Modified HICPAC Categorization Scheme* for Recommendations (Reprinted from CDC [39]).
\r\n\t1. Role and utility of animal models to understand the pathophysiology of PD and screening therapeutic molecules of dopaminergic neuroprotection
\r\n\t2. Importance of epidemiological studies and available therapeutic strategies for PD
\r\n\t3. Mechanistic insights into dopaminergic neuroprotection/neurodegeneration relating to PD
\r\n\tThe present project concerns “reducing the burden of disease” which is the prime aim of biomedical research.
",isbn:"978-1-80356-489-0",printIsbn:"978-1-80356-488-3",pdfIsbn:"978-1-80356-490-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"99788a4a7f9ee0b4de55de293a2ed3d0",bookSignature:"Prof. Sarat Chandra Yenisetti",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11583.jpg",keywords:"Cell Culture, Nutraceuticals, L-dopa, Deep Brain Stimulation, Paraquat, Rotenone, MPTP, Oxidative Stress, SOD, JNK, Catalase, ToR",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 4th 2022",dateEndSecondStepPublish:"May 5th 2022",dateEndThirdStepPublish:"July 4th 2022",dateEndFourthStepPublish:"September 22nd 2022",dateEndFifthStepPublish:"November 21st 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Sarat obtained post-doctoral training in neurogenetics from the University of Regensburg, Germany, and the National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health (NIH), Bethesda, USA. 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His laboratory, funded through multiple research grants from Department of Biotechnology (DBT), India, University of Grants Commission (UGC), India and Department of Science and Technology (DST), India, focuses on Drosophila approach to understand Parkinson's Disease associated neurodegeneration as well as identification of novel therapeutic targets which may help to reduce the burden of PD in human.",institutionString:"Nagaland University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Nagaland University",institutionURL:null,country:{name:"India"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"453624",firstName:"Martina",lastName:"Scerbe",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/453624/images/20399_n.jpg",email:"martina.s@intechopen.com",biography:null}},relatedBooks:[{type:"book",id:"7256",title:"Dopamine",subtitle:"Health and Disease",isOpenForSubmission:!1,hash:"e46d08f526c35d787be15bcb17126fb8",slug:"dopamine-health-and-disease",bookSignature:"Sarat Chandra Yenisetti",coverURL:"https://cdn.intechopen.com/books/images_new/7256.jpg",editedByType:"Edited by",editors:[{id:"181774",title:"Prof.",name:"Sarat Chandra",surname:"Yenisetti",slug:"sarat-chandra-yenisetti",fullName:"Sarat Chandra Yenisetti"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6406",title:"Parkinson's Disease",subtitle:"Understanding Pathophysiology and Developing Therapeutic Strategies",isOpenForSubmission:!1,hash:"0038453d1272466535c41e37d94ee52f",slug:"parkinson-s-disease-understanding-pathophysiology-and-developing-therapeutic-strategies",bookSignature:"Sarat Chandra Yenisetti",coverURL:"https://cdn.intechopen.com/books/images_new/6406.jpg",editedByType:"Edited by",editors:[{id:"181774",title:"Prof.",name:"Sarat Chandra",surname:"Yenisetti",slug:"sarat-chandra-yenisetti",fullName:"Sarat Chandra Yenisetti"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6550",title:"Cohort Studies in Health Sciences",subtitle:null,isOpenForSubmission:!1,hash:"01df5aba4fff1a84b37a2fdafa809660",slug:"cohort-studies-in-health-sciences",bookSignature:"R. 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About half of women will experience a UTI during their lifetime. The incidence is much lower in men but increases with age. In patients over the age of 65, at least 20% of women and 10% of men have bacteruria [1]. The incidence also increases with hospitalization or institutionalization. UTIs are the most common nosocomial infection, and more than 80% of these are associated with an indwelling catheter [2]. There is also a higher risk of UTIS in pregnancy and some chronic diseases including diabetes, multiple sclerosis, spinal cord injuries or disease, and immunosuppressive diseases such as HIV.
\nThe cost of treating UTIs is substantial both in inpatient and outpatient settings. In the United States in the year 2007, approximately 2.47 billion dollars were spent on outpatient treatment of UTI and this excluded spending on prescriptions [3]. The estimated cost of nosocomial UTIS is approximately 2.66 billion dollars in 2007 dollars [4]. There are simple and effective measures for prevention of UTIs which can significantly limit morbidity and cost, but these are often overlooked,
\nCertain patients, particularly women, despite having normal anatomy and function of the urinary tract, are genetically predisposed to urinary tract infections. This tendency seems to be related to variations in the urinary tract epithelium and it’s interaction with bacteria. Once a person has a UTI, he or she is more likely to get another within a year. Recurrence rates in women vary from 28 to 82%, with higher rates seen in women with a prior history of UTI [5]. The risk of recurrent UTIs increases with higher number of prior infections. It also decreases with a longer time interval between the first and second infections. [4] However, even with long intervals between infections, about one sixth of women have difficulties with recurrent infections throughout their lifetime [4]. Preventive strategies should be targeted to this group.
\nGiven the increasing emergence of multidrug resistant bacteria in UTIs, every effort should be made to use non-pharmacologic measures as first line preventive strategies in patient who have recurrent UTIs.
\nThere are many “old wives” tales about causes of UTIs, and many of these beliefs are ingrained in women. Women are told by other women to wear cotton underwear, avoid drinking sodas, and even to avoid strong laundry detergent in an effort to prevent UTIS.
\nStudies have not been done to evaluate most of these measures. A search of PubMed using the terms “urinary tract infection” and “sodas, carbonated beverages, hygiene, wiping patterns” did not reveal any studies. However, it is intuitive that girls and women should always wipe from front to back after a bowel movement to avoid brining fecal bacteria towards the vagina and the urethra. If a woman is predisposed to urinary tract infections, she should carefully watch hygiene. It is helpful to show these women a picture of the vulvar anatomy, explaining the close proximity of the urethra to the anal area and that an infection occurs when intestinal bacteria enter the urethra. These women should be encouraged to clean with a moist wipe (such as a baby wipe or other hygienic cleansing wipe) after a bowel movement. It is the author’s opinion that it is helpful to wash the perineum and perianal area with antibacterial soap prior to intercourse. Patients should also be instructed to avoid any sexual practices that might bring colonic bacteria forward towards the vagina, such as touching the perianal area and then the vaginal area. Voiding after intercourse has been shown to protect against UTI [5]. There is no evidence that vaginal douching after intercourse decreases UTI incidence and in fact, it may increase the risk of vaginal infections. As such, it is not a recommended practice.
\nIt is also the author’s opinion that patient with recurrent UTIs should avoid tub baths. This recommendation comes from repeated observations over years of practice that many women who present UTIs give a history of taking frequent tub baths. It is plausible that the hot water washes away some of the protective mucous coating the urethral and vaginal introitus, making the mucosa drier and more susceptible to bacterial colonization. There were no studies on this found during a literature search on PupMed and OVID using the search terms “tub bath” “bathing” and “urinary tract infection”. There were interestingly a few papers in the 70s linking Pseudomonas infections, including UTIs, to whirlpools and hot tubs, and this led the Centers for Disease Control (CDC) in the United States to establish standards for chlorination and filtration of these tubs [6]. Patient with UTIs should likely avoid these public tubs as well. Even if the water is correctly chlorinated and filtered, it is extremely hot and drying to the skin.
