate and screw types, given the need to avoid damage to the developing dentition. The treatment of pediatric patients with midfacial fractures using intermaxillary fixation is also quite difficult, and erupting or exfoliating teeth can be an issue. On the other hand, the on-going processes of tooth eruption and exfoliation may compensate for minor inaccuracies in reduction and fixation. Recognition of the differences between children and their adult counterparts is important in facial rehabilitation.
Several aspects of dentoalveolar trauma management in children differ from that in adults. Developing roots have open apices, and the preservation of pulp vitality is important. In complicated crown and crown–root fractures, pulpotomy can be performed 1–2 mm below the exposed pulp tissue and Ca(OH)2 or mineral trioxide aggregate can be applied. The second step in such cases is composite restoration or bonding of the crown fragment to the tooth. If the pulp is necrotic, apexification with intracanal application of Ca(OH)2 must be used instead of pulpotomy. In pediatric cases of intrusion, spontaneous re-eruption may occur. Orthodontic repositioning can be a second treatment plan unless movement is observed within about 3 weeks. In the pediatric dentition, osseous replacement in ankylosis occurs much faster than in adults; dentoalveolar ankylosis usually interferes with alveolar process growth, and the tooth might be malpositioned.
Fractures in the maxillary region tend to be less comminuted in children than in adults because children’s paranasal sinuses are not fully developed. Open reduction and internal fixation are the preferred treatment methods, but intermaxillary fixation may be necessary in some cases. Avoiding damage to permanent tooth germs is a mandatory indication for closed reduction. Intermaxillary fixation with arch bars presents some difficulties in patients with mixed dentition, but the fixation period can be shorter than in adults. Teeth may be avulsed by the force of arch bars, and the fixation of arch bars to the teeth may not provide adequate retention because of weak and undeveloped roots. For this reason, the fabrication and use of Gunning splints to provide retention from the zygomatic arches, piriform apertures, and mandible via circumferential wires is recommended when intermaxillary fixation is necessary. As in adults, restoration of the normal anatomic position of the midfacial skeleton in children generally requires open reduction and stable fixation with miniplates and screws. In pediatric Le Fort II and III fractures, open reduction and internal fixation are necessary to re-establish proper anatomic and functional relationships. Pediatric fractures in the maxillary region are often of the greenstick type, which increases the complexity of fragment reduction. Because a greenstick fracture line limits fragment movement, proper reduction may require osteotomy.
Paediatric orbital fractures resulting in herniation and extraocular muscle entrapment require immediate intervention and even orbital exploration. Fractures of the orbital floor or wall in children heal rapidly, increasing the risks of scar cicatrisation and related ischemic necrosis of entrapped tissues.
Because the development of the nasal septum is a very important factor in facial growth, post-traumatic septal hematoma, which may cause septal necrosis and resorption, should not be ignored because it may result in saddle nose deformity.
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Introduction",level:"1"},{id:"sec_2",title:"2. Surgical anatomy",level:"1"},{id:"sec_3",title:"3. Initial management of the midfacial trauma patient",level:"1"},{id:"sec_3_2",title:"3.1. Primary Survey: ABCs",level:"2"},{id:"sec_4_2",title:"3.2. Physical examination",level:"2"},{id:"sec_5_2",title:"3.3. Preoperative considerations",level:"2"},{id:"sec_6_2",title:"3.4. Intraoperative management",level:"2"},{id:"sec_8",title:"4. Dentoalveolar fractures",level:"1"},{id:"sec_8_2",title:"4.1. Clinical examination",level:"2"},{id:"sec_9_2",title:"4.2. Imaging",level:"2"},{id:"sec_10_2",title:"4.3. Classification ",level:"2"},{id:"sec_11_2",title:"4.4. Treatment",level:"2"},{id:"sec_11_3",title:"4.4.1. Dental tissues and pulp",level:"3"},{id:"sec_12_3",title:"4.4.2. Injuries to periodontal tissues",level:"3"},{id:"sec_13_3",title:"4.4.3. Injuries to the supporting bone",level:"3"},{id:"sec_14_3",title:"4.4.4. Complications",level:"3"},{id:"sec_17",title:"5. Le Fort fractures",level:"1"},{id:"sec_17_2",title:"5.1. Clinical Examination",level:"2"},{id:"sec_17_3",title:"5.1.1. Le Fort I fractures (Guerin fracture)",level:"3"},{id:"sec_18_3",title:"5.1.2. Le Fort II fractures",level:"3"},{id:"sec_19_3",title:"5.1.3. Le Fort III fractures",level:"3"},{id:"sec_20_3",title:"5.1.4. Treatment",level:"3"},{id:"sec_21_3",title:"5.1.5. Complications",level:"3"},{id:"sec_24",title:"6. Fractures of the zygomatic bone",level:"1"},{id:"sec_24_2",title:"6.1. Clinical examination",level:"2"},{id:"sec_25_2",title:"6.2. Treatment",level:"2"},{id:"sec_26_2",title:"6.3. Complications",level:"2"},{id:"sec_28",title:"7. Orbital fractures",level:"1"},{id:"sec_28_2",title:"7.1. Clinical examination",level:"2"},{id:"sec_29_2",title:"7.2. Treatment",level:"2"},{id:"sec_30_2",title:"7.3. Complications",level:"2"},{id:"sec_32",title:"8. Naso-orbito-ethmoidal fractures",level:"1"},{id:"sec_32_2",title:"8.1. Clinical examination",level:"2"},{id:"sec_33_2",title:"8.2. Treatment",level:"2"},{id:"sec_34_2",title:"8.3. Complications",level:"2"},{id:"sec_36",title:"9. Midfacial fractures in children",level:"1"}],chapterReferences:[{id:"B1",body:'Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Cranio-Maxillofacial Trauma: A 10 Year Review Of 9543 Cases With 21 067 İnjuries. Journal Of Cranio-Maxillofacial Surgery. 2003;31:51–61'},{id:"B2",body:'Thomas DW, Hill CM: Etiology And Changing Patterns Of Maxillofacial Trauma. In: Booth PW, Schendel SA, Hausamen JE (Eds) Maxillofacial Surgery, Vol. Churchill Livingstone, 3, 2000'},{id:"B3",body:'Mouzakes J, Koltai PJ, Kuhar S, Bernstein DS, Wing P, Salsberg E:The İmpact Of Airbags And Seat Belts On The İncidence And Severity Of Maxillofacial İnjuries İn Automobile Accidents İn New York State. Arch Otolaryngol – Head Neck Surg. 2001;127:1189–1193'},{id:"B4",body:'Cook H E, Rowe M. A Retrospective Study Of 356 Midfacial Fractures Occurring İn 225 Patients. 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Oral Maxillofac. Surg. 2010; 39: 779–782.'},{id:"B17",body:'Ellis E III. Soft Tissue and Dentoalveolar Injuries. In: Hupp J R et al. (ed.). Contemporary Oral and Maxillofacial Surgery Fifth Edition. Missouri: Mosby Elsevier; 2008. p474-7'},{id:"B18",body:'Fonseca RJ, Marciani RD, Hendler BH. Oral and maxillofacial surgery, trauma. Vol 3. Diagnosis and management of dentoalveolar injuries. Philadelphia (PA):W.B. Saunders Co; 2000. p. 48–50. '},{id:"B19",body:'Snawder KD, Bastawni AE, O’Toole TJ. Tooth fragments lodged in unexpected areas. JAMA 1976;233:1378–9.'},{id:"B20",body:'Leather D L, Gowans R E. Management of Alveolar and Dental Fractures, In: Miloro M (ed.) Peterson’s Principles of Oral and Maxillofacial Surgery Second Edition. London: BC Decker Inc; 2004; 383-400.'},{id:"B21",body:'Andreasen JO, editor. Traumatic injuries of the teeth. 1st ed. Philadelphia (PA): W.B. Saunders; 1972.'},{id:"B22",body:'Le Fort R. Etude experimentale sur les fractures de la machoire superiore. Rev Chir 1901; 23:208–27.'},{id:"B23",body:'Le Fort R. Etude experimentale sur les fractures de la machoire superiore. Rev Chir 1901;23:360–79.'},{id:"B24",body:'Le Fort R. Etude experimentale sur les fractures de la machoire superiore. Rev Chir 1901;23:479–507.'},{id:"B25",body:'Gillies HD, Kilner TP, Stone D. Fractures of the malarzygomatic compound, with a description of a new x-ray position. Br J Surg 1927;14:651.'},{id:"B26",body:'Markowitz BL, Manson PN, Sargent L, et al. Management of medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment, Plast Reconstr Surg. 1991;87:843-853'},{id:"B27",body:'Furnas DW, Bircoll MJ. Eyelash traction test to determine if the medial canthal ligament is detached. Plast Reconstr Surg 1973;52:315–7.'},{id:"B28",body:'Rowe NL. Fractures of the jaws of children. J Oral Surg. 1969;27:497-507'},{id:"B29",body:'Posnick JC, Wells M, Pron GE. Pediatric facial fractures: evolving paterns of treatment. J Oral Maxillofac Surg. 1993;51:836-844'},{id:"B30",body:'Gassner R, Tuli T, Höchl O, et al. Craniomaxillofacial trauma in children: a review of 3385 cases with 6060 injuries in 10 years. J Oral Maxillofac Surg. 2004;62:399-407'},{id:"B31",body:'Qaqish C, Caccamese Jr JF. Pediatric Mid-face Fractures. In: Bagheri SC, Bell RB, Khan HA (ed.). Current therapy in oral and maxillofacial surgery. Missouri: Saunders Elsevier; 2012.p851-8'},{id:"B32",body:'Ferreira P, Marques M, Pinho C, Rodrigues J, Reis J, Amarante J. Midfacial fractures in children and adolescents: a review of 492 cases. British Journal of Oral and Maxillofacial Surgery. 2004;42:501—505'},{id:"B33",body:'Iatrou I, Theologıe-Lygıdakıs N, Tzerbos F. Surgical Protocols And Outcome For The Treatment Of Maxillofacial Fractures İn Children: 9 Years’ Experience. Journal Of Cranio-Maxillo-Facial Surgery. 2010;38:511-516'},{id:"B34",body:'Thorén H, Iso-Kungas P, Iizuka T, Lindqvist C, Törnwall J. Changing trends in causes and patterns of facial fractures in children Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:318-324.'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Sertac Aktop",address:null,affiliation:'
Department of Oral and Maxillofacial Surgery, Marmara University, Istanbul, Turkey
Department of Oral and Maxillofacial Surgery, Marmara University, Istanbul, Turkey
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1. Introduction
The field of learning disabilities has a long history, stemming back diagnostically over the past century to the work of Hinshelwood [1] and Morgan [2] in the 1890’s, and the work of Orton in the 1920’s and 1930’s with children characterised as “word blind” [3, 4]. Methodologically, it can be traced to the techniques for treating reading, writing and spelling difficulties pioneered by Dearborn [5, 6], Monroe [7], Gates [8], Durrell [9], and Fernald [10], to the application of Orton’s theories by Gillingham and Stillman [11] and to the differing conceptualisations of treatment developed by Strauss and Lehtinen in the 1940’s [12] and by clinicians such as Cruickshank [13], Ayres [14], Dubnoff [15], Frostig [16], Kephart [17], Getman [18], Kirk [19], Spalding and Spalding [20], Freidus [21], and Johnson and Myklebust [22] in the 1950’s and 1960’s.
In teaching children to read there has also been intense debate between proponents of phonically based techniques and visually-based methods as summarised in Chall [23], as well as between those who have advocated or rejected the practice of classifying and labelling different types of reading disabilities, as outlined by Elliott and Grigorenko [24]. These debates are ongoing [25].
At this point in time, based on over a hundred years of clinical and academic work in the field, the value of teaching reading using phonologically and phonically based methods at entry point to school and also at foundation level in school has become widely accepted [26, 27, 28]. In addition, a number of different types of learning disabilities have been identified [29, 30].
Despite these advances, there is still lack of agreement as to typologies of learning disabilities, as well as to how these apply to children and adults. There is also a lack of consensus as to whether it is better to base diagnosis of learning disabilities on purely functional descriptions of the behaviours associated with how learning disabilities manifest in particular children (using terms such as “backward reading”, “specific learning disorder, with impairment in reading”, or “specific reading retardation”), or whether it is helpful to also apply a label such as “dyslexia”, “developmental dyslexia”, “dysgraphia”, or “dyscalculia” to children for diagnostic purposes.
This chapter describes a programme which uses a response to intervention model of classification [31, 32, 33], working from the standpoint that classifications of learning difficulties are provisional and emergent, with the potential of changing from hypotheses to firm and persistent categories as treatment progresses. The model is based on a process of incremental and treatment validity, in which evidence concerning a child’s response to particular procedures or techniques can add to an existing combination of assessment methods [34, 35, 36].
The model is then discussed in relation to the methods for assessment and treatment of functional difficulties with reading, writing, spelling and arithmetical concepts applied in the programme. As the difficulties of children are specific and manifest in the context of particular households and school environments, initial functional descriptions of behaviour are used in the programme as the basis for treating learning difficulties associated with difficulties with reading, writing, spelling and numeracy.
The approach to diagnosis and treatment is evidence-based, and described in Potter [37, 38]. Initial assessment provides descriptive information concerning a child’s functioning, which is then linked to specific treatment programmes. Firm classification of dyslexia, dysgraphia and dysgraphia is then linked to both ongoing assessment and to progress evaluation linked to indicators of progress to establish effects of treatment, and through this to firm classification as learning disabled [39].
2. Classification of learning disabilities
Lyon et al. [40] suggest that classification research involves forming groups or categories, which can then be evaluated for reliability, validity, and coverage. This implies that all classifications are essentially hypotheses about variables, and the relationships between variables. Classifications applying in the area of learning disabilities thus relate to both variables indicating difficulties as well as variables relating to the treatment of difficulties. Classification researchers then evaluate the reliability, validity, and coverage of hypothetical groupings of both independent and dependent variables relating to both difficulties and treatment of difficulties. This is done by conducting and analysing research on the relationships between these variables, as well as the relationships between variables conceptualised as either dependent or independent [41].
Following this logic, classifications applying in the area of learning disabilities are based on the interrelationships between a wide range of variables based on indicators associated with the learning difficulties experienced by particular children at school. As many types of behaviour are associated with both successful and unsuccessful performance in particular school environments, it would also imply that it would be unlikely that learning difficulties can be conceptualised as related to a single disability. Instead learning disability would need to be represented as a general category, which is composed of disabilities in any one or a combination of several areas or domains as these apply to the development of particular children [42].
This is the standpoint adopted in the programme described in this chapter, based on the position previously taken by others. In the 1968 federal definition of learning disabilities adopted in the United States, for example, seven domains are identified: (1) listening; (2) speaking; (3) basic reading (decoding and word recognition); (4) reading comprehension; (5) arithmetic calculation; (6) mathematics reasoning; and (7) written expression [30, 43], while Fletcher et al. [44] have suggested that the evidence supports six subgroups of learning disability involving reading (word recognition, fluency, and comprehension), math (calculations and problem solving), and probably written expression. The latter could involve either the generation of text (handwriting, spelling) or composition. Further research would be needed on these written expression components to establish whether these are distinct categories or categories which overlap other forms of learning disability.
Within these domains, the programme described in this chapter focuses on three main subgroups of learning disability:
Reading disabilities (often referred to as dyslexia)
Written language disabilities (often referred to as dysgraphia)
Math disabilities (often called dyscalculia)
Other related categories treated in the programme include disabilities that affect focus and attention, working memory, social skills, and executive functions such as personal organisation and deciding how to approach or begin a task. These difficulties are initially described functionally [37]. This is followed by a process of firmer classification based on analysis of response to intervention to programmes focused on improving functioning and performance in these areas, based on a process of evaluation which is empirical, multimethod and evidence-based [45, 46, 47].
3. Functional description of different types of learning difficulties: a response to intervention perspective
A response to intervention instructional model uses intervention as a treatment variable and response to intervention as an indicator of underlying learning disabilities. Firm classification is then based on evidence of learning difficulties which are persistent or resistant to treatment. This is the approach adopted in Dr. Charles Potter’s Reading Fluency Programme [48], which is described in this chapter. Given the difficulties inherent in measurement particularly where anxiety and emotion are involved, the programme uses a response to intervention approach in which diagnosis can be emergent, based on evidence from both response-to-intervention (RTI) and norm-referenced ability testing collected over time [49].
Since difficulties with reading, writing and/or math are recognisable problems during the school years, the signs and symptoms of learning difficulties in a particular school programme form the point of departure for treatment. Functional description of different types of learning difficulties forms the basis for establishing treatment programmes. Response to intervention then provides the basis for classification as learning disabled.