\nThere is evidence that links overactive bladder but not UTI to regular consumption of carbonated beverages. A large study that examined the prevalence and incidence of irritative voiding symptoms in men and women over a 12 months period showed a significant association between onset of overactive bladder and weekly consumption of carbonated drinks. (P=.03). These findings did not apply to men in the survey [7]. There are also several studies linking caffeine to lower urinary tract symptoms, but not infection [8], [9].
\nAlthough these data don’t indicate that dietary factors actually cause UTIS, women who have frequent UTIs often mistake the frequency and urgency caused by a dietary bladder irritant for an infection. This could lead to calls to their provider requesting therapy and the chance of overtreatment. Thus it would seem prudent for these women who are plagued with frequent UTIS to avoid an excessive amount of carbonated beverages and caffeine. There may well be other dietary bladder irritants, such as citrus and other acidic fruits that can cause urgency. It is helpful for women with frequent UTIS to keep a food diary for a short time and see if they can link certain foods to irritative voiding symptoms.
\nAlthough there are no contraceptive methods that prevent UTIs, there are several that may increase the risk, primarily diaphragms and spermicides. Diaphragms were widely used in the 1950s through the early 1980s, but are not often used now that there are more effective methods of contraception that are easier to use. Diaphragm users have been shown to have a two to threefold increased risk of UTI compared to non-users [10], [11]. This is due to partial urethral compression by the rim of the diaphragm and also is likely related to the spermicide that is used on the rim.
\nSpermicides contain nonoxynol-9 which can cause a chemical irritation to the vaginal and urethral mucosa as well as changes in the normal flora. This in turn predisposes to colonization by coliforms as well as Staph saprophyticus [12]. Patients with recurrent UTIs should avoid diaphragms and spermicide coated condoms, as well as other barrier agents containing nonoxynol-9 such as foam, suppositories, and sponges.
\nAfter menopause, the vulvar skin atrophies and thins. There is decreased blood flow to this area and decreased mucous production. The periurethral mucosa is lubricated by the Skene’s glands and these also atrophy, thus causing loss of mucous that is the first line of defense against bacteria. In addition, vaginal ph increases after menopause and lactobacilli counts decrease. These conditions set up the postmenopausal woman for higher risk of UTIs, particularly after intercourse. In addition, urinary incontinence, the presence of a cystocele and incomplete emptying and have been found to be highly associated with recurrent UTI, and these are problems that increase with age as well [13].
\nSystemic estrogen replacement therapy in the prevention of UTI has not been shown to be of help in preventing recurrent UTIs in postmenopausal women. However, there is strong evidence that
Vaginal estrogen therapy is available in three forms in the United States. These are listed in decreasing order of systemic absorption:
\nEstradiol vaginal cream: Premarin Vaginal cream = 0.625 mg/gm and Estrace vaginal cream = 0.1 mg/gm. Dosage varies from 0.5 mg to 2 mg/vagina twice weekly. Retail cost is $140/tube for both of these products (www.drugstore.com)
Estradiol vaginal tablets: Vagifem = 10 mcg estrogen per tablet. Dosage is one tablet inserted vaginally twice weekly. Retail cost is $64.00/month
Estradiol 2 mg vaginal ring. One ring is placed intravaginally and changed every 3 months. Retail cost is $216.00 per ring (3 months).
An exact dosage for vaginal estrogen therapy for UTI prevention hasn’t been established. Raz’s landmark study used 0.5 mg estriol cream intravaginally once daily for 2 weeks, then twice weekly. Estriol cream is not commercially available in the United States and most prescribers use one to two grams of Estrace or Premarin cream per vagina twice weekly. Dosage should be individualized based on patient weight and degree of atrophy present. In an obese woman with higher levels of endogenous estrogen, 0.5 mg of estrogen cream twice weekly will likely be adequate, whereas in a thin woman who is very atrophic, a higher dose will be needed, especially in the initial months of treatment. Of note, progesterone does not need to be prescribed with topical vaginal estrogen in women with a uterus. In the recommended dosages, vaginal estrogen therapy does not cause endometrial hyperplasia as the amount of systemic absorption of estrogen is quite low. Progesterone therapy does NOT need to be given in a woman with a uterus who is using vaginal estrogen on a long term basis.
\nDespite strong evidence of benefit, topical estrogen is underutilized as a preventive strategy. In a study of nursing home residents in Norway who were on preventive therapy for UTI, only about 10% were prescribed vaginal estrogen [14]. Many women have a fear of estrogen containing products due to fear of breast or uterine cancer. There is no evidence that vaginal estrogen therapy causes uterine cancer or even endometrial hyperplasia. The same holds true for breast cancer. Patients often need reassurance that vaginal estrogen is safe and doesn’t have the risk of systemic ERT, which uses much higher dosages. Vaginal estrogen therapy can be used safely in women with a prior history of breast cancer or thrombosis. The estrogen ring has the lowest amount of systemic absorption, followed by the vaginal estrogen tablets, then cream.
\nCost is also significant obstacle in the United States, as many health insurance plans don’t cover these products well, and after age 65 there is variable coverage of these with Medicare. One solution for women who cannot afford these products is to have a compounding pharmacist make an equivalent substitute. Estradiol 0.1 mg/gm can be added to a pluronic gel base that has excellent adherence to the vaginal mucosa. Cost is approximately $50.00 for a two to three month supply.
\nCranberries and their juice have long been touted for both treatment and prevention of UTI. This was previously thought to be due to acidification of the urine, but more recent research has shown that substances (proanthocyanadins) in the cranberry prevent adhesion of E. coli strains to the uroepithelium, including multidrug resistant strains [15]. Studies of cranberry prophylaxis are mixed, but several recent studies have shown that there is benefit from this simple remedy. Wang et al did a meta-analysis of randomized controlled trials comparing prevention of UTIs in users of cranberry products versus placebo or non-placebo controls. They found a risk ratio for cranberry users versus nonusers was 0.62 and statistically significant, leading them to conclude that cranberry products are associated with protection against UTIs. Further, cranberry products were more effective in certain subgroups including women with recurrent UTIs, children, cranberry juice users (as opposed to tablets) and those who used cranberry products more than twice daily [16].
\nA recent RCT examined women with recurrent UTIs, randomizing them to either cranberry juice or placebo for 6 months. Those in the cranberry juice did have lower incidence of recurrent UTIS, but it did not reach statistical significance. However, they did have significantly decreased counts of P-fimbriated E. coli in their urine during the study periods. These are uropathogenic strains with fimbriae capable of attaching to the uroepethelium. The authors concluded that though the cranberry juice didn’t significant reduce the number of recurrent UTIs, the reduction in adherent E. coli lends plausibility to a protective effect of cranberry and warrants further large scale studies [17].
\nWithin the pediatric population, several new cranberry studies have emerged. A RCT from Finland randomized 263 children with a prior history of UTI to 6 months of cranberry juice versus placebo. Their findings: the juice did not significantly reduce the number of children who experienced a recurrence of UTI, but it was effective in reducing the actual number of recurrences and related antimicrobial use [18]. Another recent randomized controlled prospective study found cranberry capsules effective in the prevention of UTI in children with neurogenic bladder caused by myelomeningocele who required chronic intermittent catheterization. The median UTI rate in this small cohort of 20 children was 0.5 UTI/year during placebo usage and 0/year with cranberry capsule usage. This decrease was statistically significant. No side effects were noted [19].
\nCranberry juice is safe in pregnancy and there is data from a small study to suggest that it may be efficacious in preventing asyptomatic bacteruria and symptomatic UTI. However in this same study, the juice was poorly tolerated by the pregnant women, and there was a high rate of withdrawal [20]. If used in pregnancy, use of cranberry pill form will likely be more effective as compliance will be higher.
\nPropolis is a resinous material collected by bees from exudates and buds of plants, then mixed with wax and bee enzymes. It has well documented antibacterial activity. Lavigne et al added propolis to proanthocyanidins from the cranberry and studied its effect on human volunteer subjects. They found that once daily ingestion offers some protection against bacterial adhesion, bacterial multiplication and virulence in the urinary tract [21].
\nBlueberries and blackberries are widely touted on the internet as effective prevention for UTIs but there are no trials of these foods found on PubMed or Ovid. Bearberry leaves are another folk remedy believed to be helpful in treating mild UTIs, but likewise, no studies of effectiveness have been undertaken. The same hold true for Vitamin C. There are no studies of this alone for prevention of UTI. However when Vitamin C was added to cranberry extract, D-mannose, fructo-oligosaccharides, and bromelain, this mixture was effective in reducing recurrent UTIs and improving quality of life in both pre and postmenopausal women [22]. More studies are needed on efficacy of these nutraceuticals.
\nIn summary, there is emerging evidence that cranberries are effective in the prevention of UTI in women and children, including children with neurogenic bladder. Both the juice and the capsules seem to be effective, the juice possibly more so, but it should be unsweetened juice to prevent high intake of unnecessary sugars. The capsules may be better tolerated however, particularly in pregnancy. Whichever form is used, it seems that it should be ingested three or more times daily for maximal effectiveness. The optimal dose of cranberry is not known and was studied in only one of the studies included in Wang’s meta-analysis [23]. He concluded that the cranberry juice provides the most benefit, and it should be ingested three times daily at a dose of 4 to 6 ounces [24]. Most over the counter cranberry preperations contain 400 to 500 mg of cranberry extract and are likely also more effective if taken three times/daily. More studies are needed in this area to determine the optimal dose and type of cranberry. Cranberries should be used with caution in patients on blood thinners and those with kidney stones.
\nAttempts have been underway to create an oral or parental immunoprophylaxis or vaccination for patients with recurrent UTIs for some time, but these efforts have been frustrated by the short lived nature of immunity created. The premise of a vaccine is inactivated bacteria or bacterial components presented to a host’s mucosal surface to boost immunity. Intransal sprays, sublingual preparations, vaginal suppositories and IM injections have been developed thus far. Recent publications show promise in this area. Currently, a vaccine has been developed by Immunotek in Spain called Uromune® a sublingual preparation which contains an inactivated bacterial cell suspension of selected strains of
Methenamine hippurate is not an antibiotic, but is a urinary antibacterial agent used for prevention of recurrent UTI when long term therapy is needed. It exhibits antibacterial activity by conversion of methenamine to formaldehyde in the presence of acidic urine. The hippuric acid component acidifies the urine and also has some antibacterial activity. This drug is often used in combination with a urinary acidifier such as sodium phosphate (Uroqid acid#2). The dose for suppression is 1 gram orally twice daily. It is safe for both adult and pediatric patients, but is contraindicated in patients with renal or hepatic insufficiency. Methenamine is Pregnancy Category C, and there are no adequate and well controlled studies of its use in pregnancy. It is excreted in breast milk and the amount excreted does not appear to adversely affect the nursing infant.
\nMethenamine is effective in the prevention of recurrent UTIs in both adult and pediatric patients, but should only be used following eradication of the infection by antibiotics. It is not as effective as nitrofurantoin or trimethoprim/sulfamethoxazole as prophylactic treatment, but also does not cause antimicrobial resistance. Per Micromedex, it has shown to be effective in reducing bacteruria in gynecological surgical patients with short term foley catheter placement up to 3 days, but was not effective in prophylaxis for patients with long term indwelling catheters.
\nMost of the studies of efficacy of methenamine were done in the 1960s and 70’s. Lee et al undertook a meta-analysis of all studies in 2007. There were 13 studies included, 6 of which reported on symptomatic UTI and eight for bacteruria. The overall estimates were difficult to interpret due to heterogeneity of the studies. Subgroup analysis did show that methenamine likely has benefit in patients without renal tract abnormalities for both symptomatic UTI and bacteruria but not in patients with known renal tract abnormalities. The authors concluded that methenamine may be effective for preventing UTI in patients without rental tract abnormalities, especially when used for short-term prophylaxis. It doesn’t appear to work in patients with neurogenic bladder or those who have renal tract abnormalities. The rate of adverse events is low. There is a need for further large well RCT to clarify the value of its longer term use for patients without renal tract abnormalities [26].
\nThere are 3 strategies commonly used today for prevention for patients with recurrent UTI:
\nPost coital therapy: The patient takes a single dose of an antibiotic immediately after intercourse
Patient initiated therapy: The patient takes a single antibiotic tablet on first noticing symptoms of infection
Continuous daily suppression: The patient takes a daily dose of suppressive antibiotic for 3 to 6 months or sometimes longer.
Choosing an effective preventive strategy should be individualized and keep in mind the ultimate goal to minimize exposure to long term antibiotics. Regardless, it should be noted that a patient will improve during any of these types of suppressive therapy, but once therapy is discontinued, the patient’s risk of recurrent UTIs increases back to baseline. This again underscores the need for more effective long-term preventive strategies.
\nFor those women who find sexual intercourse to commonly trigger an infection, post-coital therapy would be the easiest and safest option. Patient initiated therapy has been used for many years and is most beneficial for women who have infrequent or clustered recurrent UTIs. Adherent and motivated patients have been shown to be able to accurately self diagnose UTIs 95% of the time and successfully self treat with a short course of antibiotics taken at onset of symptoms [27]. Zhong et al found that patient-initiated single-dose intermittent antibiotic prophylaxis was as effective as low-dose daily antibiotic prophylaxis in the treatment of recurrent UTIs in post menopausal women and was associated with fewer gastrointestinal side effects [28].
\nFinally, continuous daily suppression has been shown in numerous studies to effectively reduce the incidence of recurrent UTIs by up to 95%. However, in an effort to decrease development of resistance, the first two options are recommended as initial therapy. This option should be reserved for those patients who don’t respond to intermittent therapy or are unable to be compliant with it. Most clinicians treat for a 6 month period, but in patients who continue to have frequent episodes, longer periods varying from 2 to 5 years have been used.
\nThe antibiotics most commonly used in suppressive therapies are nitrofurantoin, trimethoprim (TMP), trimethoprim with sulfamethoxazole (TMP/SMX), and fosfomycin. Quinolones or first generation cephalosporins were also used in some trials, but given their broader spectrum of action, they should NOT be used as prophylactic therapy. None of these antibiotics has shown superior effectiveness in UTI prophylaxis.
\nNitrofurantoin is an attractive first choice as its bactericidal action is limited to the urinary tract. The dose most often used for prophylaxis is 50 to 100 mg/day, taken after intercourse or at bedtime with food. Once ingested, it has a very short half life in serum (about 30 minutes) and is excreted into the urine. It is effective against
Despite its overall safety, rare but serious adverse effects are reported. The most widely known is pulmonary toxicity [29]. Reports also exist of toxic hepatitis and blood dyscrasias [29]. Neurotoxicity from nitrofurantoin is less recognized, and is estimated to occur in 0.0007 percent of courses of therapy [29].