Learning disabilities are thus initially defined as functional difficulties, based on evidence of unexpected underachievement in a child relative to the achievement which would be typical of other children in a particular school or learning environment. Indicators of unexpected underachievement are used at the outset to describe the difficulty, based on inability to respond to the instruction which is benefitting other children. The definition would also include other functional indicators of learning difficulties, such as ratings or test scores indicating reading, writing and spelling difficulties or difficulties with number concept and mathematical problem-solving, and would also include ratings or test scores indicating neurological markers and signs, as well as unevenness in cognitive functions.
A firm classification as learning disabled would then be based on evidence of difficulties persisting both during as well as after treatment based on longitudinal, incremental assessment and evaluation [50, 51] as outlined in Table 1.
Table 1.
Classification of learning disabilities based on response to intervention.
The model in Table 1 is a generic one which can be applied by others. How this has been applied in practice is described in the rest of this chapter with reference to a particular programme applying specific methods of assessment and treatment in a particular country context. As there are a number of different variables which can affect the development of reading, writing and spelling, the methods and materials used with each child vary, based on initial assessment to identify areas of strength and difficulty, as well as specific areas requiring intervention.
Intervention then takes place to address the variables related to the areas of difficulty. As this takes place, firm diagnosis and classification of learning disability then becomes possible, based on assessment linked to ongoing assessment and progress evaluation of the effects of multivariate treatment, based on use of particular types of methods and materials. Classification as learning disabled can then be linked to concessions to compensate for the areas of difficulty which have been demonstrated to be resistant to particular forms of treatment, as well as to ongoing treatment and learning support.
4. Initial assessment: focus on functional difficulties
The assessment process used in Dr. Charles Potter’s Reading Programme1 is based on the child’s family and scholastic history in either the private or government schooling system in South Africa, which is a country classified as both first and third world [52]. The assessment procedures conform to similar procedures used by other educational psychologists in South Africa to provide evidence which can be used for diagnostic purposes against what are termed the ICD DSM IV and ICD DSM V criteria by South African medical aid societies.2
The ICD DSM IV and ICD DSM V criteria are designed to enable initial diagnosis to be made against functional descriptions of the learning difficulties experienced by children. These can then be used as the basis for both functional classification as well as for the development of treatment programmes.
As has been described in a previous publication on the work of the programme [37], four screening tests are used at the outset of the assessment process. These are designed to yield information about reading single words and reading words in sequence, and writing and spelling single words and words in sequence. Results on these tests are then reported using reading, spelling and dictation ages, for the reason that the South African ICD DSM IV and DSM V are based on age-related expectancies which are then used by the medical aid societies for the management of claims and benefits.3
Besides following the medical aid society guidelines in focusing on basic skills in reading and written expression, the assessment procedures are also based on the procedures suggested by Luria [58] for clinical assessment of reading and writing. Qualitative analysis of an initial parent interview is combined with analysis of drawings, pragmatic writing-based tasks and observation in an initial ice-breaking session with the child. This is then followed by a second session with the child during which four screening tests are used to establish levels of basic skills in reading, writing and spelling. This information is also combined with additional evidence from a biographical inventory, parental interview, analysis of school reports and more formal psychometric testing. This includes assessment of arithmetical and mathematical problem-solving skills if these are highlighted as areas of difficulty by the child’s school and the child’s parents.
Overall, the procedures used in the assessment process thus follow Luria’s suggestion [58] that assessment should start with a preliminary conversation, and then include a careful history, detailed observation of behaviour, analysis of neurological symptoms and a series of additional objective tests. Luria suggests that the examination needs to be relatively short, and involve methods of experimental psychological investigation applied to clinical practice.
The methods of examination used in the initial sessions spent working with the child also include pragmatic assessment of repetitive and spontaneous speech, writing, reading, comprehension of texts and the solution of problems, in order to establish how reading, writing and spelling are used by the child as a functional system. This informal evidence is then combined with more formal testing of reading, writing and spelling skills, and interpreted, as Luria suggests, against a framework of knowledge of the types of difficulties normally associated with the functional system under investigation, based on current literature [59].
Assessment leads to a functional description of deficits sufficient for diagnosis of learning disability to meet medical aid requirements,4 as opposed to an attempt to link this to possible labelling of the child as dyslexic, or labelling in terms of the other types of learning disability commonly described in the literature [37]. This is consistent with the standpoint adopted by Elliott and Grigorenko [24] and Elliott [61], namely, that adding a label adds little of clarity to a functional description of deficits for purposes of intervention. Similarly, the pattern of scores on subtests of an IQ test would best be used functionally, to indicate areas of cognitive and language strength and weakness, as well as areas in sequencing and working memory which may need to be worked with in therapy.
5. Evidence-based multivariate treatment: a response to intervention model
Following Luria [62], the aim is to move from assessment to statement of areas of deficit, and from this to specific programmatic intervention. The statement of areas of deficit can then be used as the basis for diagnosis for medical aid purposes, recommendations concerning the need for additional more in-depth testing (e.g. cognitive testing, speech and language and/or visual assessment, more in-depth analysis of phonological and phonic skills) or for more in-depth neurological or paediatric investigation,5 as well as to recommend specific types of programmatic activities which can be used to address the areas of deficit.
Being based on the DSM IV criteria,6 the diagnosis is related to the ICD10 classifications of possible types of developmental disorders affecting the development of scholastic skills, which are as follows:
F81 Specific developmental disorders of scholastic skills
F81.0 Specific reading disorder
F81.2 Mathematics disorder
F81.8 Other developmental disorders of scholastic skills
F81.81 Disorder of written expression
F81.89 Other developmental disorders of scholastic skills
This classification then enables parents to be able to claim benefits from their medical aid societies. At the same time, the statement of areas of deficit then enables recommendations to be made for more in-depth testing, as well as for commencing treatment. This is done matching the behaviours tapped by the tests used in the assessment process with the functional descriptions associated with the following literature-based based categorisation of types of learning disability associated with the ICD 10 developmental disorders of scholastic skills [42, 64, 65]:
Dyslexia: learning difficulties affecting reading and related language-based processing skills.
Auditory processing problems: difficulties with the sound system of the language, with phonological awareness, with listening in the classroom, and with processing and remembering the sounds associated with the letters in reading, writing and spelling.
Language processing problems: difficulties in processing spoken language, affecting both receptive and expressive language.
Reading Comprehension Deficits: learning difficulties affecting an individual’s understanding of what they read.
Dysgraphia: learning difficulties affecting a person’s handwriting ability and fine motor skills.
Visual, Visual perceptual or visual motor deficits: poor eye-hand coordination, difficulties in navigating surroundings, difficulties in visual tracking of print or losing one’s place when reading.
Non-Verbal Learning Deficits: learning difficulties affecting the child’s social interactions, manifesting in difficulties interpreting nonverbal cues such as facial expressions or body language, or difficulties relating to poor coordination.
Dyscalculia: learning difficulties affecting a person’s ability to understand numbers and learn arithmetic or mathematical facts.
As the work done in my practice is related to the ICD 10 classification and medical aid codes, the functional difficulties associated with the ICD 10 codes related to the above categories (dyslexia, reading comprehension deficits, dysgraphia and dyscalculia) form the basis for the types of treatment initially developed for working with the child. Functional difficulties in the other four areas are referred to other therapists (e.g. occupational therapists, physiotherapists, visual therapists and speech and language specialists) working in the field.
This enables the work done in the practice to meet medical aid requirements, while at the same time focusing on use of particular methods and materials in working with reading, writing and spelling difficulties, difficulties with numeracy and mathematical problem-solving, as well as the attentional, emotional and social aspects which accompany difficulties at school (Table 2) [37, 38, 66].
Table 2.
Diagnosis of learning disability based on response to intervention prior to, during and subsequent to treatment.
The model for evidence-based classification can be represented as follows:
The model thus involves evidence-based multivariate treatment as the basis for firm classification of particular types of learning disability based on response to intervention over time. At each stage in the application of the model, classification of learning disability is based on incremental validity based on specific evidence relating to particular types of treatment. It is also related to the emotional, social, family and classroom issues involved in treating learning difficulties at school.
How the model has been applied in practice is outlined in the following sections. While this is done with reference to the multivariate programmes developed in the practice for treating learning disabilities, the model could also be applied in other programmes working in a similar evidence-based way.
6. Applying the model: treatment of reading difficulties
Dr. Charles Potter’s Reading Programme is a fluency-based programme for treating learning difficulties [67]. The methods used for treating reading difficulties in the programme are based on the theories of the Russian neuropsychologist A.R. Luria [58, 68, 69] and have been described in a number of previous publications [37, 38, 66, 70, 71]. The materials used in the programme are electronic, and can either be downloaded or sent out by email.
At pre-reading level, the material is activity-based and focuses on developing phonological and phonemic awareness. The methods used in working with the material are described in accompanying manuals [72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86] which can be used by parents, teachers and therapists, and form the basis for the training of programme implementers.
The programme works with children from pre-reading and school readiness level. The transition to foundation level is made once the child has developed alphabetic awareness and the associations between the letters of the alphabet and the sounds used to represent the letters in English. The child is then introduced to reading through a series of fifteen foundation level reading books, using a structured language experience approach which integrates reading, writing, phonics and spelling with drawing and illustration. This is done through six activity books based on families of rhyming words, which accompany the first six of the foundation level reading books, with the methods used described in accompanying manuals [75, 82, 86].
Once the child has developed the ability to read three letter words and words based on short vowel sounds and beginning and ending consonant blends and clusters, repetitive paired reading is introduced, focusing initially on reading of sentences. Comprehension is developed through drawing and illustration of reading content.
Once the child can read and write phonically based words as well as sentences using three letter words in context, reading fluency work is commenced using large print phonically based reading books, based on the model for treatment of reading acquisition, reading fluency and reading comprehension development represented in Table 3.
Table 3.
Model for Reading fluency development.
The procedures used are documented in a user’s manual which includes both theory and the methods used in programme implementation [72]. In addition, there is a parent implementer’s manual which presents a step by step approach to implementation [78].
7. Methods used for treatment of reading fluency difficulties
The development of the large-print, phonically based material used for developing reading fluency in the programme has been described in a separate publication [66]. The methods used for developing reading fluency involve use of a paired reading method called the 3 x 3 Oral Impress Method. This is designed to be used with a series of electronic reading fluency books which are graded, and written in a way which builds repetition into the words used, as well as phrases used in sentences.
The material presents letters and letter strings associated with particular sounds repetitively in an uncluttered format. Repetitive oral reading is then used together with visual tracking of the printed words to develop and then automatise the associations between the configuration of the letters within phonically regular words and their sounds as used in the written language the child sees, the spoken language the child hears, and the words read by both adult and child [87].
This is done by working with the reading material three paragraphs at a time in the following way (Table 4).
Paragraph One
Child reads
Parent and Child read together
Parent reads
Paragraph Two
Parent reads
Child reads
Parent and Child read together
Paragraph Three
Parent and Child read together
Parent reads
Child reads
Table 4.
The 3 x 3 Oral impress method.
The aim, as Luria suggests [58, 68], is to enhance cerebral organisation based on a repetitive process. This was also Heckelman’s view when he pioneered the use of paired reading as a procedure [88, 89, 90], suggesting that paired reading is “one of the most direct and fundamental systems of reading” involving a “combination of reflexive neurological systems.” We have reported similar positive results [38, 66], supporting Heckelman’s position that gains made are based on increasing neurological integrity.
The model for developing using the phonically-based, large print reading materials to develop reading fluency would be conceptualised as based on the coding and recoding of phonic associations [91, 92, 93]. Following Dehaene [94, 95], what the 3 x 3 Oral Impress Method does when used with our phonically based large-print reading fluency books is to present the visual word form area in the brain with strings of letters representing sounds repeatedly. This would have the effect of strengthening the connections between the visual areas in the brain and the areas of the brain involved in processing sounds and oral language, thus enabling the child first to read, and then to read fluently.
8. Treating difficulties with rapid naming
The relationship between rapid naming and reading difficulties has been established by a number of researchers [96, 97, 98, 99, 100, 101, 102]. What has not been clearly established is whether rapid naming is a separate factor influencing reading performance, and whether it is responsive to training [103, 104]. Recent research indicates that training interventions in this area are possible [105, 106], but that more controlled studies are still necessary on whether rapid naming can be trained, and how it can be trained. The descriptions provided in this section should be viewed in this context.
Our methods focus on teaching rapid naming of letters, words and numbers, as well as teaching rapid reading. At initial stages in the programme, rapid naming of letters is conducted using phonogram cards. Rapid naming of words is conducted using key words drawn from our phonically-based large print reading material. Rapid naming of numbers is trained through rapid marking of arithmetic worksheets. Rapid reading is also taught developmentally using the 3 x 3 Oral Impress Method [72], which focuses on accurate naming of phonically regular words and sentences, and then on rapid and accurate reading of a wider range of reading material.
The material used is phonically graded as well as repetitive, and the aim in the initial stages is to work with words which become increasingly familiar to the child, to develop accurate and rapid naming ability for individual words and words in sequence. This is done through the repetitive methods used to develop automaticity in reading [74], as well as through activities in which the child is asked to name letters and numbers in worksheets based on both familiar and unfamiliar content. Tachistoscopic work is then introduced at later stages in the programme [107], working repetitively with words of increasing length drawn from an electronic dictionary, as well as with words drawn from graded revisualisation materials and the child’s school books.
Using computer-based presentation, length of words presented, time exposure of the presentation of each word and time between the exposure of each word can be treated as variables. Other variables involve the ways in which words can be presented, read, revisualised and written down, following the procedures outlined in Table 5.
Table 5.
Methods for treating rapid naming difficulties.
The methods used for developing rapid naming in the child’s programme thus link with the methods used for training fluency in reading, and include activities methods designed to develop rapid naming of words as well as activities aimed at developing increasing familiarity with words. Based on Luria’s theories of automaticity [58], repetition would be intrinsic to the development of fluency in reading. As Dehaene [95] has noted, familiarity with material influences fluency. The aim of our methods is to use repetitive paired reading to develop the coding, recoding, working memory and rapid naming abilities necessary for fluent and accurate reading, and for self-teaching [108].
9. Developing automaticity in writing and spelling
Fluency in writing and spelling is addressed in our programme through a variety of methods involving linking the teaching of phonic associations with training in basic skills in writing and copying. This is done by teaching the child how to work from print to sound, how to analyse words based on phonic analysis of how words work, and how to use the letters and letter combinations used to represent the vowels in words as the basis for remembering how words are spelled both individually and in sequence. This is done through a process we call “phonological referencing” which focuses on the coding and recoding of phonic associations [80].
This is done using word families of between five and six words, supported by sentences in which the words are analysed in sequence, revisualised and then tested. The aim is to use revisualisation of words and sequences of words as an integral part of the process of learning to write and spell, with the aim of developing the phonological, phonic and sequential working memory processes involved in writing rapidly and accurately in sequence [84, 85].
The model for using our phonically-based, large print materials for developing writing and spelling fluency, is represented in Table 6.
Table 6.
Model for developing writing and spelling fluency based on activities involving development of reading, writing, spelling, phonic analysis and revisualisation.
Following Luria’s theories [58], our methods use repetition as intrinsic to the development of automaticity in writing and spelling fluency. As with reading fluency, the aim is to develop the coding, recoding and working memory abilities necessary for fluent and accurate writing and spelling [91, 92, 93, 108, 109].
At initial stages in the programme, the aim is to build phonological, orthographic and morphological awareness through phonological referencing [86]. This involves developing the child’s phonic analysis, visual memory and sequential working memory skills by methods which combine phonic analysis and revisualisation [74].
The phonic abilities of the child are established from analysis of the child’s errors on spelling tests, in the child’s descriptive writing, creative writing and school work, as well as through a series of phonic inventories [79]. Based on the pattern of errors, we initially involve the child in work with word families and phonogram cards targeting specific phonic errors in the profile. In the process, the child is introduced to working with the Seven Vowel Phonic Analysis System, which is a procedure for teaching children through activities involving mapping the combinations of letters used in writing words to the sounds made when those words are spoken orally [73, 74].
The aim is to combine phonic analysis and revisualisation in developing skills in word attack, spelling and sequential working memory. This is done through activities focusing on analysis of the letters and letter combinations used to represent the vowel sounds in words, combined with revisualisation activities focused on remembering sequences of words [84]. The sequence of instruction followed, and the links between phonological referencing, the introduction and application of the Seven Vowel Phonic Analysis System, and the combination of phonic analysis and revisualisation in the Targeted Revisualisation Programme [83], are represented in Table 7 below.
Table 7.
Introducing phonological referencing and the seven vowel phonic analysis system.