Fosfomycin tromethamine is a powder mixed with four ounces of water and drank. It is supplied in a sachet containing 3 grams. The dose is 3 gram as a one-time treatment of uncomplicated UTI. It has also been shown to be highly effective in prophylaxis of UTI recurrence at a dose of 3 grams every 10 days [30]. There is no data on its use as post-coital therapy. It inhibits bacterial cell wall synthesis and also decreases bacterial adherence of to the urothelium. It is most active against Staphylococci (including
TMP-SMX has long been used as suppressive therapy and is effective. There is not much data on the effectiveness of Trimethoprim alone. The dose is trimethoprim 40 mg/sulfamethoxazole 200 mg either after intercourse, three times weekly, or daily. It is Pregnancy Category C but is considered safe to use in pregnancy, though if alternatives are available, another agent is recommended in the first trimester due to the folic acid anatagonist activity of trimethoprim. It is also considered safe to use during breastfeeding. Increasing resistance to this agent should be noted. In the recent Antimicrobial Resistance Epidemiology in Females with Cystitis (ARSEC) study in nine European countries and Brazil, 30-50% of all isolated urinary pathogens were resistant to TMP-SMX [31]. Side effects of TMP-SMX are common and primary gastrointestinal: nausea, emesis and anorexia. Rash is also common. Rarely, more serious side effects occur such as Stevens-Johnson syndrome, toxic epidermal necrolysis or aplastic anemia.
\nUTIS are the most common nosocomial infection worldwide, accounting for about 40% of these. The great majority of these infections are due to the presence of an indwelling urethral catheter in hospitals and long-term care facilities (LTCF) and are commonly referred to as catheter-associated UTI (CAUTI). These infections add significantly to morbidity and sometimes even mortality for the patient. The cost of these infections is substantial, estimated at 2.66 billion dollars in 2007 US dollars [32].
\nMore than 1.5 million people in the United States live in nursing homes. Within the last decade, the severity of illness of nursing home residents has increased such that these residents (average age 80) have a risk of developing health care-associated infection (HAI) that approaches that seen hospital inpatients. The use of indwelling foley catheters has decreased in this setting and is currently about 5 to 10%, but UTI remains the leading infection in long term care facilities (LTCFs). Guidelines for prevention of CA-UTI applies to both these settings [33]. Of note, the catheter literature commonly reports on catheter-associated asymptomatic bacteruria (CA-ASB) and catheter associated bacteruria if no distinction is made between CA-ASB and CA-UTI. CA-bacteruria is the predominant outcome measure reported in most clinical trials.
\nUndoubtedly, the best way to prevent UTI is to avoid long term catheterization. The risk of UTI goes up markedly about 72 hours after a foley catheter is inserted. As long term foley use is often unavoidable in the hospitalized or nursing home patient, much attention has been devoted to efforts to prevent CAUTI worldwide. The Department of Public Health in England developed guidelines in 2001 and updated them in 2007 [34]. A short time later, in 2008 the European Association of Urology (EAU), the Urological Association of Asia (UAA), and others published
Recently Conway and Larsen reviewed and compared a total of 8 guidelines worldwide to prevent CAUTI. They found broad agreement between the guidelines overall but noted that different grading systems for the level of evidence to support each recommendation made comparisons difficult. They also noted that most of the guidelines didn’t distinguish between true catheter associated infections as opposed to catheter associated asymptomatic bacteruria. They wisely noted that “For clinicians seeking to prevent CAUTI, the distinction is a moot point, because all symptomatic CAUTI begins as asymptomatic bacteruria”. Their article included an excellent, concise summary of all 8 of these guidelines. This included an overview of recommendations for catheter use, catheter types, insertion techniques, maintenance, and antimicrobials [38].
\nWithin the United States, the guidelines for prevention are very similar between the CDC and ISDA 2009 guidelines. These guidelines are summarized below. The ISDA guidelines note that most of their recommendations pertain to the prevention of catheter-associated bacteruria as this is the reported outcome in most trials, whereas the CDC doesn’t differentiate between bacteruria and symptomatic UTI. Both guidelines provided evidence for strength of each recommendation. The CDC evidence levels were used in this summary and are defined in Table 1. They are noted in blue.
\nCategory IA | \nA strong recommendation supported by high to moderate quality† evidence suggesting net clinical benefits or harms | \n
Category IB | \nA strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (e.g., aseptic technique) supported by low to very low quality evidence | \n
Category IC | \nA strong recommendation required by state or federal regulation. | \n
Category II | \nA weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms | \n
No recommendation/ unresolved issue | \n Unresolved issue for which there is low to very low quality evidence with uncertain trade offs between benefits and harms | \n
Modified HICPAC Categorization Scheme* for Recommendations (Reprinted from CDC [39]).
Insert catheter only for appropriate indications (see Table 2) and leave in place only as long as needed (Category 1B)
Catheters should NOT be placed for incontinence or nursing convenience. For the postoperative patient who needs an indwelling catheter, remove within 24 hours unless there are indications for continued use, such as surgery on the urinary tract or an open perineal wound. Then remember to remove as soon as medically feasible. The use of condom catheters in incontinent male patients should be considered but this is considered an unresolved issue due to insufficient data.
\nPatient has acute urinary retention or bladder outlet obstruction | \n
Need for accurate measurements of urinary output in critically ill patients | \n
Perioperative use for selected surgical procedures: 1. Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract 2. Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU) 3. Patients anticipated to receive large-volume infusions or diuretics during surgery 4. Need for intraoperative monitoring of urinary output | \n
To assist in healing of open sacral or perineal wounds in incontinent patients | \n
Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures) | \n
To improve comfort for end of life care if needed | \n
\n | \n
As a substitute for nursing care of the patient or resident with incontinence | \n
As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void | \n
For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anaesthesia, etc.) | \n
Examples of Appropriate Indications for Indwelling Urethral Catheter Use (Reprinted from CDC [39]).
Use alternative to indwelling catheters when appropriate
– Condom catheters in male patients without obstruction or retention (Category II). The use of condom catheters vs indwelling catheter has been studied in a randomized controlled trial of hospitalized men aged 40 and over. Results showed condom catheter use is less likely to lead to bacteruria, symptomatic UTI, or death than the use of indwelling catheters. This was especially apparent in men without dementia, and the patients overwhelmingly preferred the condom catheters [40].
– Intermittent catheterization for the following subgroups (Category II)
Spinal cord injury patient
Patients with bladder emptying dysfunction. This should include postoperative patients, including women with surgery on the genitourinary tract. Hakvoort et al randomized 87 patients who had recent vaginal prolapse surgery and a post void residual > 150 ccs after first void to either foley placement or clean intermittent catheterization (CIC). They found a significant decrease in bacteruria in the CIC group (12 vs 34%). The CIC patients also noted decreased time until return of spontaneous voiding: 18 hours in the CIC group versus 72 hours in the foley group [41]. Moreover, a subsequent study by this same group surveyed the study patients and found that the great majority preferred CIC instead of placement of a foley [42].
Children with neurogenic badders, (e.g. myelomeningocele)
– Further research needed on (Unresolved issue)
Benefits of urethral stent as an alternative to indwelling catheter in selected patients with bladder outlet obstruction
Benefits of suprapubic catheters as an alternative to indwelling urethral catheters in patients requiring short or long term catheterization.
There are studies that have compared suprapubic catheters with urethral catheters. In the gynecology literature, there are few studies. A recent meta-analysis by Healy et al found only 12 randomized controlled trials. They found that although suprapubic catheters had lower overall infection rates when compared to urethral Foleys, (20% compared with 31%), the complication rates were higher (29 % vs 11%) [43]. One study randomized a group of 257 women who underwent anterior repairs with or without vaginal hysterectomy to 3 day suprapubic vs 3 day urethral foley vs 1 day urethral foley. There were fewer infections in the suprapubic group but a significantly higher risk of complications which led to early withdrawal of this arm of the study. Complications included blockage most commonly, urinary retention, and one pyelectasia. They authors concluded that in their trial, the optimal bladder catheter after anterior colporrhaphy was an urethral catheter for 24 hours [44]. Katsumi et al found that men with spinal cord injuries who need chronic catheterization have similar complication rates in terms of UTI, and recurrent bladder and renal calculi with urinary catheters as with suprapubic catheters. Catheter complications rates were similar, though differing in type. Men with urinary catheters had more urethral and scrotal complications, while men with suprapubic tubes had more leakage and 13% required revision [45].
\nIndwelling urethral catheters should be inserted with proper sterile technique and sterile equipment by trained personnel (Category IB)
– Use appropriate hand hygiene before and after insertion or any manipulation of catheter or site (Category 1B)
– Properly secure catheters after insertion to prevent movement and urethral trauma and traction (Category IB)
– Use a closed drainage system (Category IB)
– Use the smallest bore catheter possible to minimize trauma to the urethra and bladder neck (Category II)
Intermittent catheter recommendations
– Clean (non-sterile) technique is acceptable for patients requiring chronic intermittent catheterization (CIC) (Category IA)
– Perform at regular intervals to prevent bladder overdistension (Category IB)
– Optimal cleaning and storage methods for catheters used for CIC is not determined. (Unresolved issue)
Maintenance of catheter once inserted (all Category IB)
– Maintain closed drainage system
– Keep urine flow unobstructed:
Avoid kinking
Keep collecting bag below level of bladder at all times
Empty the collecting bag regularly and avoid contact of the drainage spigot with the collecting container
Changing of indwelling catheters or drainage bags at fixed intervals is not recommended. Change is only recommended for infection, obstruction of compromise of the system (Category II)
Do
– Further research is needed on the prophylactic use of urinary antiseptics such as methenamine (unresolved issue).
Do
Do
– Routine irrigation of bladder with antibiotics is not recommended
– Routine instillation of antiseptic or antimicrobial solutions into the urinary drainage bag is not recommended
– Further research is needed on the use of bacterial interference (bladder inoculation with a nonpathogenic bacterial strain) to prevent UTI in patients requiring long term urinary catheterization (Unresolved issue)
\n
– Silicone catheters might reduce the risk of encrustation in long-term catheterized patients with frequent obstruction (Category II)
– Hydrophilic catheters, (catheters designed to be lubricated when moistened with water, which eases friction on the urethra upon insertion) might be preferable to standard catheters for patients using CIC (Category II)
– The benefit of catheter valves in reducing the risk of CAUTI is unclear and further research is needed (unresolved issue). Catheter valves (see Figure 1) are small tubes usually 8 to 12 cm in length with a stopcock mechanism that fit on the end of a foley catheter, replacing the drainage bag. This allows the patient to self empty the catheter in a typical voiding fashion at regular intervals, doing away with the need for a drainage bag. They should not be used by patients with detrusor instability, as bladder wall contractions against a closed bladder outlet could lead to reflux. They also cannot be used by patients with cognitive impairment or limited manual dexterity
Colpoplast catheter valve
\n
– Unresolved issues:
Benefit of irrigating catheter with acidifying solutions or use of oral urease inhibitors in patients with long -term indwelling catheters and frequent obstructions.
Use of portable bladder scanners to evaluate for obstruction in patients with indwelling catheters and low urine output
Use of methenamine to prevent encrustation in patients at high risk for obstruction
\n
– For culture: obtain these aseptically by aspirating the urine from the needleless sampling port with a sterile syringe after cleaning the port with disinfectant
– Large volumes or urine for analysis (not culture) can be obtained aseptically from the drainage bag.
When implemented, there is good evidence that these programs can reduce the risk of CAUTI. (Category IB). Their purpose should be:
\nTo assure appropriate use of catheters
To identify and remove catheters that are no longer needed: Alerts or reminders within the medical record that identify patients with catheters in place and note how many days they have been in have been shown to increase the removal rate of catheters. Even placing a sticker on the patient’s chart reminding physicians to discontinue unnecessary foleys is beneficial. This simple intervention in a community hospital caused a significant reduction in the rate of CA-UTI after 3 months (7.02 vs 2.08; P <.001) and 6 months post-intervention (7.02 vs 2.72; P <.001) [46].
To ensure adherence to hand hygiene and proper care of catheters.
Guidelines for peri-operative catheter management:
Procedure specific guidelines for catheter placement preoperatively and post-operative removal
Protocols for management of postoperative urinary retention, such as nurse directed use of intermittent catheterization and use of ultrasound bladder scanners.
The use of prophylaxis for CAUTI with cranberry products is mentioned in the IDSA guidelines but not in the CDC, with the note that cranberry products should not be used routinely to reduce CAUTI in patients with neurogenic bladders with chronic intermittent OR indwelling catheters. They also noted insufficient date to recommend using cranberry products for other groups. However, these guidelines were published in 2009 before more recent studies that have shown some benefit to cranberry products. The previously cited study by Mutlu, although small, concluded that cranberry capsules could be an encouraging option for the prevention of recurrent UTI in children with neurogenic bladder caused by myelomeningocele who required chronic intermittent catheterization [47.] Because cranberry capsules are safe, inexpensive, well tolerated and don’t cause any drug resistance, it would seem worthwhile to use them in these high risk populations as a first line preventive measures.
\nUrinary tract infection is one of the most common healthcare problems facing women, and almost half of women will have a UTI during their lifetime. The incidence is much lower in men, but increases with age. About 15% of women will have problems with recurrent UTI despite having no anatomic abnormalities of the urinary tract. This is likely due to genetic variations in their mucosal protective defense mechanisms that predispose them to bacterial colonization. Preventive strategies should be used liberally in this group of patients and should focus on non-pharmacologic measures first to avoid the ever-increasing drug resistance that is developing worldwide.
\nSimple hygienic measures are helpful, including proper wiping techniques and voiding after intercourse, and possibly avoiding tub baths. Diaphragms and contraceptive methods containing nonoxynol-9 should be avoided. Cranberry juice or tablets are likely an effective and risk free preventive measure, and should be taken three times daily. Methenamine is an old measure that has been shown to be effective for uncomplicated patients as well. After menopause, these women should use vaginal estrogen therapy which has been shown to decrease recurrences in several studies. If patients continue to have frequent infections despite these measures, a regimen of antibiotic prophylaxis should be started. This can be a single dose taken after intercourse if the patient is sexually active and intercourse triggers an infection. For women who don’t have this problem but still have frequent infections, patient- initiated therapy is very effective. The patient has a supply of antibiotic on hand to take at the first sign of symptoms. Finally, for women who continue to have infections despite these strategies, a daily dose of suppression may be needed for 3 to 6 months. However, her risk of infection returns to baseline and remains high when this therapy is discontinued. The antibiotics used most often in suppressive regimens are nitrofurantoin and TMP/SMX
\nCAUTI remains the leading cause of hospital acquired infections worldwide. Although use of a urethral catheter is at times a necessary part of caring for patients, there are proven steps that can decrease the infection rate. Most importantly, catheters should be placed only for accepted indications and not for incontinence or convenience. For postoperative female patients undergoing uncomplicated procedures, including gynecologic procedures, we should rethink the practice of routine foley placement during the procedure. Instead, consider intermittent in/out catheterization until she is able to ambulate and void satisfactorily. For men without cognitive impairment and obstruction, a condom catheter should be used. More research is needed in the bladder management of the postoperative patient, as well as the role of cranberry to prevent CAUTI. When Foleys are placed, the need for ongoing catheterization should be assessed daily and the catheter discontinued as soon as possible. Reminder systems, whether an electronic reminder or a paper sticker for those not yet using electronic systems, have been shown to lower infection rates and should always be used when a foley is placed.