The sequence of instruction followed in implementing the programme thus integrates reading, writing and spelling through activities which are phonically-based, linking phonological, phonemic, visual memory and sequential working memory development. The methods used are outlined in a series of manuals which can be used by therapists, teachers, schools and parents [81, 82, 83, 84, 85].
10. Mapping the associations between spoken and written words
Both phonological referencing and the Seven Vowel Phonic Analysis System are used for point to point analysis of the links between the sequences of letters used in written words and the sequence of sounds made which the words are spoken orally. This is done through activities in which the child is taught to map the associations between the sequences of letters used in written words and the sequences of sounds used when the words are spoken orally [80].
The sequence of instruction followed in teaching the child is as follows:
After the child has learned the associations between sounds and letters, the child works with word families as well as with phonogram and rime cards, which are used side by side with the process of phonological referencing. The basis for mapping is to link the individual letters and sequences of letters with the sequences of sounds made when the words are spoken out loud, based on the principle that “what we say is what we write.”
This stage involves activities in which the hand is placed under the chin to increase the ease by which the vowel sounds in words can be identified as part of the process of mapping letters to sounds and sounds to letters.
Particular focus is placed on identifying the vowel sounds in words (which are spoken when the mouth opens) and the consonant sounds (which are spoken when the mouth closes). The letters the child has written or typed form the departure point for linking what is written on paper with both sounds and mouth movements.
The aim is to enable the child to identify the vowel letters and the consonant letters used in written words, and then to link these back to the sounds made when the word is spoken orally.
Reverse mapping between the sequence of sounds in the word and the letters used in writing the word then takes place. Once the vowel sound in the word has been identified, the letters used to represent the vowel sound are then colour coded. In the process, short vowel sounds are identified as normally being made by one letter working by itself, while long vowel sounds are identified as normally being made by two letters working together.
As the focus lies on mapping the consistency between the sequences of letters used in written words with the sequences of sounds used when the words are spoken orally, the aim is to enable the child to build the variety of phonic associations necessary to read, write and spell in sequence. Visual memory, revisualisation and dictation activities are also used to develop the metacognitive and working memory processes necessary to remember and write sounds and letters in sequence, and words in sequence [110, 111, 112, 113, 114, 115, 116].
11. Increasing the transparency of written English
Much has been written about the transparency of the English language compared to other languages [117, 118, 119, 120, 121, 122], for the reason that the phonic associations underpinning English orthography are varied, with similar sounds being represented by different letter combinations. This means that both reading and spelling in English are not as easy for children to learn as in many other languages such as Italian, Afrikaans, Welsh, German, or French [123, 124, 125, 126, 127, 128, 129, 130]. This has potentially negative effects on the progress of children with learning disabilities [118, 119, 131, 132, 133].
Our materials attempt to overcome this problem at initial stages in the programme through the use of carefully chosen vocabulary. Phonic associations are initially taught through graded rhyming word activities, and then developed through activities involving reading, writing and use of working memory in spelling. Once the child has been introduced to the phonological referencing and colour coding process with individual words and families of rhyming words, he or she is also introduced to activities involving use of visual memory and revisualisation of words in sequence.
Word families of written words are used as the basis for analysing individual words, while written sentences are used as the basis for analysing words in sequence. This is done through activities based on sentences and paragraphs which include words in which the y and w combine with other letters to form long vowel sounds. These letter-sound associations are identified and then mapped using the Seven Vowel Phonic Analysis System [73, 74, 83].
In the process, the child is taught that a, e, i, o and u are the letters normally used to represent the vowel sounds in words, but that y and w can also be used to represent the represent the vowel sounds in positions at or near the end of written words in English. The Seven Vowel Phonic Analysis System is then worked with and applied through activities in which the child speaks the word out loud and then identifies the letters used as vowels in the word. Through activity-based learning, the child is introduced to the principle that there needs to be a vowel in every word, that the letters a, e, i, o and u are used to represent the vowels in all positions in words, and that the use of y and w as vowels at the end of words is both logical and consistent, applying to nearly all words in English.
The use of the Seven Vowel Phonic Analysis System thus enables the letters used to represent the sounds in both simple and complex written words to be identified through phonological referencing, and to be analysed following the principle that “what we say we write.” The aim is make written English as transparent as written Welsh, in which the use of the seven vowels a, e, i, o, and u, as well as y and w, also applies [122, 123, 133], making it logical and easier for children to learn.
12. Combining phonic analysis and revisualisation in developing sequential working memory for words
The methods for teaching spelling in our programme have been described in Potter [38, 70] and follow the phonologically and phonically-based stages in spelling described by Moats [134, 135], as well as the stages in a set of three phonic inventories based on the foundation level curriculum taught in primary schools in South Africa [79]. Phonic associations are initially introduced through graded rhyming word activities involving reading, writing and use of working memory in spelling. Focus is placed on teaching through synthetic phonic approaches incorporating teaching children to isolate sounds and blend sounds into words, as well as how to create families of rhyming words based on similar phonological and phonemic elements [75].
These are introduced side by side with reading fluency activities using our foundation level and then our basic level readers, through methods which use activity-based learning to build the variety of phonic associations necessary to read, write and spell. Phonic analysis is then introduced using phonological referencing [80], which is applied working with families of between five and seven words, each of which are based on a similar consonant blend of cluster. These are then contextualised in short sentences in which the words are then phonically analysed and revisualised in sequence. The aim is to develop the working memory integrities necessary to write accurately in sequence.
In the ck word family, for example, the following words would be written in the child’s writing book.
shock
brick
check
stack
cluck
trick
The vowel in each word would then be underlined in colour and matched with the way the mouth opens in making each vowel sound and the way the mouth closes in making each consonant sound. After this, the child would work with his or her reading partner and phonologically reference each word in the ck word family, by linking the sounds in each word when the word is spoken out loud with the letters used when the word is written down.
This would be done through an activity-based process, in which the child is asked to:
Point to the written word on the page and say it.
Look at the two letters at the beginning of the written word. Say the sound of these letters out loud.
Look at the vowel in the middle of the written word. Say the sound of this letter out loud.
Look at the two letters at the end of the written word. Say the the sound of these letters out loud.
The phonic rule applied in each of the words would then be focused on working with the reading partner. This would be done by focusing on how the beginning sound, the middle sound and the ending sound work together to make each word, and how the ck ending applies in each word.
Each of the words in the family would then be contextualised in sequence in a short sentence. The sentence would be written down by the child, and the vowel or vowels in each word in the sentence underlined in colour. After this, each word in the sentence would then be revisualised in sequence working memory tested by asking the child to rewrite the sentence from memory. These sequential revisualisation techniques would then be used further at higher levels in the programme [84].
13. Linking the development of phonic associations, visual memory and sequential working memory skills
The sequence of instruction followed with each child varies based on evidence of how the child learns, but is conducted with the aim of linking the development of phonic analysis, visual memory and working memory skills as represented in Table 8.
Table 8.
Methods linking phonic analysis, visual memory for strings of letters and words and sequential working memory for written words, phrases, sentences and paragraphs.
It will be apparent from Table 8 that the aim at each level of the programme is to work to combine phonological and phonic skills development with the development of visual memory and sequential working memory. This is done through methods which to combine the process of phonic analysis with the process of revisualisation in developing sequential working memory for words [83, 84], through a longitudinal process in which:
The child is taught to map the associations between the sequences of letters used in words and the sequences of sounds used when words are spoken orally through phonological referencing, as well as through use of phonogram and rime cards.
The child is taught that each written word is logical and can be analysed on the principle that “what we say is what we write.”
The child is shown how to use revisualisation to remember the sequences of letters used in individual words and the sequences of words in used in sentences.
Both phonic analysis and revisualisation are thus used to develop the child’s ability to store each word in working memory in sequence. This is initially done working with words in the context of sentences, and then with sequences of sentences. The child’s sequential working memory is tested through dictation.
At each level in the programme, the methods used are repetitive and follow the procedures for developing automaticity outlined by Luria [58, 68, 69], and are summarised in illustrated implementer manuals for users [74, 81, 83, 84, 85]. Once the child is able to recall sentences of between five and seven words accurately, span of sequential working memory is increased by phonic analysis and revisualisation of sentences of increasing length, as well as by phonic analysis and revisualisation of increasing numbers of sentences in sequence.
As our reading fluency materials are graded and phonically based, sentences and paragraphs from these can be used as the basis for activities which link reading, writing, spelling and sequential working memory work. More complex graded paragraphs and sequences of paragraphs are then introduced once the Targeted Analysis, Revisualisation and Sequential Spelling Programme is commenced, as described in the section following.
14. The targeted analysis, revisualisation and sequential spelling programme
Once the child is able to recall the words used in individual sentences and sequences of sentences accurately, the materials used in the Targeted Analysis, Revisualisation and Sequential Spelling Programme are introduced. The methods target words with more than one vowel, which are first written, then typed, then colour coded and then syllabified. The target words are then revisualised and tested [136].
After analysing and recalling the target words, the text of the graded materials is then worked with, focusing on each word in each sentence in sequence. Sequential revisualisation techniques are used. We call this process “targeted revisualisation” as each word is targeted in sequence, using techniques which combine the procedures used for phonic analysis of the target words with the types of mental imagery the child uses in recalling words. These build on the activities linking phonic analysis and revisualisation, and the methods used for developing sequential working memory used at previous levels in the programme.
The aim is to use accuracy in use of sequential working memory for words as the basis for developing fluency and automaticity in writing and spelling [38]. This is done in four stages, as outlined in Table 9.
Level of mediation
Focuses of phonic analysis
Focuses of revisualisation
Focuses of use of sequential working memory
Stage One: Focus on Words based on Short Vowel Sounds
Introduce concept that vowels are used in all spoken and written words. Identify and mediate short vowel sounds a, e, i, o, and u.
Construct, deconstruct, mentally image and revisualise words and rhyming word families containing short vowel sounds.
Use working memory in writing rhyming words based on short vowel sounds in sequence.
Stage Two: Focus on Words based on Long Vowel Sounds
Identify and mediate long vowel sounds involving use of digraphs involving a, e, i, o, and u. Introduce the letters y and w as vowels in positions at or near the end of words.
Construct, deconstruct, mentally image and revisualise words and rhyming word families containing long vowel sounds, including use of the letters y and w as vowels in positions at or near the end of words.
Use working memory in writing sequences of words containing both long and short vowel sounds, including use of the letters y and w as vowels in positions at or near the end of words.
Stage Three: Focus on Sequentialisation of Words in Sentences
Identify letters used as vowels in words used in sequence in sentences.
Identify, phonically analyse, mentally image and revisualise single syllable and polysyllabic words in sequence in sentences.
Use working memory in writing single syllable and polysyllabic words in sequence in sentences and sequences of sentences.
Stage Four: Focus on Sequentialisation of Words and Sentences in Paragraphs
Identify letters used as vowels in words used in sequence in sentences, and in sentences used in sequence in paragraphs.
Identify, phonically analyse, mentally image and revisualise single syllable and polysyllabic words in sequence in paragraphs.
Use working memory in writing sentences in sequence in paragraphs of increasing length and phonic complexity.
Table 9.
Stages and focuses of mediation in the targeted analysis, revisualisation and sequential spelling programme.
The Targeted Analysis, Revisualisation and Sequential Spelling Programme is applied using graded paragraphs, which increase in complexity as well as length. As these are worked with, the process of combining phonic analysis and revisualisation in using the Seven Vowel Phonic Analysis System is applied repetitively. This is done by working from printed word to sound, and from sound back to print. These phonological recoding skills provide the building blocks on which writing and spelling fluency is developed [71].
On a phonological and phonic level, the methods used are based on the coding and recoding of phonic associations through activities in which the child writes, types and colour codes the vowels in words by underlining the letters used to represent the vowel sounds in colour as well as using the colour coding feature in a word processing programme. This adds a visual dimension to the targeted revisualisation process, as the methods used are designed to make the letters used to represent the vowel sounds in words stand out in colour [83].
Both phonic associations and visual contrasts are then used to identify the letters representing the vowel sounds in words, with the aim of enabling the child to develop working memory for individual words as well as sequential working memory for words in sequence. Fluency in writing and spelling is then based on increasing span of sequential working memory as well as automaticity in recalling the sequences of letters used in individual words, the sequences of words used in sentences, and the sequences of sentences used in paragraphs.
At higher levels in the programme, rapid reading of words and working memory for words are also developed through use of tachistoscopic methods conducted side by side with targeted revisualisation [107]. Children who have worked in this way report effects in improving word attack in reading, as well as improvements in rate of processing words, rate of reading, spelling accuracy and rate of work.
15. Treatment of difficulties with calculation and numerical problem-solving
In addition to the strands in the child’s programme focused on treating difficulties with reading, writing and spelling, numerical and problem-solving activities are also included in the programme, using electronic materials which can be worked with online, as well as sent to parents and children by email [71]. The aim of using this format-based multivariate treatment system is to enable treatment of the functional difficulties identified in assessment, while at the same time addressing needs indicated by the errors made by the child in his or her school work.
The format system is flexible and comprehensive enough to be able to focus on areas of strength as well as needs, while also enabling email delivery of the activities included in each child’s individual programme. Number concept development can also be linked to language and problem-solving activities, with support programmes linked to the developmental model outlined in Table 10. These activities are then implemented side by side with the mathematical curriculum taught at school.
Table 10.
Model for development of number concept, numerical fluency, numerical reasoning and numerical problem solving.
It will be apparent from Table 10 that at the same time as treating numerical and mathematical difficulties identified in the initial assessment, the learning support provided is both diagnostic and based on clinical teaching, as well as linked to numerical and mathematical concepts covered in the child’s work at school. As with other areas of our programme, the aim is to treat functional difficulties as well as to evaluate the child’s response to specific types of interventions, as outlined in the section following.
16. Progress evaluation
Work with each child is conducted longitudinally, and is based on a cycle in which evaluation forms an integral part of both planning and implementation. Feedback on specific activities in the format is also provided by photographs sent by email or WhatsApp, enabling the planning of the next format in the child’s programme to be evidence-based, linked to ongoing evaluation of learning needs. Assessment is then built into programme implementation at regular intervals.
The model used for implementation is action research based [137, 138, 139], and can be summarised as follows (Table 11).
Table 11.
Action research cycle for planning and implementation of activity-based online programmes.
As the programme’s data base is extensive, the planning and implementation model implies that each child’s programme is evidence-based and multivariate, addressing a number of different learning needs through use of a variety of graded activities. The programme is then implemented using online sessions supported by learning materials provided by email [71].
The aim is that programme implementation can take place with support from parents, teachers, tutors or au paires as reading partners, working with a variety of electronic materials delivered by email or made accessible online via links to websites. Methods used in the programme are documented in illustrated implementer manuals, and are demonstrated working online, supported by cell phone and email contact.
Both evaluation programme activities and evaluation of progress are linked to evidence from the child’s school work and school reports at regular points in primary, with full re-assessment and summative evaluation being conducted at point of transition to high school. The aim at this point is to make a firm diagnosis of learning disability which can be linked to concessions.
The aim is to ensure that firm classification and labelling of a child as learning disabled is valid [36], based both on longitudinal analysis of test results as well as response to specific interventions [140, 141], on the model described in the section following.
17. Firm classification of particular types of learning disability on the basis of response to intervention
In implementing the different types of interventions which have been described in this chapter, the programme focuses on a number of different variables related to the areas of difficulty. Interventions are normally longitudinal and conducted side by side with the curriculum taught in the child’s school.
The programme works with the aim of providing fluency-based interventions which can develop basic skills and competences in reading, writing, spelling as well as numeracy. At the same time, evidence-based learning support is provided focused on areas of the school curriculum with which the child is experiencing difficulties. This type of multivariate intervention is implemented using formats based on an online session providing counselling followed by an intervention, supported by electronic materials which can then be used by parents and children working in conjunction with a teacher or therapist, or independently [71].
At the outset the child’s difficulties are described functionally. This enables labelling to be avoided, until such time as the child has had benefit of focused multivariate treatment, and is also likely to be more developmentally and neurologically mature [142, 143, 144, 145]. As maturation takes place, firm diagnosis and classification of learning disability then becomes to the child’s benefit, as it can be linked to concessions related to areas of ongoing difficulty. This can be linked both to cross-sectional assessment as well as evaluation of response to interventions which have been based on multivariate treatment using particular types of methods and materials.
In our programme, firm classification as learning disabled is thus normally undertaken at the end of a child’s primary school years, based on evidence collected by use of different methods over time [146, 147], within a model of inference based on a process of incremental validity [34, 35, 148]. Diagnosis can then be linked to concessions to compensate for those areas of difficulty which have been demonstrated to be resistant to particular forms of treatment, as well as to ongoing treatment and learning support in particular areas of the high school curriculum.