\nMany epidemiologic studies report an increase in incidence and prevalence of Crohn’s disease [CD] and Ulcerative Colitis (UC) in a global proportion. It is more evident in countries that going through an industrialization process, e.g., Asia, South America and Middle East [1, 2, 3]. The incidence follows the country industrialization and people living in urban areas has a greater incidence of IBD [4, 5]. The global prevalence of IBD has increased from 79.5 to 84.3 per 100,000 persons in recent years. IBD has been considered a disease of high-income regions. The USA had the highest age-standardized prevalence rate globally; approximately a quarter of total global patients with IBD living there in 2017. The UK had the highest age-standardized prevalence in Europe. The prevalence of IBD range from 252 to 439 cases per 100 000 population in the USA and 373 per 100 000 population in UK [6].
The complete mechanism of pathogenesis of IBD still unclear. IBD has a complex immune-mediated inflammatory disease that affects primarily the digestive tube. Those individuals with a genetic predisposition when exposed to different environmental factors may initiate an inflammatory response that is influenced by gut microbiome (Figure 1) [7]. The process is characterized by chronic relapsing and remitting inflammation for life.
Pathogenesis of IBD.
Many diet components were reported to be protective factors to IBD as fiber, short-chain fatty acids, wheat, gluten, zinc, vitamin D. On the other hand some kind of food may worsen the disease: FODMAPs, red meat, emulsifiers and sugar [8].
The interaction of diet components with the microbiome is not so simple: more fiber, less flares. Some patients complain worsening of symptoms with fibers consumption. One hypothesis is that altered microbiome may produce incomplete fermentation and then, originating pro-inflammatory byproducts as succinate [9].
The microbiome is the group of all organisms found in the whole gut and includes bacteria, fungi, viruses and protozoa. Most of them are found in the colon. Many studies showed that IBD patients have altered microbiome and pro-inflammatory bacteria. When you treat a patient with Crohn disease and make an ostomy avoid intestinal transit in affected bowel segment it result in decreased inflammation [10, 11, 12, 13].
Another evidence of environmental factor is the impairment in Peroxisome proliferator-activated receptors-γ (PPARγ) activity. Environmental pollutants can block the PPARy signaling pathway while mesalazine enhances its expression [14].
The Hippo pathway is an evolutionarily conserved pathway that controls organ size and homoeostasis through modulating cell proliferation, survival, apoptosis, and stemness. Hippo pathway is involved in the IBD pathogenesis, including intestinal cell regeneration, gut microbiota, and angio- genesis of the intestines [15, 16].
Crohn disease (CD) and Ulcerative Colitis (UC) are grouped as inflammatory bowel diseases but each one has distinct clinical characteristics (Table 1). These differences have to be in mind when a bowel resection and anastomosis is done in a patient with Crohn disease.
Differences | Crohn disease | Ulcerative colites |
---|---|---|
Full thickness inflammation of bowel wall | Compromise mucosa | |
All gastrointestinal segments; Generally ilium and colon; Non-continuous pattern. | Rectum and/or entire colon; Continuous pattern. | |
Abscesses, fistulas, strictures. | Bleeding, perforation, toxic megacolon. |
Characteristics of n disease (CD) and Ulcerative Colites (UC).
Clinically CD may be classified into three phenotypes: inflammatory, penetrating (fistulizing) and stricturing [17]. During the diagnosis evaluation 10% may be in the stricturing group and one decade later up to one third of patients may present stricturing Figure 2 [18, 19].
Natural progression of Crohn disease. (From Jacques Cosnes et al. [
The treatment of strictures may be done by endoscopy (endoscopic balloon dilatation, strictureplasty or surgical resection of bowel segment.
According to Cosnes et al. [18] the site of lesions is the most important factor to determine the disease behavior and progression to complication:
Small bowel and anoperineal > stricture and penetrating complications;
Esphagogastroduodenal and colon > inflammation.
In general, 75% of patients with strictures may require surgery once during lifetime but it may range from 70–90%. Right timing in indication of surgery for CD may reduce complication rates, diminish operative technical difficulties and stoma indication, less emergency surgeries and also better mortality rates [18, 20, 21].
As CD does not have cure, surgery has a well-defined hole in therapeutic armamentarium. The aim of surgery is to treat complications, control symptoms, to try to preserve bowel length and keep to bowel function (Table 2).
|
Indications for surgery in CD.
Endoscopy may confirm the IBD diagnosis in most cases up to 90% of patients with Crohn disease or Ulcerative colitis. It allows a detailed examination of the mucosa of terminal ilium, colon and rectum. It is considered the gold standard exam for IBD diagnosis. Enteroscopy is indicated in patients with normal colonoscopy and gastroscopy but present suspection of Crohn disease. Enteroscpy may be diagnostic or therapeutic with dilation of strictures areas (Figure 3) [22].
Enteroscopy showing lesions in the jejunum and normal ileum.
Both radiological methods CT or MR Enterography have been the best non-invasive exams to evaluate the small bowel in Crohn disease. Enterography may identify affected segments, disease activity and complications (abscess and fistula). Enterography may help to differentiate inflammatory or fibrotic areas of stenosis (Figure 4–6). Stricture is defined as a bowel segment with luminal narrowing and unequivocal upstream bowel dilation (Table 3) [23].
Axial contrast- enhanced CT enterography: homogeneous mural hyperenhancement (long arrow) and stratified mural hyperenhacement (short arrow).
A – Coronal T2 sequence MR enterography: homogeneous small bowel wall thickening and sacculations (arrow); B - Coronal T2 sequence MR enterography: small bowel wall thickening with stratified (bilaminar) mural hyperenhancement (arrow).
A – Coronal T2 sequence MR enterography: homogeneous small bowel wall thickening (arrow); B - Coronal contrast-enhanced fat-suppressed T1-weighted MR enterography: small bowel wall thickening with stratified (bilaminar) mural hyperenhancement (arrow).
Segmental mural hyperenhancement |
|
Wall thickening |
|
Stricture |
|
Radiological findings in CT or MR enterography in Crohn disease.
The primary approach is to resect the small bowel stricture. Resection is associated to lower rates of recurrence. Patients submitted do strictureplasty alone may present a higher rate of disease recurrence [24]. The patient should have a small length stricture and no prior resection (Table 4).
Crohn’s disease is a panintestinal disease, with intermittent activity and the potential of focal exacerbations throughout the patient’s life |
It is impossible to cure Crohn’s disease by excision. The surgeon is required only to treat the complications |
The essence of surgical treatment is to make the operation as safeas possible. If the operation becomes safe and patients survive, they will inevitably have recurrences and so repeated operations may be required. |
Therefore, it is important to conserve as much gut as possible All diseased bowels need not be excised, only that part with complications |
If only stenotic complications are being treated, perhaps the stenosis can be simply widened by strictureplasty or dilatation |
Five “Golden Rules” of surgical management of Crohn’s disease.
Surgery may be done by laparotomy or laparoscopy with same good results and 2 cm margins of normal tissue is advised to make an anastomosis. Both anastomosis may be used: hand-sewn or stapled.
When a ileocolic resection is done the mesentery should be removed. When mesentery is left it is associated with higher recurrence rates and reoperations [25].
Bypass surgery has been rarely employed due to the risk of neoplasia in the excluded segment [26, 27]. It may be an option to treat duodenal disease. There are two types of bypass: simples bypass and exclusion bypass [28]. Exclusion bypass is used when you cannot remove the affected segment because adherences to the retroperitoneum (Figure 7).
Bypass surgery: simples bypass (A) and exclusion bypass (B).
Strictureplasty is indicated to prevent small bowel syndrome in those patients after repeated resections or extensive bowel resections. Strictures are identified by palpation of the small bowel or alternatively introducing a 20 mm ball into the intestine and locating those points where the ball stops. The type of surgery is chosen according to the size of stricture (Table 5). The most used techniques are Heineke-Mikulicz 81%, Finney 10%, side-to-side isoperistaltic 5%, others 4%. The segments more affected are jejunum and/or ileum (94%), previous ileocolonic or ileorectal anastomosis (IRA) (4%), duodenum (1%), and colon (1%) [29, 30].
Size of stricture | Techniques |
---|---|
Short-length (<10 cm) | Heineke-Mikulicz |
Moskel-Walske-Neumayer | |
Judd | |
Medium-length (10–20 cm) | Finney |
Jaboulay | |
Long-length (>20 cm) | Michelassi |
Poggioli | |
Sasaki | |
Hotokezaka |
Techniques of strictureplasty.
Strictureplasty should be used in those patients with concern for development of short bowel syndrome [31, 32].
Diffuse involvement of the small bowel with multiple strictures.
Non phlegmonous fibrotic stricture.
Rapid recurrence of Crohn’s disease manifested as obstruction.
Stricture(s) in a patient who had undergone previous major resection(s) of small bowel (>100 cm).
Stricture in a patient with intestinal failure or short bowel syndrome.
Strictureplasty has some contraindications [29, 32]:
Colonic strictures.
Free or contained perforation of the small bowel.
Hypoalbuminemia (<2.0 g/dL).
Multiple strictures within a short segment.
Phlegmonous inflammation involving the affected site.
Stricture in close proximity to a site chosen for resection.
The technique of Heineke-Mikulicz [33, 34] (Figure 8) is the most used one and is similar to that used for pyloroplasty. A small incision over the stricture is extended to 2 cm in normal tissue. The incision is closed transversally: 1 or 2 layers with absorbable suture and continuous or separate stitch. The Moskel-Walske-Neumayer technique (Figure 9) is used when you have a great difference in the width of bowel to anastomosis. If you have a fistula in the stricture the Judd (Figure 10) technique is preferable to remove the fistula tract and repair the stenosis.
The Heineke-Mikulicz technique. A - Longitudinal incision; B - transverse suture; C - final aspect.
The Moskel-Walske-Neumayer technique. A-Stenosis between segments with different diameters; B - It is made an Y shape incision; C - A free-tension suture is made.
The Judd technique. A- stenosis with fistula; B - the fistula is removed; C - end-to-end anastomosis.
The Jaboulay technique requires 2 incisions in normal segments avoiding the center of the stenosis (Figure 11).
The Jaboulay technique (1): two incisions in normal segments. A1 - the diseased segment is escluded fron the incision; B1 - Posterior and C1 - anterior sutures are made. The Finney technique (2): A2- one incision including the deseased segment is made; B2 and C2 show the posterior and anterior sutures.
The Finney technique (Figure 11) consist in one incision along the stenosis reaching up the normal tissue and them the bowel is folded in a U shape to be closed.
In the Michelassi technique [35] the stenotic segment is divided in the middle and a longitudinal incision is made in both segments. A restoring anastomosis is made with the overlapping of both diseased segments (Figure 12). The Sasaki technique is a modification of Michelassi technique with the use of nonspatulated bowel ends to create an additional Heineke-Mikulicz strictureplasty on both ends [36] (Figure 12).
The Michelassi technique (1): A1 - anastomosis of two stenotic segments B1 - the edges of bowel can be trimmed to allow better approximation; C1 - latero-lateral anastomosis; D1- final aspect. The variation is the Sasaki technique (2): A2 - anastomosis of two diseased segments; B2 - the edges of bowels are mantained; C2 - the end of the anastomosis is then transversely closed; D2 - final aspect.
The Poggioli technique [37] is a modification of Michelassi technique and the difference is that we overlap a diseased segment with a non-diseased segment (Figure 13).
The Poggioli technique. A - long diseased segment; B - the diseased segment is separated from normal segment; C - a longitudinal incision is made in both segments; D - lateral enterostomy with overlap of affected and normal segments.
A combination of resection and enterostomy was described by Hotokezaka [38] (Figure 14). The bowel segment with severe stenosis is removed. The remaining segment with stenosis is divide in the midpoint. A side-to-side antimesenteric enterostomy with the 2 bowel segments are made and them and end-to-end anastomosis are made between the strictureplasty and the resection site.
The Hotokezaka technique. A - cecum and terminal ilium are resectes; B - a less affected segment is used to strictureplasty; C - Diseased segment is divide at the midle; D - side-to-side antimesenteric enterostomy with the 2 bowel segments is made; E - final aspect.
Results Strictureplasty vs. Resection.
The rate of complication for strictureplasty is about 4% to abscess, fistula and leakage [31]. Bowel resection is associated with lower recurrence rate (25.1%) compared to structureplasty (35.9%; p = 0.04). Recurrence-free survival was longer for bowel resection vs. strictureplasty (p = 0.02) [39, 40].
Surgical recurrence was higher for bowel resection (29.4%) vs. strictureplasty (39.7%; p = 0.002). No difference was observed for medical recurrence for bowel resection (12.4%) vs. strictureplasty (18.0%; p = 0.82) and also for overall morbidity between bowel resection (18.1%) vs. strictureplasty (10.7%; p = 0.65) [39, 40].
In fact, most cases a combination of techniques are used: resection for the severe lesion and plasty for the other. This approach seems to have the same rate of complications. This approach may decrease the risk of intestinal failure because patients may need future interventions and additional resection. Young age may be a risk for recurrent stricture. The 5-year reoperation rate for recurrent obstruction was 22% for resection alone, 30% for strictureplasty alone and 42% for strictureplasty and resection (P = 0.038) [39, 40].
Kono et al. [41] reported a new technique of anchored anastomosis that could prevent recurrence. After resection of a severe stenosis with linear staple both end are put together with suture and a Jaboulay like side-to-side anastomosis is performed [42] (Figure 15).
Kono-S anastomosis: A - stenosis is removed; B - the ends of both segments are closed; C - both ends are put send-to-end; D - longitudinal incisions are made in both segments; E - the suture column beside the laterallateral anastomosis may sustain the lumen open and prevent stenosis; F - final aspect.
The use of fecal diversion is not common but in some clinical conditions may be indicated [31]:
long-term and/or high-dose steroid use,
recent use of biologics,
malnutrition with hypoalbumenia (<2 g/dL).
Colonic Crohn disease may be treated by segmental or total colectomy with ileo-rectal anastomosis. Total proctocolectomy with definitive ileostomy are indicated in those patients with severe perineal disease. Ileal pouch–anal anastomosis is less indicated due to pouch complications.
Strictureplasty should not be used in large bowel because the risk of malignization. Chronic inflammation is a risk factor for colon cancer and dysplasia is considered to be the precursor of most colorectal cancer in IBD patients [43].
Due to its anatomical characteristics duodenal stricture may require different therapeutic alternatives: endoscopic dilatation, bypass, resection or strictureplasty. The incidence of duodenal or upper gastrointestinal tract by Crohn disease varies according to age: adults 0.3 to 5%, adolescents 28% and 43% in pediatric patients with CD [44]. Patients with duodenal CD may present more aggressive evolution with high rates of recurrence and needs for surgical treatments [45].