The model for classification of learning disabilities is reflected in Table 12 on the previous page. It will be noted that the model is multimethod, based on summative assessment linked to progress evaluation of longitudinal interventions conducted across a number of areas of functional difficulty, enabling triangulation across different data points over time [131].
Table 12.
Classification of learning disabilities based on response to multivariate fluency-based interventions.
This enables firmer conclusions as to the type of learning disability involved, as well as classification of learning disability based on specific evidence relating to response to particular types of treatment [141].
18. Summary and implications
This chapter has focused on treatment of the functional learning difficulties associated with dyslexia, dysgraphia and dyscalculia, as three dimensions of learning disability. As each of these dimensions can be associated with a range of reading, writing, spelling and working memory difficulties, the model of classification described in this chapter has been described with reference to a particular programme which uses a large data base to implement a variety of different activities with children diagnosed as having learning problems.
Owing to the measurement error implicit in testing young children who may have attention and focus difficulties in addition to functional difficulties with reading, writing, spelling and maths, the model of classification assumes that initial diagnosis of learning disabilities is at best provisional. For this reason, labelling of children is avoided at the outset. Functional indicators based on actual versus expected performance are used in preference, using ICD10 codes and descriptors as opposed to labelling using terms such as Dyslexia, Auditory Processing Problems, Language Processing Problems, Reading Comprehension Deficits, Dysgraphia, Visual Perceptual or Visual Motor Deficits, Non-Verbal Learning Deficits or Dyscalculia.
Detailed description of the initial assessment process has been provided in order to show that functional ICD 10 descriptors can be used instead of labels as the basis for establishing needs and areas of treatment. Treatments can then be targeted at these descriptors, being related to focus on specific problems with reading, writing and spelling, as well as numerical concepts and mathematical problem-solving. Difficulties outside these areas are then referred to other specialists.
Detailed description of particular methods, materials and programmes has also been provided in this chapter to indicate that once initial functional classification has taken place linked to specific areas of difficulty, multivariate interventions can then be developed and implemented. Firm classification then becomes possible based on the child’s progress over time.
One implication is that initial diagnosis of learning difficulties can be rigorous despite being provisional, providing detailed descriptions of specific areas of difficulty which are made with a view to undertaking multivariate treatment. Firm classification can then be made based on response to intervention at a time in the child is likely to be more developmentally and neurologically mature, and prior making a transition to new forms of teaching and new areas of learning at high school level.
Another implication is that the process of establishing firm diagnosis and classification would best be conducted at the end of a child’s primary school years, with a view to establishing concessions as well as the possibility of further treatment at higher levels in the curriculum. At this point firm diagnosis as having dyslexia, dysgraphia or dyscalculia can act to the child’s maximal benefit, in maximising the chances of obtaining the concessions and further treatments necessary to making the grade.
As the response to intervention classification model described in this chapter has been successfully applied in practice,7 a third implication is that the model is feasible and may have wider relevance. It offers the possibility that firm classification as learning disabled can be based on the child’s response to treatment which has been focused, multivariate and multimethod. In terms of the model, firm diagnosis of children as dyslexic, dysgraphic or dyscalculaic becomes an outcome taking place after treatment, linked to the possibility of concessions as well as additional interventions.
\n',keywords:"dyslexia, dysgraphia, dyscalculia, reading, writing, spelling, numeracy, working memory, assessment, evaluation, response to intervention, incremental validity; multivariate treatment",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/79900.pdf",chapterXML:"https://mts.intechopen.com/source/xml/79900.xml",downloadPdfUrl:"/chapter/pdf-download/79900",previewPdfUrl:"/chapter/pdf-preview/79900",totalDownloads:152,totalViews:0,totalCrossrefCites:0,dateSubmitted:"August 22nd 2021",dateReviewed:"October 11th 2021",datePrePublished:"January 5th 2022",datePublished:"March 30th 2022",dateFinished:"January 5th 2022",readingETA:"0",abstract:"This chapter provides a model for classification of dyslexia, dysgraphia and dyscalculia through analysis of the response of children to treatment. The model is discussed with reference to the types of multivariate treatment applied in a particular programme which works interactively online using an electronic data-base for linking functional difficulties in learning to treatment, and through this to firm diagnosis and classification. In applying the model, initial diagnosis of learning disabilities is treated as provisional, based on functional indicators as well as test data. Firm classification becomes possible through longitudinal assessment, analysis of response to multivariate intervention as well as response to specific programmes. Diagnosis can then be linked both to concessions as well as ongoing treatment.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/79900",risUrl:"/chapter/ris/79900",signatures:"Charles Potter",book:{id:"10910",type:"book",title:"Learning Disabilities",subtitle:"Neurobiology, Assessment, Clinical Features and Treatments",fullTitle:"Learning Disabilities - Neurobiology, Assessment, Clinical Features and Treatments",slug:"learning-disabilities-neurobiology-assessment-clinical-features-and-treatments",publishedDate:"March 30th 2022",bookSignature:"Sandro Misciagna",coverURL:"https://cdn.intechopen.com/books/images_new/10910.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83968-588-0",printIsbn:"978-1-83968-587-3",pdfIsbn:"978-1-83968-589-7",isAvailableForWebshopOrdering:!0,editors:[{id:"103586",title:null,name:"Sandro",middleName:null,surname:"Misciagna",slug:"sandro-misciagna",fullName:"Sandro Misciagna"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"93190",title:"Dr.",name:"Charles",middleName:null,surname:"Potter",fullName:"Charles Potter",slug:"charles-potter",email:"pottercs@gmail.com",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93190/images/6641_n.jpg",institution:{name:"University of the Witwatersrand",institutionURL:null,country:{name:"South Africa"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Classification of learning disabilities",level:"1"},{id:"sec_3",title:"3. Functional description of different types of learning difficulties: a response to intervention perspective",level:"1"},{id:"sec_4",title:"4. Initial assessment: focus on functional difficulties",level:"1"},{id:"sec_5",title:"5. Evidence-based multivariate treatment: a response to intervention model",level:"1"},{id:"sec_6",title:"6. Applying the model: treatment of reading difficulties",level:"1"},{id:"sec_7",title:"7. Methods used for treatment of reading fluency difficulties",level:"1"},{id:"sec_8",title:"8. Treating difficulties with rapid naming",level:"1"},{id:"sec_9",title:"9. Developing automaticity in writing and spelling",level:"1"},{id:"sec_10",title:"10. Mapping the associations between spoken and written words",level:"1"},{id:"sec_11",title:"11. Increasing the transparency of written English",level:"1"},{id:"sec_12",title:"12. Combining phonic analysis and revisualisation in developing sequential working memory for words",level:"1"},{id:"sec_13",title:"13. Linking the development of phonic associations, visual memory and sequential working memory skills",level:"1"},{id:"sec_14",title:"14. The targeted analysis, revisualisation and sequential spelling programme",level:"1"},{id:"sec_15",title:"15. Treatment of difficulties with calculation and numerical problem-solving",level:"1"},{id:"sec_16",title:"16. Progress evaluation",level:"1"},{id:"sec_17",title:"17. Firm classification of particular types of learning disability on the basis of response to intervention",level:"1"},{id:"sec_18",title:"18. Summary and implications",level:"1"}],chapterReferences:[{id:"B1",body:'Hinshelwood J. Congenital word blindness. The Lancet. 1900:1506-1508'},{id:"B2",body:'Morgan WP. A case of congenital word blindness. British Medical Journal. 1896;1378'},{id:"B3",body:'Orton ST. “Word-blindness” in school children. 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Berlin: Walter de Gruyter; 1976'},{id:"B70",body:'Potter CS. Training reading, writing and spelling fluency: Centre-periphery dissemination through interactive multimedia. In: Cvetković D, editor. Interactive Multimedia - Multimedia Production and Digital Storytelling. London: InIntech; 2019 Available from: https://www.intechopen.com/books/interactive-multimedia-multimedia-production-and-digital-storytelling/training-reading-writing-and-spelling-fluency-centre-periphery-dissemination-through-interactive-mul'},{id:"B71",body:'Potter CS. Activity-Based Online Learning: A Response to Dyslexia and COVID. London: IntechOpen; 2021. DOI: 10.5772/intechopen.96359 Available from: https://www.intechopen.com/online-first/75959'},{id:"B72",body:'Potter CS. 2012. The 3 x 3 Oral Impress System: A Manual. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B73",body:'Potter CS. 2014. The Seven Vowel Phonic Analysis System: A Manual. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B74",body:'Potter CS. 2018. Introducing the Seven Vowel Phonic Analysis System: A Manual for Parent Implementers. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B75",body:'Potter CS. 2018. Foundation Level Manual. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B76",body:'Potter CS. 2018. Pre-reading Level Manual. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B77",body:'Potter CS. 2018. Manual for Administration of Core Tests. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B78",body:'Potter CS. 2019. Introducing the 3 x 3 Oral Impress Method: A Manual for Parent Implementers. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B79",body:'Potter CS. 2019. Introducing the Phonic Inventories: A Parent Implementer\'s Manual. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B80",body:'Potter CS. 2019. Using Phonological Referencing to Develop Phonic Associations: A Guide for Parent Implementers. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B81",body:'Potter CS. 2020. Introducing the Targeted Analysis, Revisualisation and Sequential Spelling Programme: A Manual for Parent Implementers. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B82",body:'Potter CS. 2020. Introducing the Foundation Level Activity Books Using the Structured Language Experience Approach: A Parent Implementer’s Manual. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B83",body:'Potter CS. 2020. Using the Targeted Analysis, Revisualisation and Sequential Spelling Programme: Method for Teaching Targeted Revisualisation in Implementing the Seven Vowel Phonic Analysis System. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B84",body:'Potter CS. 2020. Using the Targeted Analysis, Revisualisation and Sequential Spelling Programme: Method for Developing Working Memory for Individual Words, Rhyming Word Families and Sequences of Words in Sentences. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B85",body:'Potter CS. 2020. Using the Targeted Analysis, Revisualisation and Sequential Spelling Programme: Method for Increasing Span of Working Memory for Sequences of Words and Sequences of Sentences. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B86",body:'Potter CS. 2021. Introducing the Pre-Reading and Foundation Level Materials: A Parent Implementer’s Manual. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B87",body:'Rayner K, Sereno SC, Lesch MF, Pollatsek A. Phonological codes are automatically activated during reading: Evidence from an eye movement priming paradigm. Psychological Science. 1995;6:26-32'},{id:"B88",body:'Heckelman RG. In: Heckelman RG, editor. A Neurological Impress Method of Reading Instruction. Merced, CA: Merced County Schools Office; 1962'},{id:"B89",body:'Heckelman RG. A neurological-impress method of remedial-reading instruction. Academic Therapy. 1969;4(4):277-282'},{id:"B90",body:'Heckelman RG. N.I.M. revisited. Academic Therapy. 1986;21(4):411-420'},{id:"B91",body:'Jorm A, Share D. Phonological recoding and reading acquisition. Applied PsychoLinguistics. 1983;4:103-147'},{id:"B92",body:'Jorm A, Share D, Maclean R, Matthews R. Phonological recoding skills and learning to read: A longitudinal study. Applied PsychoLinguistics. 1984;5:201-207'},{id:"B93",body:'Share DL. Phonological recoding and self-teaching: Sine qua non of reading acquisition. Cognition. 1995;55(2):151-218'},{id:"B94",body:'Dehaene S. Reading in the Brain. New York: Penguin Books; 2009'},{id:"B95",body:'Dehaene S. How We Learn: Why Brains Learn Better than Any Machine... for now. New York: Penguin Books; 2020'},{id:"B96",body:'Bowers PG, Wolf M. Theoretical links between naming speed, precise timing mechanisms and orthographic skill in dyslexia. Reading and Writing: An Interdisciplinary Journal. 1993;5:69-85'},{id:"B97",body:'Wolf M, Bowers PG. The double-deficit hypothesis for the developmental dyslexias. Journal of Educational Psychology. 1999;91:415-438'},{id:"B98",body:'Cutting LE, Denckla MB. The relationship of serial rapid naming and word reading in normally developing readers: An exploratory model. Reading and Writing. 2001;14:673-705'},{id:"B99",body:'Wolf M, Bowers PG, Biddle K. Naming-speed processes, timing, and reading: A conceptual review. Journal of Learning Disabilities. 2000;33(4):387-407'},{id:"B100",body:'Norton ES, Wolf M. Rapid automatized Naming (RAN) and reading fluency: Implications for understanding and treatment of reading disabilities. Annual Review of Psychology. 2012;63(1):427-452'},{id:"B101",body:'Araújo S, Inácio F, Francisco A, Faísca L, Petersson KM, Reis A. Component processes subserving rapid automatized naming in dyslexic and non-dyslexic readers. Dyslexia. 2011;17:242-255'},{id:"B102",body:'Araújo S, Reis A, Petersson KM, Faísca L. Rapid automatized naming and reading performance: A meta-analysis. Journal of Educational Psychology. 2015;107(3):868-883'},{id:"B103",body:'Lemoine HE, Levy BA, Hutchinson A. Increasing the naming speed of poor readers: Representations formed across repetitions. Journal of Experimental Child Psychology. 1993;55(3):297-328'},{id:"B104",body:'De Jong PF, Vrielink LO. Rapid automatic naming: Easy to measure, hard to improve (quickly). 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Butterfield, Advances in Cognition and Educational Practice, VoL 2: Children\'s Writing: Toward a Process Theory of the Development of Skilled Writing. Greenwich, CI: JAI Press, pp. 31-56'},{id:"B114",body:'McCutchen D. A capacity theory of writing: Working memory in composition. Educational Psychology Review. 1996;8(3):299-325'},{id:"B115",body:'Newcomer PL, Barenbaum EM. The written composing ability of children with learning disabilities: A review of the literature from 1980 to 1990. J. Learn. Disab. 1991;24:578-593'},{id:"B116",body:'McCutchen D. Knowledge, processing, and working memory: Implications for a theory of writing. Educational Psychologist. 2000;35(1):13-23'},{id:"B117",body:'Seymour PHK, Aro M, Erskine JM. Foundation literacy acquisition in European orthographies. British Journal of Psychology. 2003;94:143-174'},{id:"B118",body:'Ziegler JC, Perry C, Ma-Wyatt A, Ladner D, Körne GS. Developmental dyslexia in different languages: Language specific or universal? Journal of Experimental Child Psychology. 2003;86:169-193'},{id:"B119",body:'Ziegler JC, Goswami U. Reading acquisition, developmental dyslexia, and skilled reading across languages: A psycholinguistic grain size theory. Psychological Bulletin. 2005;131(1):3-29'},{id:"B120",body:'Serrano F, Defior S. Dyslexia speed problems in a transparent orthography. Annals of Dyslexia. 2008;58:81'},{id:"B121",body:'Hengeveld K, Leufkens S. Transparent and non-transparent languages. Folia Linguistica. 2018;52(1):139-175'},{id:"B122",body:'Ellis NC, Hooper AM. Why learning to read is easier in Welsh than in English: Orthographic transparency effects evinced with frequency-matched tests. Applied PsychoLinguistics. 2001;22:571-599'},{id:"B123",body:'Spencer LH, Hanley JR. Effects of orthographic transparency on reading and phoneme awareness in children learning to read in Wales. British Journal of Psychology. 2003;94(1):1-28'},{id:"B124",body:'De Sousa D, Greenop K, Fry J. Cross-language transfer of spelling strategies in English and Afrikaans Grade 3 children. International Journal of Bilingual Education and Bilingualism. 2011;14(1):49-67'},{id:"B125",body:'Bruck M, Genesee F, Caravolas M. A cross-linguistic study of early literacy acquisition. In: Blachman BA, editor. Foundations of Reading Acquisition and Dyslexia: Implications for Early Intervention. Mahwah, NJ: Erlbaum; 1997. pp. 145-162'},{id:"B126",body:'Geva E, Wade-Woolley L, Shany M. The concurrent development of spelling and decoding in two different orthographies. Journal of Reading Behavior. 1993;25:383-406'},{id:"B127",body:'Sprenger-Charolles L, Siegel LS, Bonnet P. Reading and spelling acquisition in French: The role of phonological mediation and orthographic factors. Journal of Experimental Child Psychology. 1998;68:134-165'},{id:"B128",body:'Wimmer H, Goswami U. The influence of orthographic consistency on reading development: Word recognition in English and German children. Cognition. 1994;51:91-103'},{id:"B129",body:'Landerl K, Wimmer H, Frith U. The impact of orthographic consistency on dyslexia: A German–English comparison. Cognition. 1997;63:315-334'},{id:"B130",body:'Landerl K. Influences of orthographic consistency and reading instruction on the development of nonword reading skills. European Journal of Psychology of Education. 2000;15:239-257'},{id:"B131",body:'Potter CS. Multimethod research. In: Wagner C, Kawulich B, Garner M, editors. Doing Social Research: A Global Context. New York: McGrawhill; 2012. pp. 161-174'},{id:"B132",body:'De Jong PF, van der Leij A. Developmental changes in the manifestation of a phonological deficit in dyslexic children learning to read a regular orthography. Journal of Educational Psychology. 2003;95:22-40'},{id:"B133",body:'Hanley JR, Masterson J, Spencer LH, Evans D. How long do the advantages of learning a transparent orthography last? An investigation of the reading skills and incidence of dyslexia in Welsh children at 10 years of age. Quarterly Journal of Experimental Psychology: Human Experimental Psychology. 2004;57(A):1393-1410'},{id:"B134",body:'Moats LC. How spelling supports reading: And why it is more regular and predictable than you may think. American Educator. 2005;6(12–22):12-43'},{id:"B135",body:'Moats L. Knowledge foundations for teaching reading and spelling. Reading and Writing. 2009;22:379-399'},{id:"B136",body:'Potter CS. 2020. Introducing the Targeted Analysis, Revisualisation and Sequential Spelling Programme: A Manual for Parent Implementers. Electronic copy available from my practice by emailing me at pottercs@gmail.com'},{id:"B137",body:'Rudduck J, Hopkins D, editors. Research as a Basis for Teaching: Readings from the Work of Lawrence Stenhouse. London: Heinemann; 1985'},{id:"B138",body:'Stenhouse L. An Introduction to Curriculum Research and Development. London: Heinemann; 1975'},{id:"B139",body:'Stenhouse L. Curriculum Research and the Art of the Teacher. Curriculum. 1980;1((1), (Spring Issue)):40-44'},{id:"B140",body:'McIntosh K, Brown JA, Borgmeier CJ. Validity of functional behavior assessment within a response to intervention framework: Evidence, recommended practice, and future directions. Assessment for Effective Intervention. 2008;34(1):6-14'},{id:"B141",body:'Barnett D.W., Hawkins R., Prasse D., Graden J., Nantais M., Pan W. (2007). Decision-making validity in response to intervention. In: S.R. Jimerson, M.K. Burns & A.M. Van Der Heyden (Eds)., Handbook of Response to Intervention The Science and Practice of Assessment and Intervention. Boston, MA: Springer'},{id:"B142",body:'Spreen O. Learning disability, neurology, and long-term outcome: Some implications for the individual and for society. Journal of Clinical and Experimental Neuropsychology. 1989;11(3):389-408'},{id:"B143",body:'Doehring DG. Reading Disabilities: The Interaction of Reading, Language, and Neuro-Psychological Deficits. New York: Academic Press; 1981'},{id:"B144",body:'Denckla MB. Biological correlates of learning and attention: What is relevant to learning disability and attention-deficit hyperactivity disorder? Developmental and Behavioral Pediatrics. 1996;17:114-119'},{id:"B145",body:'Cherkes-Julkowski M. Learning disability, attention-deficit disorder, and language impairment as outcomes of prematurity: A longitudinal descriptive study. Journal of Learning Disabilities. 1998;31(3):294-306'},{id:"B146",body:'Guba EG, Lincoln YS. Epistemological and methodological bases of naturalistic inquiry. Educational Communication & Technology Journal. 1982;30(4):233-252'},{id:"B147",body:'Guba EG, Lincoln YS. Naturalistic Inquiry. Beverly Hills, CA: Sage Publications; 1985. p. 1985'},{id:"B148",body:'Dawes RM. Two methods for studying the incremental validity of a Rorschach variable. Psychological Assessment. 1999;11:297-302'}],footnotes:[{id:"fn1",explanation:"Dr. Charles Potter’s Reading Programme is an intervention programme linked to the author’s practice as a psychologist. The programme uses electronic materials as the basis for intervention, and has assembled an extensive database of reading fluency books as well as developmental writing and spelling materials which are implemented using methods developed as part of my clinical work as a psychologist. Training is offered to prospective users of the materials and methods, and as a result there is now a network of parent, teacher and therapist users in different countries who connect with each other by cell phone and email."},{id:"fn2",explanation:"The ICD-10 (International Statistical Classification of Diseases and Related Health Problems – Tenth Revision) is a diagnostic coding standard owned and maintained by the World Health Organisation (WHO) [53]. The coding standard has been adopted by the National Health Information System of South Africa (NHISSA), and forms part of the health information strategy of the South African National Department of Health (NDoH). The standard serves as the diagnostic coding standard of choice in both the public and private healthcare sectors in South Africa for morbidity coding under Regulation 5(f) of the Medical Schemes Act 131 of 1998 [54]."},{id:"fn3",explanation:"The ICD is produced by a global health agency (The World Health Organisation) with a constitutional public health mission, while the DSM is produced by a national professional association (The American Psychiatric Association). While initially using different diagnostic classification systems, the DSM and ICD have over time become very similar, due to collaboration between the two organisations, with the result that the coding system utilised by the DSM-IV [55] is designed to correspond with codes from the International Classification of Diseases, Ninth Revision, Clinical Modification, commonly referred to as the ICD-9-CM [56]. The coding system for the later revised DSM-IV TR [57] is designed to correspond with codes from the International Classification of Diseases, Tenth Revision, commonly referred to as ICD-10 [53], which has been adopted by South African medical aid societies."},{id:"fn4",explanation:"In South Africa, due to the similarity between the DSM IV and ICD classification systems, the DSM IV criteria have been used since August 2005 for the purpose of deriving ICD-10 codes by all healthcare providers except pharmacists, clinical support and allied healthcare providers [60]. The mandatory submission of ICD-10 codes by these groups was postponed until 1 January 2006. As from this date. The criteria have been referred to as the ICD DSMIV criteria, and ICD-10 coding has been mandatory for all health providers (including pharmacists and clinical support and allied healthcare providers). At time of writing the ICD DSMIV criteria have been phased out by South African medical aids and replaced by the ICD DSM V criteria."},{id:"fn5",explanation:"The author has worked with children under the care of a number of paediatricians and neurologists, but particularly closely with Dr. Graeme Maxwell, neurosurgeon, of Sandton Clinic until his retirement in 2020, and more recently with Dr. Dimitri Manoussakis, neurologist, of Flora Clinic. The stabilisation of focus and attentional difficulties as well as attendant attentional lapses and symptoms of cortical irritability has been an essential feature of the fluency-based interventions provided in the author’s practice. Behavioural, emotional, parental as well as chemical interventions are also likely to contribute to the gains made by children treated by the programmes described in this chapter."},{id:"fn6",explanation:"In South Africa, due to the similarity between the DSM IV and ICD classification systems, the DSM IV criteria have been used since August 2005 for the purpose of deriving ICD-10 codes by all healthcare providers except pharmacists, clinical support and allied healthcare providers. The DSM V criteria were published in May 2013, with both ICD-9-CM and ICD-10-CM codes assigned to each of the DSM V diagnoses [63]."},{id:"fn7",explanation:"The author has applied the response to intervention classification model working in association with Robert Thomas-Stark, psychologist, of the Centre for Therapeutic Excellence, Johannesburg. To maximise validity, this has involved longitudinal and cross-sectional assessment by two therapists, leading to a collaborative diagnostic report."}],contributors:[{corresp:"yes",contributorFullName:"Charles Potter",address:"pottercs@gmail.com",affiliation:'
Educational Psychologist in Private Practice, Johannesburg, South Africa
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Shohel"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"104",title:"Geology and Geophysics",slug:"geology-and-geophysics",parent:{id:"10",title:"Earth and Planetary Sciences",slug:"earth-and-planetary-sciences"},numberOfBooks:68,numberOfSeries:0,numberOfAuthorsAndEditors:1462,numberOfWosCitations:2116,numberOfCrossrefCitations:1212,numberOfDimensionsCitations:2613,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicId:"104",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"10013",title:"Geothermal Energy",subtitle:null,isOpenForSubmission:!1,hash:"a5f5277a1c0616ce6b35f4b44a4cac7a",slug:"geothermal-energy",bookSignature:"Basel I. 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Perotti, S. Carruba, M. Rinaldi, G. Bertozzi, L. Feltre and M. Rahimi",authors:[{id:"38310",title:"Dr.",name:"Stefano",middleName:null,surname:"Carruba",slug:"stefano-carruba",fullName:"Stefano Carruba"},{id:"42459",title:"Prof.",name:"Cesare",middleName:null,surname:"Perotti",slug:"cesare-perotti",fullName:"Cesare Perotti"},{id:"42460",title:"Dr.",name:"Marco",middleName:null,surname:"Rinaldi",slug:"marco-rinaldi",fullName:"Marco Rinaldi"},{id:"42465",title:"Dr.",name:"Giuseppe",middleName:null,surname:"Bertozzi",slug:"giuseppe-bertozzi",fullName:"Giuseppe Bertozzi"},{id:"42466",title:"Dr.",name:"Luca",middleName:null,surname:"Feltre",slug:"luca-feltre",fullName:"Luca Feltre"},{id:"42467",title:"Dr.",name:"Mashallah",middleName:null,surname:"Rahimi",slug:"mashallah-rahimi",fullName:"Mashallah Rahimi"}]},{id:"57384",doi:"10.5772/intechopen.71049",title:"A Review: Remote Sensing Sensors",slug:"a-review-remote-sensing-sensors",totalDownloads:3617,totalCrossrefCites:22,totalDimensionsCites:40,abstract:"The cost of launching satellites is getting lower and lower due to the reusability of rockets (NASA, 2015) and using single missions to launch multiple satellites (up to 37, Russia, 2014). In addition, low-orbit satellite constellations have been employed in recent years. These trends indicate that satellite remote sensing has a promising future in acquiring high-resolution data with a low cost and in integrating high-resolution satellite imagery with ground-based sensor data for new applications. These facts have motivated us to develop a comprehensive survey of remote sensing sensor development, including the characteristics of sensors with respect to electromagnetic spectrums (EMSs), imaging and non-imaging sensors, potential research areas, current practices, and the future development of remote sensors.",book:{id:"6334",slug:"multi-purposeful-application-of-geospatial-data",title:"Multi-purposeful Application of Geospatial Data",fullTitle:"Multi-purposeful Application of Geospatial Data"},signatures:"Lingli Zhu, Juha Suomalainen, Jingbin Liu, Juha Hyyppä, Harri\nKaartinen and Henrik Haggren",authors:[{id:"213512",title:"Dr.",name:"Lingli",middleName:null,surname:"Zhu",slug:"lingli-zhu",fullName:"Lingli Zhu"},{id:"213522",title:"Dr.",name:"Suomalainen",middleName:null,surname:"Juha",slug:"suomalainen-juha",fullName:"Suomalainen Juha"},{id:"213523",title:"Prof.",name:"Jingbin",middleName:null,surname:"Liu",slug:"jingbin-liu",fullName:"Jingbin Liu"},{id:"220941",title:"Prof.",name:"Juha",middleName:null,surname:"Hyyppä",slug:"juha-hyyppa",fullName:"Juha Hyyppä"},{id:"220942",title:"Prof.",name:"Harri",middleName:null,surname:"Kaartinen",slug:"harri-kaartinen",fullName:"Harri Kaartinen"},{id:"220943",title:"Prof.",name:"Henrik",middleName:null,surname:"Haggren",slug:"henrik-haggren",fullName:"Henrik Haggren"}]},{id:"60049",doi:"10.5772/intechopen.75493",title:"GNSS Error Sources",slug:"gnss-error-sources",totalDownloads:3090,totalCrossrefCites:18,totalDimensionsCites:28,abstract:"This chapter discusses the most serious sources of error affecting global navigation satellite systems (GNSS) signals, classifying these in a new way, according to their nature and/or effects. For instance, errors due to clock bias or drift are grouped together. Errors related to the signal propagation medium, too, are treated in the same way. GNSS errors need to be corrected to achieve accepted positioning and navigational accuracy. We provide a theoretical description for each source, supporting these with diagrams and analytical figures where possible. Some common metrics to measure the magnitude of GNSS errors, including the user equivalent range error (UERE) and the dilution of precision (DOP), are also presented. The chapter concludes with remarks on the significance of the sources of error.",book:{id:"6540",slug:"multifunctional-operation-and-application-of-gps",title:"Multifunctional Operation and Application of GPS",fullTitle:"Multifunctional Operation and Application of GPS"},signatures:"Malek Karaim, Mohamed Elsheikh and Aboelmagd Noureldin",authors:[{id:"227711",title:"Mr.",name:"Malek",middleName:null,surname:"Karaim",slug:"malek-karaim",fullName:"Malek Karaim"},{id:"240292",title:"Prof.",name:"Aboelmagd",middleName:null,surname:"Noureldin",slug:"aboelmagd-noureldin",fullName:"Aboelmagd Noureldin"},{id:"243124",title:"Dr.",name:"Mohamed",middleName:null,surname:"Elsheikh",slug:"mohamed-elsheikh",fullName:"Mohamed Elsheikh"}]}],mostDownloadedChaptersLast30Days:[{id:"71931",title:"Open Pit Mining",slug:"open-pit-mining",totalDownloads:1525,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Open pit mining method is one of the surface mining methods that has a traditional cone-shaped excavation and is usually employed to exploit a near-surface, nonselective and low-grade zones deposits. It often results in high productivity and requires large capital investments, low operating costs, and good safety conditions. The main topics that will be discussed in this chapter will include an introduction into the general features of open pit mining, ore body characteristics and configurations, stripping ratios and stripping overburden methods, mine elements and parameters, open pit operation cycle, pit slope angle, stability of mine slopes, types of highwall failures, mine closure and reclamation, and different variants of surface mining methods including opencast mining, mountainous mining, and artisan mining.",book:{id:"8620",slug:"mining-techniques-past-present-and-future",title:"Mining Techniques",fullTitle:"Mining Techniques - Past, Present and Future"},signatures:"Awwad H. Altiti, Rami O. Alrawashdeh and Hani M. Alnawafleh",authors:[{id:"313182",title:"Prof.",name:"Rami",middleName:null,surname:"Alrawashdeh",slug:"rami-alrawashdeh",fullName:"Rami Alrawashdeh"},{id:"313522",title:"Dr.",name:"Awwad",middleName:null,surname:"Altiti",slug:"awwad-altiti",fullName:"Awwad Altiti"},{id:"313523",title:"Prof.",name:"Hani",middleName:null,surname:"Alnawafleh",slug:"hani-alnawafleh",fullName:"Hani Alnawafleh"}]},{id:"64027",title:"Stages of a Integrated Geothermal Project",slug:"stages-of-a-integrated-geothermal-project",totalDownloads:4234,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"A geothermal project constitutes two big stages: the exploration and the exploitation. Each one has a single task whose results allow defining the feasibility of a geothermal project, until achieving the construction and operation stage of the power generation plant. The first stage contains the area recognition, its limitation to the target, and elimination of external factors until defining a geothermal zone with characteristics to be commercially exploited. The main studies and analysis that can be applied during the exploration stage are listed, and the major indicator to continue with the project or suspend is the prefeasibility report. The major risks in the exploration stage are due to studies that are carried out on the surface; at this stage, the costs can be considered low. The main results of the exploration are the selection of sites to drill three or four initial wells. Each well provides a direct overview of the reservoir: depth, production thicknesses, thermodynamic parameters, and production characteristics. The drilling of three to four exploratory wells is recommended, as far as there is certainty of the feasibility of the project, and the development of the field begins with drilling of sufficient wells to feed the plant. In this stage, the cost increases, but the risks decrease.",book:{id:"7504",slug:"renewable-geothermal-energy-explorations",title:"Renewable Geothermal Energy Explorations",fullTitle:"Renewable Geothermal Energy Explorations"},signatures:"Alfonso Aragón-Aguilar, Georgina Izquierdo-Montalvo,\nDaniel Octavio Aragón-Gaspar and Denise N. Barreto-Rivera",authors:[{id:"258358",title:"Dr.",name:"Alfonso",middleName:null,surname:"Aragón-Aguilar",slug:"alfonso-aragon-aguilar",fullName:"Alfonso Aragón-Aguilar"}]},{id:"63059",title:"Generation, Evolution, and Characterization of Turbulence Coherent Structures",slug:"generation-evolution-and-characterization-of-turbulence-coherent-structures",totalDownloads:3518,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"Turbulence stands as one of the most complicated and attractive physical phenomena. The accumulated knowledge has shown turbulent flow to be composed of islands of vortices and uniform-momentum regions, which are coherent in both time and space. Research has been concentrated on these structures, their generation, evolution, and interaction with the mean flow. Different theories and conceptual models were proposed with the aim of controlling the boundary layer flow and improving numerical simulations. Here, we review the different classes of turbulence coherent structures and the presumable generation mechanisms for each. The conceptual models describing the generation of turbulence coherent structures are generally classified under two categories, namely, the bottom-up mechanisms and the top-down mechanisms. The first assumes turbulence to be generated near the surface by some sort of instabilities, whereas the second assigns an active role to the large outer layer structures, perhaps the turbulent bulges. Both categories of models coexist in the flow with the first dominating turbulence generation at low Reynolds number and the second at high Reynolds number, such as the case in the atmospheric boundary layer.",book:{id:"7214",slug:"turbulence-and-related-phenomena",title:"Turbulence and Related Phenomena",fullTitle:"Turbulence and Related Phenomena"},signatures:"Zambri Harun and Eslam Reda Lotfy",authors:[{id:"243152",title:"Dr.",name:"Zambri",middleName:null,surname:"Harun",slug:"zambri-harun",fullName:"Zambri Harun"},{id:"252195",title:"Dr.",name:"Eslam",middleName:null,surname:"Reda",slug:"eslam-reda",fullName:"Eslam Reda"}]},{id:"64562",title:"Electrical Resistivity Tomography: A Subsurface-Imaging Technique",slug:"electrical-resistivity-tomography-a-subsurface-imaging-technique",totalDownloads:3152,totalCrossrefCites:7,totalDimensionsCites:9,abstract:"Electrical resistivity tomography (ERT) is a popular geophysical subsurface-imaging technique and widely applied to mineral prospecting, hydrological exploration, environmental investigation and civil engineering, as well as archaeological mapping. This chapter offers an overall review of technical aspects of ERT, which includes the fundamental theory of direct-current (DC) resistivity exploration, electrode arrays for data acquisition, numerical modelling methods and tomographic inversion algorithms. The section of fundamental theory shows basic formulae and principle of DC resistivity exploration. The section of electrode arrays summarises the previous study on all traditional-electrode arrays and recommends 4 electrode arrays for data acquisition of surface ERT and 3 electrode arrays for cross-hole ERT. The section of numerical modelling demonstrates an advanced version of finite-element method, called Gaussian quadrature grid approach, which is advantageous to a numerical simulation of ERT for complex geological models. The section of tomographic inversion presents the generalised standard conjugate gradient algorithms for both the l1- and l2-normed inversions. After that, some synthetic and real imaging examples are given to show the near-surface imaging capabilities of ERT.",book:{id:"8361",slug:"applied-geophysics-with-case-studies-on-environmental-exploration-and-engineering-geophysics",title:"Applied Geophysics with Case Studies on Environmental, Exploration and Engineering Geophysics",fullTitle:"Applied Geophysics with Case Studies on Environmental, Exploration and Engineering Geophysics"},signatures:"Bing Zhou",authors:null},{id:"17670",title:"The Qatar–South Fars Arch Development (Arabian Platform, Persian Gulf): Insights from Seismic Interpretation and Analogue Modelling",slug:"the-qatar-south-fars-arch-development-arabian-platform-persian-gulf-insights-from-seismic-interpreta",totalDownloads:8877,totalCrossrefCites:16,totalDimensionsCites:40,abstract:null,book:{id:"1297",slug:"new-frontiers-in-tectonic-research-at-the-midst-of-plate-convergence",title:"New Frontiers in Tectonic Research",fullTitle:"New Frontiers in Tectonic Research - At the Midst of Plate Convergence"},signatures:"C.R. Perotti, S. Carruba, M. Rinaldi, G. Bertozzi, L. Feltre and M. Rahimi",authors:[{id:"38310",title:"Dr.",name:"Stefano",middleName:null,surname:"Carruba",slug:"stefano-carruba",fullName:"Stefano Carruba"},{id:"42459",title:"Prof.",name:"Cesare",middleName:null,surname:"Perotti",slug:"cesare-perotti",fullName:"Cesare Perotti"},{id:"42460",title:"Dr.",name:"Marco",middleName:null,surname:"Rinaldi",slug:"marco-rinaldi",fullName:"Marco Rinaldi"},{id:"42465",title:"Dr.",name:"Giuseppe",middleName:null,surname:"Bertozzi",slug:"giuseppe-bertozzi",fullName:"Giuseppe Bertozzi"},{id:"42466",title:"Dr.",name:"Luca",middleName:null,surname:"Feltre",slug:"luca-feltre",fullName:"Luca Feltre"},{id:"42467",title:"Dr.",name:"Mashallah",middleName:null,surname:"Rahimi",slug:"mashallah-rahimi",fullName:"Mashallah Rahimi"}]}],onlineFirstChaptersFilter:{topicId:"104",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81184",title:"Introduction to the Volcanology",slug:"introduction-to-the-volcanology",totalDownloads:48,totalDimensionsCites:0,doi:"10.5772/intechopen.102771",abstract:"The main volcanological concept is shown and expressed so that any volcano can be understood easily. Volcanic products are listed and explained in plain language from lava flow to various pyroclastic products. The volcanic products have been explained schematically and their textural, field relationships characteristics are highlighted. The origin of magma within the interior of the Earth is also explained and the link between mantle and crust has been shown. The relationship among crust, mantle, and core has been highlighted embracing the source-to-surface model. An updated explanation of the Pyroclastic Density Currents (PDC) has been done to perceive their danger. Some of the most successful Volcanology books have been used. This will help the students, with a passion for Volcanology, to understand the principles of Volcanology.",book:{id:"10851",title:"Progress in Volcanology",coverURL:"https://cdn.intechopen.com/books/images_new/10851.jpg"},signatures:"Angelo Paone and Sung-Hyo Yun"},{id:"79332",title:"The Geothermal Power Plants of Amiata Volcano, Italy: Impacts on Freshwater Aquifers, Seismicity and Air",slug:"the-geothermal-power-plants-of-amiata-volcano-italy-impacts-on-freshwater-aquifers-seismicity-and-ai",totalDownloads:129,totalDimensionsCites:0,doi:"10.5772/intechopen.100558",abstract:"Production of geothermal energy for electricity at Amiata Volcano uses flash-type power plants with cooling towers that evaporate much of the geothermal fluid to the atmosphere to condense the geothermal vapour extracted. Because the flash occurs also within the geothermal reservoir, it causes a significant depressurization within it that, in turns, results in a drop of the water table inside the volcano between 200 and 300 m. The flow rates of natural springs around the volcano have also substantially decreased or ceased since the start of geothermal energy exploitation. Continuous recording of aquifer conditions shows substantial increases in salinity (>20%) and temperature (>2°C) as the water table falls below about 755–750 m asl. In addition to hydrologic impacts, there are also a large numbers of induced earthquakes, among which the ML 3.9, April 1, 2000 earthquake that generated significant damage in the old villages and rural houses. Relevant impacts on air quality occur when emissions are considered on a per-MW basis. For example, CO2+CH4 emissions at Amiata are comparable to those of gas-fired power plants, while the acid-rain potential is about twice that of coal-fired power plants. Also, a significant emission of primary and secondary fine particles is associated with the cooling towers. These particles contain heavy metals and are enriched in sodium, vanadium, zinc, phosphorous, sulphur, tantalium, caesium, thallium, thorium, uranium, and arsenic relative to comparable aerosols collected in Florence and Arezzo. Measurements have shown that mercury emitted at Amiata comprises 42% of the mercury emitted from all Italian industries, while an additional comparable amount is emitted from the other geothermal power plants of Tuscany. We believe that the use of air coolers in place of the evaporative cooling towers, as suggested in 2010 by the local government of Tuscany, could have and can now drastically reduced the environmental impact on freshwater and air. On the opposite side of the coin, air-coolers would increase the amount of reinjection, increasing the risk of induced seismicity. We conclude that the use of deep borehole heat exchangers could perhaps be the only viable solution to the current geothermal energy environmental impacts.",book:{id:"10851",title:"Progress in Volcanology",coverURL:"https://cdn.intechopen.com/books/images_new/10851.jpg"},signatures:"Andrea Borgia, Alberto Mazzoldi, Luigi Micheli, Giovanni Grieco, Massimo Calcara and Carlo Balducci"},{id:"78173",title:"Miocene Volcaniclastic Environments Developed in the Distal Sector of the Bermejo Basin, Argentina",slug:"miocene-volcaniclastic-environments-developed-in-the-distal-sector-of-the-bermejo-basin-argentina",totalDownloads:125,totalDimensionsCites:0,doi:"10.5772/intechopen.99081",abstract:"During the Miocene, in the distal sectors of the Bermejo Basin, a complex relationship developed between a floodplain and contemporary volcanic activity. Seven stages of sedimentation are established to interpret this paleoenvironmental relationship. Stage I corresponds to the development of the floodplain previous to pyroclastic activity; in Stage II, pyroclastic activity is manifested by fall deposits and dry pyroclastic surges. A probable calm in the volcanic activity, associated with exceptional rains, generates laharic deposits (Stage III). Stage IV is dry pyroclastic surges that collapse the floodplain. Subsequently, the river system is reestablished (Stage V) under a regime of low to null volcanic activity. During Stages VI and VII, thick deposits of dry and wet pyroclastic surges, which have records of contemporary seismic activity. The presence of deformational structures within the pyroclastic deposits and lahars indicate that the volcanic centers were in distant areas. The volcanism that generated these deposits is probably associated with the migration to the east of the Miocene volcanic arc of the Cordillera de Los Andes or could be associate with the volcanism of the Sierra de Famatina.",book:{id:"10851",title:"Progress in Volcanology",coverURL:"https://cdn.intechopen.com/books/images_new/10851.jpg"},signatures:"José L. Lagos and Ana M. Combina"},{id:"77349",title:"Effusive Badi Silicic Volcano (Central Afar, Ethiopian Rift); Sparse Evidence for Pyroclastic Rocks",slug:"effusive-badi-silicic-volcano-central-afar-ethiopian-rift-sparse-evidence-for-pyroclastic-rocks",totalDownloads:124,totalDimensionsCites:0,doi:"10.5772/intechopen.98558",abstract:"We report field observation, textural description (thin section and scanning electron microscope (SEM)) and mineral chemistry (backscattered electron imaging and dispersive X-ray analysis) for rhyolitic obsidian lavas from previously under described effusive Badi volcano, central Afar within the Ethiopian rift. These rhyolitic obsidian lavas are compositionally homogeneous and contain well developed flow bands. Textural analysis is undertaken to understand the formation of flow band, and to draw inferences on the mechanism of emplacement of this silicic volcano. Flow band arises from variable vesicularity (i.e., alternating domains of vesicular, light glass and non-vesicular, brown glass). Such textural heterogeneities have been developed during distinct cooling and degassing of the melt in the conduit.",book:{id:"10851",title:"Progress in Volcanology",coverURL:"https://cdn.intechopen.com/books/images_new/10851.jpg"},signatures:"Dereje Ayalew, David Pyle and David Ferguson"},{id:"77437",title:"Petrology and Geochemistry of Nakora Ring Complex with Emphasis on Tectonics and Magmatism, Neoproterozoic Malani Igneous Suite, Western Rajasthan, India",slug:"petrology-and-geochemistry-of-nakora-ring-complex-with-emphasis-on-tectonics-and-magmatism-neoproter",totalDownloads:113,totalDimensionsCites:0,doi:"10.5772/intechopen.98609",abstract:"The present contribution reports on the field, petrographical and geochemical observations of the volcano-plutonic rocks of the Nakora Ring Complex (NRC) from the Neoproterozoic, Malani Igneous Suite (MIS) (Northwestern Peninsular India) and confers about their magmatic evolution and tectonic implications. Three magmatic phases are notable in the NRC which is Extrusive, Intrusive and Dyke phase where with small quantities of basaltic flows was initiated and accompanied by extensive/voluminous acidic flows. Petrographically, rhyolite shows flow bands, porphyritic, spherulitic, aphyritic and perlitic textures whereas basalt flows are distinguished by the presence of labradorite in lath-shaped crystals (plagioclase feldspar) and clinopyroxene (augite). The presence of high silica and total alkalis in NRC rocks, as well as high field strength elements (HFSE), enrichment of trace elements and negative anomalies of Sr., Eu, P, and Ti indicates that the emplacement of the lava flows was controlled by complex magmatic processes such as fractional crystallization, crustal contamination and partial melting. The association of basalt-trachyte-rhyolite means that the magma chamber was supplied a significant amount of heat to the crust before the eruption. Moreover, a volcanic vent was also reported at NRC where rhyolite was associated with agglomerate, volcanic breccia, perlite and tuff. The current research proposed that the Neoproterozoic magmatism at NRC was controlled by rift-related mechanism and produced from crustal source where the heat was supplied by mantle plume.",book:{id:"10851",title:"Progress in Volcanology",coverURL:"https://cdn.intechopen.com/books/images_new/10851.jpg"},signatures:"Naresh Kumar and Radhika Sharma"},{id:"76904",title:"Tropical Volcanic Residual Soil",slug:"tropical-volcanic-residual-soil",totalDownloads:217,totalDimensionsCites:0,doi:"10.5772/intechopen.98285",abstract:"In West Lampung, Sumatra, Indonesia, tropical volcanic residual soils are formed from weathering of volcanic breccias in hydrothermal alteration areas with a thickness of up to 20 m. This soil has the characteristics of clayey silt, low to high plasticity, brownish-red color, has the potential to swelling, easily eroded, and slide when it is saturated, and contains the minerals kaolinite, halloysite, illite, dickite, nacrite, montmorillonite, despujolsite, hematite, and magnetite. The results showed that this soil can cause corrosion of steel and is widely used by the community as a medium for growing plants and vegetables and as a foundation for infrastructure (for example, houses). The volcanic residual soil of the research area had Low Rare Earth Element (LREE) potential and specific uses. The soil with characteristic low plasticity has Liquid Limit (LL) brine value <50% will be suitable for agriculture purposes, building foundations, and earth construction. At the same time, the other category is soil with intermediate to high plasticity characteristics, which has an Liquid Limit (LL) brine value >50%, was more ideal for the primary forest.",book:{id:"10851",title:"Progress in Volcanology",coverURL:"https://cdn.intechopen.com/books/images_new/10851.jpg"},signatures:"Prahara Iqbal, Dicky Muslim, Zufialdi Zakaria, Haryadi Permana, Arifan Jaya Syahbana, Nugroho Aji Satriyo, Yunarto Yunarto, Jakah Jakah and Nur Khoirullah"}],onlineFirstChaptersTotal:8},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:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:288,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:10,numberOfPublishedChapters:103,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:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:11,numberOfOpenTopics:4,numberOfUpcomingTopics:1,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:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983",scope:"Biochemistry, the study of chemical transformations occurring within living organisms, impacts all areas of life sciences, from molecular crystallography and genetics to ecology, medicine, and population biology. Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"May 24th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:27,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"10",title:"Animal Physiology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/10.jpg",isOpenForSubmission:!0,editor:{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. Dr. Rutland has also written popular science books for the public. https://orcid.org/0000-0002-2009-4898. www.nottingham.ac.uk/vet/people/catrin.rutland",institutionString:null,institution:{name:"University of Nottingham",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null},{id:"11",title:"Cell Physiology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/11.jpg",isOpenForSubmission:!0,editor:{id:"133493",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala",profilePictureURL:"https://mts.intechopen.com/storage/users/133493/images/3091_n.jpg",biography:"Prof. Dr. Angel Catalá \r\nShort Biography Angel Catalá was born in Rodeo (San Juan, Argentina). He studied \r\nchemistry at the Universidad Nacional de La Plata, Argentina, where received aPh.D. degree in chemistry (Biological Branch) in 1965. From\r\n1964 to 1974, he worked as Assistant in Biochemistry at the School of MedicineUniversidad Nacional de La Plata, Argentina. From 1974 to 1976, he was a Fellowof the National Institutes of Health (NIH) at the University of Connecticut, Health Center, USA. From 1985 to 2004, he served as a Full Professor oBiochemistry at the Universidad Nacional de La Plata, Argentina. He is Member ofthe National Research Council (CONICET), Argentina, and Argentine Society foBiochemistry and Molecular Biology (SAIB). His laboratory has been interested for manyears in the lipid peroxidation of biological membranes from various tissues and different species. Professor Catalá has directed twelve doctoral theses, publishedover 100 papers in peer reviewed journals, several chapters in books andtwelve edited books. Angel Catalá received awards at the 40th InternationaConference Biochemistry of Lipids 1999: Dijon (France). W inner of the Bimbo PanAmerican Nutrition, Food Science and Technology Award 2006 and 2012, South AmericaHuman Nutrition, Professional Category. 2006 award in pharmacology, Bernardo\r\nHoussay, in recognition of his meritorious works of research. Angel Catalá belongto the Editorial Board of Journal of lipids, International Review of Biophysical ChemistryFrontiers in Membrane Physiology and Biophysics, World Journal oExperimental Medicine and Biochemistry Research International, W orld Journal oBiological Chemistry, Oxidative Medicine and Cellular Longevity, Diabetes and thePancreas, International Journal of Chronic Diseases & Therapy, International Journal oNutrition, Co-Editor of The Open Biology Journal.",institutionString:null,institution:{name:"National University of La Plata",institutionURL:null,country:{name:"Argentina"}}},editorTwo:null,editorThree:null},{id:"12",title:"Human Physiology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/12.jpg",isOpenForSubmission:!0,editor:{id:"195829",title:"Prof.",name:"Kunihiro",middleName:null,surname:"Sakuma",slug:"kunihiro-sakuma",fullName:"Kunihiro Sakuma",profilePictureURL:"https://mts.intechopen.com/storage/users/195829/images/system/195829.jpg",biography:"Professor Kunihiro Sakuma, Ph.D., currently works in the Institute for Liberal Arts at the Tokyo Institute of Technology. He is a physiologist working in the field of skeletal muscle. He was awarded his sports science diploma in 1995 by the University of Tsukuba and began his scientific work at the Department of Physiology, Aichi Human Service Center, focusing on the molecular mechanism of congenital muscular dystrophy and normal muscle regeneration. His interest later turned to the molecular mechanism and attenuating strategy of sarcopenia (age-related muscle atrophy). His opinion is to attenuate sarcopenia by improving autophagic defects using nutrient- and pharmaceutical-based treatments.",institutionString:null,institution:{name:"Tokyo Institute of Technology",institutionURL:null,country:{name:"Japan"}}},editorTwo:null,editorThree:{id:"331519",title:"Dr.",name:"Kotomi",middleName:null,surname:"Sakai",slug:"kotomi-sakai",fullName:"Kotomi Sakai",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000031QtFXQA0/Profile_Picture_1637053227318",biography:"Senior researcher Kotomi Sakai, Ph.D., MPH, works at the Research Organization of Science and Technology in Ritsumeikan University. She is a researcher in the geriatric rehabilitation and public health field. She received Ph.D. from Nihon University and MPH from St.Luke’s International University. Her main research interest is sarcopenia in older adults, especially its association with nutritional status. Additionally, to understand how to maintain and improve physical function in older adults, to conduct studies about the mechanism of sarcopenia and determine when possible interventions are needed.",institutionString:null,institution:{name:"Ritsumeikan University",institutionURL:null,country:{name:"Japan"}}}},{id:"13",title:"Plant Physiology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/13.jpg",isOpenForSubmission:!0,editor:{id:"332229",title:"Prof.",name:"Jen-Tsung",middleName:null,surname:"Chen",slug:"jen-tsung-chen",fullName:"Jen-Tsung Chen",profilePictureURL:"https://mts.intechopen.com/storage/users/332229/images/system/332229.png",biography:"Dr. Jen-Tsung Chen is currently a professor at the National University of Kaohsiung, Taiwan. He teaches cell biology, genomics, proteomics, medicinal plant biotechnology, and plant tissue culture. Dr. Chen\\'s research interests include bioactive compounds, chromatography techniques, in vitro culture, medicinal plants, phytochemicals, and plant biotechnology. 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Buchholz",profilePictureURL:"https://mts.intechopen.com/storage/users/89438/images/6463_n.jpg",biography:"Full Professor and Vice Chair, Division of Pharmacology, Loma Linda University, School of Medicine. He received his B.S. Degree in Biology at La Sierra University, Riverside California (1980) and a PhD in Pharmacology from Loma Linda University School of Medicine (1988). Post-Doctoral Fellow at University of California, Irvine, College of Medicine 1989-1992 with a focus on autonomic nerve function in blood vessels and the impact of aging on the function of these nerves and overall blood vessel function. Twenty years of research funding and served on NIH R01 review panels, Editor-In-Chief of Edorium Journal of Aging Research. Serves as a peer reviewer for biomedical journals. Military Reserve Officer serving with the 100 Support Command, 100 Troop Command, 40 Infantry Division, CA National Guard.",institutionString:null,institution:{name:"Loma Linda University",institutionURL:null,country:{name:"United States of America"}}}]},{type:"book",id:"6925",title:"Endoplasmic Reticulum",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6925.jpg",slug:"endoplasmic-reticulum",publishedDate:"April 17th 2019",editedByType:"Edited by",bookSignature:"Angel Català",hash:"a9e90d2dbdbc46128dfe7dac9f87c6b4",volumeInSeries:2,fullTitle:"Endoplasmic Reticulum",editors:[{id:"196544",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala",profilePictureURL:"https://mts.intechopen.com/storage/users/196544/images/system/196544.jpg",biography:"Angel Catalá studied chemistry at Universidad Nacional de La Plata, Argentina, where he received a Ph.D. in Chemistry (Biological Branch) in 1965. From 1964 to 1974, he worked as an Assistant in Biochemistry at the School of Medicine at the same university. From 1974 to 1976, he was a fellow of the National Institutes of Health (NIH) at the University of Connecticut, Health Center, USA. From 1985 to 2004, he served as a Full Professor of Biochemistry at the Universidad Nacional de La Plata. He is a member of the National Research Council (CONICET), Argentina, and the Argentine Society for Biochemistry and Molecular Biology (SAIB). His laboratory has been interested for many years in the lipid peroxidation of biological membranes from various tissues and different species. Dr. Catalá has directed twelve doctoral theses, published more than 100 papers in peer-reviewed journals, several chapters in books, and edited twelve books. He received awards at the 40th International Conference Biochemistry of Lipids 1999 in Dijon, France. He is the winner of the Bimbo Pan-American Nutrition, Food Science and Technology Award 2006 and 2012, South America, Human Nutrition, Professional Category. In 2006, he won the Bernardo Houssay award in pharmacology, in recognition of his meritorious works of research. Dr. Catalá belongs to the editorial board of several journals including Journal of Lipids; International Review of Biophysical Chemistry; Frontiers in Membrane Physiology and Biophysics; World Journal of Experimental Medicine and Biochemistry Research International; World Journal of Biological Chemistry, Diabetes, and the Pancreas; International Journal of Chronic Diseases & Therapy; and International Journal of Nutrition. He is the co-editor of The Open Biology Journal and associate editor for Oxidative Medicine and Cellular Longevity.",institutionString:"Universidad Nacional de La Plata",institution:{name:"National University of La Plata",institutionURL:null,country:{name:"Argentina"}}}]},{type:"book",id:"6924",title:"Adenosine Triphosphate in Health and Disease",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6924.jpg",slug:"adenosine-triphosphate-in-health-and-disease",publishedDate:"April 24th 2019",editedByType:"Edited by",bookSignature:"Gyula Mozsik",hash:"04106c232a3c68fec07ba7cf00d2522d",volumeInSeries:3,fullTitle:"Adenosine Triphosphate in Health and Disease",editors:[{id:"58390",title:"Dr.",name:"Gyula",middleName:null,surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik",profilePictureURL:"https://mts.intechopen.com/storage/users/58390/images/system/58390.png",biography:"Gyula Mózsik MD, Ph.D., ScD (med), is an emeritus professor of Medicine at the First Department of Medicine, Univesity of Pécs, Hungary. He was head of this department from 1993 to 2003. His specializations are medicine, gastroenterology, clinical pharmacology, clinical nutrition, and dietetics. His research fields are biochemical pharmacological examinations in the human gastrointestinal (GI) mucosa, mechanisms of retinoids, drugs, capsaicin-sensitive afferent nerves, and innovative pharmacological, pharmaceutical, and nutritional (dietary) research in humans. He has published about 360 peer-reviewed papers, 197 book chapters, 692 abstracts, 19 monographs, and has edited 37 books. He has given about 1120 regular and review lectures. He has organized thirty-eight national and international congresses and symposia. He is the founder of the International Conference on Ulcer Research (ICUR); International Union of Pharmacology, Gastrointestinal Section (IUPHAR-GI); Brain-Gut Society symposiums, and gastrointestinal cytoprotective symposiums. He received the Andre Robert Award from IUPHAR-GI in 2014. Fifteen of his students have been appointed as full professors in Egypt, Cuba, and Hungary.",institutionString:"University of Pécs",institution:{name:"University of Pecs",institutionURL:null,country:{name:"Hungary"}}}]},{type:"book",id:"8008",title:"Antioxidants",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/8008.jpg",slug:"antioxidants",publishedDate:"November 6th 2019",editedByType:"Edited by",bookSignature:"Emad Shalaby",hash:"76361b4061e830906267933c1c670027",volumeInSeries:5,fullTitle:"Antioxidants",editors:[{id:"63600",title:"Prof.",name:"Emad",middleName:null,surname:"Shalaby",slug:"emad-shalaby",fullName:"Emad Shalaby",profilePictureURL:"https://mts.intechopen.com/storage/users/63600/images/system/63600.png",biography:"Dr. Emad Shalaby is a professor of biochemistry on the Biochemistry Department Faculty of Agriculture, Cairo University. He\nreceived a short-term scholarship to carry out his post-doctoral\nstudies abroad, from Japan International Cooperation Agency\n(JICA), in coordination with the Egyptian government. Dr.\nShalaby speaks fluent English and his native Arabic. He has 77\ninternationally published research papers, has attended 15 international conferences, and has contributed to 18 international books and chapters.\nDr. Shalaby works as a reviewer on over one hundred international journals and is\non the editorial board of more than twenty-five international journals. He is a member of seven international specialized scientific societies, besides his local one, and\nhe has won seven prizes.",institutionString:"Cairo University",institution:{name:"Cairo University",institutionURL:null,country:{name:"Egypt"}}}]}]},openForSubmissionBooks:{},onlineFirstChapters:{},subseriesFiltersForOFChapters:[],publishedBooks:{},subseriesFiltersForPublishedBooks:[],publicationYearFilters:[],authors:{paginationCount:617,paginationItems:[{id:"158492",title:"Prof.",name:"Yusuf",middleName:null,surname:"Tutar",slug:"yusuf-tutar",fullName:"Yusuf Tutar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/158492/images/system/158492.jpeg",biography:"Prof. Dr. Yusuf Tutar conducts his research at the Hamidiye Faculty of Pharmacy, Department of Basic Pharmaceutical Sciences, Division of Biochemistry, University of Health Sciences, Turkey. He is also a faculty member in the Molecular Oncology Program. He obtained his MSc and Ph.D. at Oregon State University and Texas Tech University, respectively. He pursued his postdoctoral studies at Rutgers University Medical School and the National Institutes of Health (NIH/NIDDK), USA. His research focuses on biochemistry, biophysics, genetics, molecular biology, and molecular medicine with specialization in the fields of drug design, protein structure-function, protein folding, prions, microRNA, pseudogenes, molecular cancer, epigenetics, metabolites, proteomics, genomics, protein expression, and characterization by spectroscopic and calorimetric methods.",institutionString:"University of Health Sciences",institution:null},{id:"180528",title:"Dr.",name:"Hiroyuki",middleName:null,surname:"Kagechika",slug:"hiroyuki-kagechika",fullName:"Hiroyuki Kagechika",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180528/images/system/180528.jpg",biography:"Hiroyuki Kagechika received his bachelor’s degree and Ph.D. in Pharmaceutical Sciences from the University of Tokyo, Japan, where he served as an associate professor until 2004. He is currently a professor at the Institute of Biomaterials and Bioengineering (IBB), Tokyo Medical and Dental University (TMDU). From 2010 to 2012, he was the dean of the Graduate School of Biomedical Science. Since 2012, he has served as the vice dean of the Graduate School of Medical and Dental Sciences. He has been the director of the IBB since 2020. Dr. Kagechika’s major research interests are the medicinal chemistry of retinoids, vitamins D/K, and nuclear receptors. He has developed various compounds including a drug for acute promyelocytic leukemia.",institutionString:"Tokyo Medical and Dental University",institution:{name:"Tokyo Medical and Dental University",country:{name:"Japan"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNVJQA4/Profile_Picture_2022-03-07T13:23:04.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals.",institutionString:null,institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Associate Prof.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. She has been a Professor since 1996. Currently, she is the Head of the Laboratory of Metabolism, a division of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation. N.V. Beloborodova has many years of clinical experience in the field of intensive care and surgery. She studies infectious complications and sepsis. She initiated a series of interdisciplinary clinical and experimental studies based on the concept of integrating human metabolism and its microbiota. Her scientific achievements are widely known: she is the recipient of the Marie E. Coates Award \\"Best lecturer-scientist\\" Gustafsson Fund, Karolinska Institutes, Stockholm, Sweden, and the International Sepsis Forum Award, Pasteur Institute, Paris, France (2014), etc. Professor N.V. Beloborodova wrote 210 papers, five books, 10 chapters and has edited four books.',institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"354260",title:"Ph.D.",name:"Tércio Elyan",middleName:"Azevedo",surname:"Azevedo Martins",slug:"tercio-elyan-azevedo-martins",fullName:"Tércio Elyan Azevedo Martins",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/354260/images/16241_n.jpg",biography:"Graduated in Pharmacy from the Federal University of Ceará with the modality in Industrial Pharmacy, Specialist in Production and Control of Medicines from the University of São Paulo (USP), Master in Pharmaceuticals and Medicines from the University of São Paulo (USP) and Doctor of Science in the program of Pharmaceuticals and Medicines by the University of São Paulo. Professor at Universidade Paulista (UNIP) in the areas of chemistry, cosmetology and trichology. Assistant Coordinator of the Higher Course in Aesthetic and Cosmetic Technology at Universidade Paulista Campus Chácara Santo Antônio. Experience in the Pharmacy area, with emphasis on Pharmacotechnics, Pharmaceutical Technology, Research and Development of Cosmetics, acting mainly on topics such as cosmetology, antioxidant activity, aesthetics, photoprotection, cyclodextrin and thermal analysis.",institutionString:null,institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"334285",title:"Ph.D. Student",name:"Sameer",middleName:"Kumar",surname:"Jagirdar",slug:"sameer-jagirdar",fullName:"Sameer Jagirdar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334285/images/14691_n.jpg",biography:"I\\'m a graduate student at the center for biosystems science and engineering at the Indian Institute of Science, Bangalore, India. I am interested in studying host-pathogen interactions at the biomaterial interface.",institutionString:null,institution:{name:"Indian Institute of Science Bangalore",country:{name:"India"}}},{id:"329795",title:"Dr.",name:"Mohd Aftab",middleName:"Aftab",surname:"Siddiqui",slug:"mohd-aftab-siddiqui",fullName:"Mohd Aftab Siddiqui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329795/images/15648_n.jpg",biography:"Dr. Mohd Aftab Siddiqui is currently working as Assistant Professor in the Faculty of Pharmacy, Integral University, Lucknow for the last 6 years. He has completed his Doctor in Philosophy (Pharmacology) in 2020 from Integral University, Lucknow. He completed his Bachelor in Pharmacy in 2013 and Master in Pharmacy (Pharmacology) in 2015 from Integral University, Lucknow. He is the gold medalist in Bachelor and Master degree. He qualified GPAT -2013, GPAT -2014, and GPAT 2015. His area of research is Pharmacological screening of herbal drugs/ natural products in liver and cardiac diseases. He has guided many M. Pharm. research projects. He has many national and international publications.",institutionString:"Integral University",institution:null},{id:"255360",title:"Dr.",name:"Usama",middleName:null,surname:"Ahmad",slug:"usama-ahmad",fullName:"Usama Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255360/images/system/255360.png",biography:"Dr. Usama Ahmad holds a specialization in Pharmaceutics from Amity University, Lucknow, India. He received his Ph.D. degree from Integral University. Currently, he’s working as an Assistant Professor of Pharmaceutics in the Faculty of Pharmacy, Integral University. From 2013 to 2014 he worked on a research project funded by SERB-DST, Government of India. He has a rich publication record with more than 32 original articles published in reputed journals, 3 edited books, 5 book chapters, and a number of scientific articles published in ‘Ingredients South Asia Magazine’ and ‘QualPharma Magazine’. He is a member of the American Association for Cancer Research, International Association for the Study of Lung Cancer, and the British Society for Nanomedicine. Dr. Ahmad’s research focus is on the development of nanoformulations to facilitate the delivery of drugs that aim to provide practical solutions to current healthcare problems.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"30568",title:"Prof.",name:"Madhu",middleName:null,surname:"Khullar",slug:"madhu-khullar",fullName:"Madhu Khullar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/30568/images/system/30568.jpg",biography:"Dr. Madhu Khullar is a Professor of Experimental Medicine and Biotechnology at the Post Graduate Institute of Medical Education and Research, Chandigarh, India. She completed her Post Doctorate in hypertension research at the Henry Ford Hospital, Detroit, USA in 1985. She is an editor and reviewer of several international journals, and a fellow and member of several cardiovascular research societies. Dr. Khullar has a keen research interest in genetics of hypertension, and is currently studying pharmacogenetics of hypertension.",institutionString:"Post Graduate Institute of Medical Education and Research",institution:{name:"Post Graduate Institute of Medical Education and Research",country:{name:"India"}}},{id:"223233",title:"Prof.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/223233/images/system/223233.png",biography:"Xianquan Zhan received his MD and Ph.D. in Preventive Medicine at West China University of Medical Sciences. He received his post-doctoral training in oncology and cancer proteomics at the Central South University, China, and the University of Tennessee Health Science Center (UTHSC), USA. He worked at UTHSC and the Cleveland Clinic in 2001–2012 and achieved the rank of associate professor at UTHSC. Currently, he is a full professor at Central South University and Shandong First Medical University, and an advisor to MS/PhD students and postdoctoral fellows. He is also a fellow of the Royal Society of Medicine and European Association for Predictive Preventive Personalized Medicine (EPMA), a national representative of EPMA, and a member of the American Society of Clinical Oncology (ASCO) and the American Association for the Advancement of Sciences (AAAS). He is also the editor in chief of International Journal of Chronic Diseases & Therapy, an associate editor of EPMA Journal, Frontiers in Endocrinology, and BMC Medical Genomics, and a guest editor of Mass Spectrometry Reviews, Frontiers in Endocrinology, EPMA Journal, and Oxidative Medicine and Cellular Longevity. He has published more than 148 articles, 28 book chapters, 6 books, and 2 US patents in the field of clinical proteomics and biomarkers.",institutionString:"Shandong First Medical University",institution:{name:"Affiliated Hospital of Shandong Academy of Medical Sciences",country:{name:"China"}}},{id:"297507",title:"Dr.",name:"Charles",middleName:"Elias",surname:"Assmann",slug:"charles-assmann",fullName:"Charles Assmann",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/297507/images/system/297507.jpg",biography:"Charles Elias Assmann is a biologist from Federal University of Santa Maria (UFSM, Brazil), who spent some time abroad at the Ludwig-Maximilians-Universität München (LMU, Germany). He has Masters Degree in Biochemistry (UFSM), and is currently a PhD student at Biochemistry at the Department of Biochemistry and Molecular Biology of the UFSM. His areas of expertise include: Biochemistry, Molecular Biology, Enzymology, Genetics and Toxicology. He is currently working on the following subjects: Aluminium toxicity, Neuroinflammation, Oxidative stress and Purinergic system. Since 2011 he has presented more than 80 abstracts in scientific proceedings of national and international meetings. Since 2014, he has published more than 20 peer reviewed papers (including 4 reviews, 3 in Portuguese) and 2 book chapters. He has also been a reviewer of international journals and ad hoc reviewer of scientific committees from Brazilian Universities.",institutionString:"Universidade Federal de Santa Maria",institution:{name:"Universidade Federal de Santa Maria",country:{name:"Brazil"}}},{id:"217850",title:"Dr.",name:"Margarete Dulce",middleName:null,surname:"Bagatini",slug:"margarete-dulce-bagatini",fullName:"Margarete Dulce Bagatini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217850/images/system/217850.jpeg",biography:"Dr. Margarete Dulce Bagatini is an associate professor at the Federal University of Fronteira Sul/Brazil. She has a degree in Pharmacy and a PhD in Biological Sciences: Toxicological Biochemistry. She is a member of the UFFS Research Advisory Committee\nand a member of the Biovitta Research Institute. She is currently:\nthe leader of the research group: Biological and Clinical Studies\nin Human Pathologies, professor of postgraduate program in\nBiochemistry at UFSC and postgraduate program in Science and Food Technology at\nUFFS. She has experience in the area of pharmacy and clinical analysis, acting mainly\non the following topics: oxidative stress, the purinergic system and human pathologies, being a reviewer of several international journals and books.",institutionString:"Universidade Federal da Fronteira Sul",institution:{name:"Universidade Federal da Fronteira Sul",country:{name:"Brazil"}}},{id:"226275",title:"Ph.D.",name:"Metin",middleName:null,surname:"Budak",slug:"metin-budak",fullName:"Metin Budak",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226275/images/system/226275.jfif",biography:"Metin Budak, MSc, PhD is an Assistant Professor at Trakya University, Faculty of Medicine. He has been Head of the Molecular Research Lab at Prof. Mirko Tos Ear and Hearing Research Center since 2018. His specializations are biophysics, epigenetics, genetics, and methylation mechanisms. He has published around 25 peer-reviewed papers, 2 book chapters, and 28 abstracts. He is a member of the Clinical Research Ethics Committee and Quantification and Consideration Committee of Medicine Faculty. His research area is the role of methylation during gene transcription, chromatin packages DNA within the cell and DNA repair, replication, recombination, and gene transcription. His research focuses on how the cell overcomes chromatin structure and methylation to allow access to the underlying DNA and enable normal cellular function.",institutionString:"Trakya University",institution:{name:"Trakya University",country:{name:"Turkey"}}},{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",slug:"anca-pantea-stoian",fullName:"Anca Pantea Stoian",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243049/images/system/243049.jpg",biography:"Anca Pantea Stoian is a specialist in diabetes, nutrition, and metabolic diseases as well as health food hygiene. She also has competency in general ultrasonography.\n\nShe is an associate professor in the Diabetes, Nutrition and Metabolic Diseases Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. She has been chief of the Hygiene Department, Faculty of Dentistry, at the same university since 2019. Her interests include micro and macrovascular complications in diabetes and new therapies. Her research activities focus on nutritional intervention in chronic pathology, as well as cardio-renal-metabolic risk assessment, and diabetes in cancer. She is currently engaged in developing new therapies and technological tools for screening, prevention, and patient education in diabetes. \n\nShe is a member of the European Association for the Study of Diabetes, Cardiometabolic Academy, CEDA, Romanian Society of Diabetes, Nutrition and Metabolic Diseases, Romanian Diabetes Federation, and Association for Renal Metabolic and Nutrition studies. She has authored or co-authored 160 papers in national and international peer-reviewed journals.",institutionString:null,institution:{name:"Carol Davila University of Medicine and Pharmacy",country:{name:"Romania"}}},{id:"279792",title:"Dr.",name:"João",middleName:null,surname:"Cotas",slug:"joao-cotas",fullName:"João Cotas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/279792/images/system/279792.jpg",biography:"Graduate and master in Biology from the University of Coimbra.\n\nI am a research fellow at the Macroalgae Laboratory Unit, in the MARE-UC – Marine and Environmental Sciences Centre of the University of Coimbra. My principal function is the collection, extraction and purification of macroalgae compounds, chemical and bioactive characterization of the compounds and algae extracts and development of new methodologies in marine biotechnology area. \nI am associated in two projects: one consists on discovery of natural compounds for oncobiology. The other project is the about the natural compounds/products for agricultural area.\n\nPublications:\nCotas, J.; Figueirinha, A.; Pereira, L.; Batista, T. 2018. An analysis of the effects of salinity on Fucus ceranoides (Ochrophyta, Phaeophyceae), in the Mondego River (Portugal). Journal of Oceanology and Limnology. in press. DOI: 10.1007/s00343-019-8111-3",institutionString:"Faculty of Sciences and Technology of University of Coimbra",institution:null},{id:"279788",title:"Dr.",name:"Leonel",middleName:null,surname:"Pereira",slug:"leonel-pereira",fullName:"Leonel Pereira",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/279788/images/system/279788.jpg",biography:"Leonel Pereira has an undergraduate degree in Biology, a Ph.D. in Biology (specialty in Cell Biology), and a Habilitation degree in Biosciences (specialization in Biotechnology) from the Faculty of Science and Technology, University of Coimbra, Portugal, where he is currently a professor. In addition to teaching at this university, he is an integrated researcher at the Marine and Environmental Sciences Center (MARE), Portugal. His interests include marine biodiversity (algae), marine biotechnology (algae bioactive compounds), and marine ecology (environmental assessment). Since 2008, he has been the author and editor of the electronic publication MACOI – Portuguese Seaweeds Website (www.seaweeds.uc.pt). He is also a member of the editorial boards of several scientific journals. Dr. Pereira has edited or authored more than 20 books, 100 journal articles, and 45 book chapters. He has given more than 100 lectures and oral communications at various national and international scientific events. He is the coordinator of several national and international research projects. In 1998, he received the Francisco de Holanda Award (Honorable Mention) and, more recently, the Mar Rei D. Carlos award (18th edition). He is also a winner of the 2016 CHOICE Award for an outstanding academic title for his book Edible Seaweeds of the World. In 2020, Dr. Pereira received an Honorable Mention for the Impact of International Publications from the Web of Science",institutionString:"University of Coimbra",institution:{name:"University of Coimbra",country:{name:"Portugal"}}},{id:"61946",title:"Dr.",name:"Carol",middleName:null,surname:"Bernstein",slug:"carol-bernstein",fullName:"Carol Bernstein",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/61946/images/system/61946.jpg",biography:"Carol Bernstein received her PhD in Genetics from the University of California (Davis). She was a faculty member at the University of Arizona College of Medicine for 43 years, retiring in 2011. Her research interests focus on DNA damage and its underlying role in sex, aging and in the early steps of initiation and progression to cancer. In her research, she had used organisms including bacteriophage T4, Neurospora crassa, Schizosaccharomyces pombe and mice, as well as human cells and tissues. She authored or co-authored more than 140 scientific publications, including articles in major peer reviewed journals, book chapters, invited reviews and one book.",institutionString:"University of Arizona",institution:{name:"University of Arizona",country:{name:"United States of America"}}},{id:"182258",title:"Dr.",name:"Ademar",middleName:"Pereira",surname:"Serra",slug:"ademar-serra",fullName:"Ademar Serra",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/182258/images/system/182258.jpeg",biography:"Dr. Serra studied Agronomy on Universidade Federal de Mato Grosso do Sul (UFMS) (2005). He received master degree in Agronomy, Crop Science (Soil fertility and plant nutrition) (2007) by Universidade Federal da Grande Dourados (UFGD), and PhD in agronomy (Soil fertility and plant nutrition) (2011) from Universidade Federal da Grande Dourados / Escola Superior de Agricultura Luiz de Queiroz (UFGD/ESALQ-USP). Dr. Serra is currently working at Brazilian Agricultural Research Corporation (EMBRAPA). His research focus is on mineral nutrition of plants, crop science and soil science. Dr. Serra\\'s current projects are soil organic matter, soil phosphorus fractions, compositional nutrient diagnosis (CND) and isometric log ratio (ilr) transformation in compositional data analysis.",institutionString:"Brazilian Agricultural Research Corporation",institution:{name:"Brazilian Agricultural Research Corporation",country:{name:"Brazil"}}}]}},subseries:{item:{id:"12",type:"subseries",title:"Human Physiology",keywords:"Anatomy, Cells, Organs, Systems, Homeostasis, Functions",scope:"Human physiology is the scientific exploration of the various functions (physical, biochemical, and mechanical properties) of humans, their organs, and their constituent cells. The endocrine and nervous systems play important roles in maintaining homeostasis in the human body. Integration, which is the biological basis of physiology, is achieved through communication between the many overlapping functions of the human body's systems, which takes place through electrical and chemical means. Much of the basis of our knowledge of human physiology has been provided by animal experiments. Because of the close relationship between structure and function, studies in human physiology and anatomy seek to understand the mechanisms that help the human body function. The series on human physiology deals with the various mechanisms of interaction between the various organs, nerves, and cells in the human body.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/12.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11408,editor:{id:"195829",title:"Prof.",name:"Kunihiro",middleName:null,surname:"Sakuma",slug:"kunihiro-sakuma",fullName:"Kunihiro Sakuma",profilePictureURL:"https://mts.intechopen.com/storage/users/195829/images/system/195829.jpg",biography:"Professor Kunihiro Sakuma, Ph.D., currently works in the Institute for Liberal Arts at the Tokyo Institute of Technology. He is a physiologist working in the field of skeletal muscle. He was awarded his sports science diploma in 1995 by the University of Tsukuba and began his scientific work at the Department of Physiology, Aichi Human Service Center, focusing on the molecular mechanism of congenital muscular dystrophy and normal muscle regeneration. His interest later turned to the molecular mechanism and attenuating strategy of sarcopenia (age-related muscle atrophy). His opinion is to attenuate sarcopenia by improving autophagic defects using nutrient- and pharmaceutical-based treatments.",institutionString:null,institution:{name:"Tokyo Institute of Technology",institutionURL:null,country:{name:"Japan"}}},editorTwo:null,editorThree:{id:"331519",title:"Dr.",name:"Kotomi",middleName:null,surname:"Sakai",slug:"kotomi-sakai",fullName:"Kotomi Sakai",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000031QtFXQA0/Profile_Picture_1637053227318",biography:"Senior researcher Kotomi Sakai, Ph.D., MPH, works at the Research Organization of Science and Technology in Ritsumeikan University. She is a researcher in the geriatric rehabilitation and public health field. She received Ph.D. from Nihon University and MPH from St.Luke’s International University. Her main research interest is sarcopenia in older adults, especially its association with nutritional status. Additionally, to understand how to maintain and improve physical function in older adults, to conduct studies about the mechanism of sarcopenia and determine when possible interventions are needed.",institutionString:null,institution:{name:"Ritsumeikan University",institutionURL:null,country:{name:"Japan"}}},series:{id:"10",title:"Physiology",doi:"10.5772/intechopen.72796",issn:"2631-8261"},editorialBoard:[{id:"213786",title:"Dr.",name:"Henrique P.",middleName:null,surname:"Neiva",slug:"henrique-p.-neiva",fullName:"Henrique P. Neiva",profilePictureURL:"https://mts.intechopen.com/storage/users/213786/images/system/213786.png",institutionString:null,institution:{name:"University of Beira Interior",institutionURL:null,country:{name:"Portugal"}}},{id:"39275",title:"Prof.",name:"Herbert Ryan",middleName:null,surname:"Marini",slug:"herbert-ryan-marini",fullName:"Herbert Ryan Marini",profilePictureURL:"https://mts.intechopen.com/storage/users/39275/images/9459_n.jpg",institutionString:null,institution:{name:"University of Messina",institutionURL:null,country:{name:"Italy"}}},{id:"196218",title:"Dr.",name:"Pasquale",middleName:null,surname:"Cianci",slug:"pasquale-cianci",fullName:"Pasquale Cianci",profilePictureURL:"https://mts.intechopen.com/storage/users/196218/images/system/196218.png",institutionString:null,institution:{name:"University of Foggia",institutionURL:null,country:{name:"Italy"}}}]},onlineFirstChapters:{},publishedBooks:{},testimonialsList:[{id:"18",text:"It was great publishing with IntechOpen, the process was straightforward and I had support all along.",author:{id:"71579",name:"Berend",surname:"Olivier",institutionString:"Utrecht University",profilePictureURL:"https://mts.intechopen.com/storage/users/71579/images/system/71579.png",slug:"berend-olivier",institution:{id:"253",name:"Utrecht University",country:{id:null,name:"Netherlands"}}}},{id:"27",text:"The opportunity to work with a prestigious publisher allows for the possibility to collaborate with more research groups interested in animal nutrition, leading to the development of new feeding strategies and food valuation while being more sustainable with the environment, allowing more readers to learn about the subject.",author:{id:"175967",name:"Manuel",surname:"Gonzalez Ronquillo",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/175967/images/system/175967.png",slug:"manuel-gonzalez-ronquillo",institution:{id:"6221",name:"Universidad Autónoma del Estado de México",country:{id:null,name:"Mexico"}}}},{id:"8",text:"I work with IntechOpen for a number of reasons: their professionalism, their mission in support of Open Access publishing, and the quality of their peer-reviewed publications, but also because they believe in equality.",author:{id:"202192",name:"Catrin",surname:"Rutland",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",slug:"catrin-rutland",institution:{id:"134",name:"University of Nottingham",country:{id:null,name:"United Kingdom"}}}}]},submityourwork:{pteSeriesList:[],lsSeriesList:[],hsSeriesList:[],sshSeriesList:[],subseriesList:[],annualVolumeBook:{},thematicCollection:[],selectedSeries:null,selectedSubseries:null},seriesLanding:{item:null},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"chapter.detail",path:"/chapters/44970",hash:"",query:{},params:{id:"44970"},fullPath:"/chapters/44970",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()