Clinically patient complain: Epigastric pain, nausea, anorexia, early satiety, blation and belching, weight, Less common symptoms are: anemia, diarrhea, feculent vominiting, hematemesis or melena [46].
Surgical treatment indication: outlet obstruction (83%), refractory pain (11%), and bleeding (5%) [47]. Surgical options are: resection, gastrojejunostomy, duodeno- jejunostomy, gastroduodenostomy and by-pass.
Ulcerative colitis (UC) is a chronic inflammatory condition of the colon and rectum. Initial therapeutic approach is based in different classes of medicine: anti-inflammatory, immunosuppressant (aminosalicylates, corticosteroids, thiopurines) and biological treatment as anti-tumor necrosis factor (anti-TNF), anti-integrins, anti-jak and other. However, most patients have successful clinical control and good evolution approximately 20–30% of patients will require surgery during their life [48].
However, surgery is a curative treatment for UC, the decision about an elective surgery is preference-sensitive. Generally, the indications for surgery are: medically refractory disease, dysplasia and carcinoma.
The surgery basically is total proctocolectomy with anastomosis or end ileostomy. The proctocolectomy with anastomosis is the ileal pouch–anal anastomosis (IPAA).
Total abdominal colectomy with ileorectal anastomosis is not indicated to patients with UC. The reasons are: half of patients will have a worsen disease in the rectum that will need protectomy and the risk of rectal cancer is 7–8% [49].
Proctocolectomy and ileal pouch–anal anastomosis (IPAA)
IPAA procedure may be done in stages:
Three-stage operation: (1) total colectomy with end ileostomy and rectal stump, (2) proctectomy with IPAA and loop ileostomy, and (3) ileostomy closure;
Two-stage operation: (1) total proctocolectomy with IPAA and loop ileostomy and (2) ileostomy tclosure;
One-stage operation: total proctocolectomy with IPAA and no diversion.
There are different types of pouch and most surgeons favor the J pouch due to the simplicity to construct and good outcomes. The procedure may be done by laparotomy, laparoscopy, robotic or associated approaches.
It is indicated for those patients who does not meet the criteria for IPAA. It is contraindicated in obese patients. The patient has to be able to handle the ostomy and do self-intubation.
Surgery for bowel Crohn disease is not curative and procedures hat to be as less aggressive as possible. Surgery is indicated only in those cases with complication as obstruction and fistula. Resection approach is preferable to patients without risk to develop short bowel syndrome. Strictureplasty may be used to preserve bowel integrity. Different techniques are used depend upon the length of the stenosis. Bowel Resection is associated with lower recurrence rate and longer recurrence-free survival.
Dr. Carlos Alberto Ximenes Filho for providing CT and MR figures.
The authors declare no conflict of interest.
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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:"94311",title:"Prof.",name:"Martins",middleName:"Ochubiojo",surname:"Ochubiojo Emeje",slug:"martins-ochubiojo-emeje",fullName:"Martins Ochubiojo Emeje",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94311/images/system/94311.jpeg",biography:"Martins Emeje obtained a BPharm with distinction from Ahmadu Bello University, Nigeria, and an MPharm and Ph.D. from the University of Nigeria (UNN), where he received the best Ph.D. award and was enlisted as UNN’s “Face of Research.” He established the first nanomedicine center in Nigeria and was the pioneer head of the intellectual property and technology transfer as well as the technology innovation and support center. Prof. Emeje’s several international fellowships include the prestigious Raman fellowship. He has published more than 150 articles and patents. He is also the head of R&D at NIPRD and holds a visiting professor position at Nnamdi Azikiwe University, Nigeria. He has a postgraduate certificate in Project Management from Walden University, Minnesota, as well as a professional teaching certificate and a World Bank certification in Public Procurement. Prof. Emeje was a national chairman of academic pharmacists in Nigeria and the 2021 winner of the May & Baker Nigeria Plc–sponsored prize for professional service in research and innovation.",institutionString:"National Institute for Pharmaceutical Research and Development",institution:{name:"National Institute for Pharmaceutical Research and Development",country:{name:"Nigeria"}}},{id:"268659",title:"Ms.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/268659/images/8143_n.jpg",biography:"Dr. Zhan received his undergraduate and graduate training in the fields of preventive medicine and epidemiology and statistics at the West China University of Medical Sciences in China during 1989 to 1999. He received his post-doctoral training in oncology and cancer proteomics for two years at the Cancer Research Institute of Human Medical University in China. In 2001, he went to the University of Tennessee Health Science Center (UTHSC) in USA, where he was a post-doctoral researcher and focused on mass spectrometry and cancer proteomics. Then, he was appointed as an Assistant Professor of Neurology, UTHSC in 2005. He moved to the Cleveland Clinic in USA as a Project Scientist/Staff in 2006 where he focused on the studies of eye disease proteomics and biomarkers. He returned to UTHSC as an Assistant Professor of Neurology in the end of 2007, engaging in proteomics and biomarker studies of lung diseases and brain tumors, and initiating the studies of predictive, preventive, and personalized medicine (PPPM) in cancer. In 2010, he was promoted to Associate Professor of Neurology, UTHSC. Currently, he is a Professor at Xiangya Hospital of Central South University in China, Fellow of Royal Society of Medicine (FRSM), the European EPMA National Representative in China, Regular Member of American Association for the Advancement of Science (AAAS), European Cooperation of Science and Technology (e-COST) grant evaluator, Associate Editors of BMC Genomics, BMC Medical Genomics, EPMA Journal, and Frontiers in Endocrinology, Executive Editor-in-Chief of Med One. He has\npublished 116 peer-reviewed research articles, 16 book chapters, 2 books, and 2 US patents. His current main research interest focuses on the studies of cancer proteomics and biomarkers, and the use of modern omics techniques and systems biology for PPPM in cancer, and on the development and use of 2DE-LC/MS for the large-scale study of human proteoforms.",institutionString:null,institution:{name:"Xiangya Hospital Central South University",country:{name:"China"}}},{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:"418340",title:"Dr.",name:"Jyotirmoi",middleName:null,surname:"Aich",slug:"jyotirmoi-aich",fullName:"Jyotirmoi Aich",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038Ugi5QAC/Profile_Picture_2022-04-15T07:48:28.png",biography:"Biotechnologist with 15 years of research including 6 years of teaching experience. Demonstrated record of scientific achievements through consistent publication record (H index = 13, with 874 citations) in high impact journals such as Nature Communications, Oncotarget, Annals of Oncology, PNAS, and AJRCCM, etc. Strong research professional with a post-doctorate from ACTREC where I gained experimental oncology experience in clinical settings and a doctorate from IGIB where I gained expertise in asthma pathophysiology. A well-trained biotechnologist with diverse experience on the bench across different research themes ranging from asthma to cancer and other infectious diseases. An individual with a strong commitment and innovative mindset. Have the ability to work on diverse projects such as regenerative and molecular medicine with an overall mindset of improving healthcare.",institutionString:"DY Patil Deemed to Be University",institution:null},{id:"349288",title:"Prof.",name:"Soumya",middleName:null,surname:"Basu",slug:"soumya-basu",fullName:"Soumya Basu",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035QxIDQA0/Profile_Picture_2022-04-15T07:47:01.jpg",biography:"Soumya Basu, Ph.D., is currently working as an Associate Professor at Dr. D. Y. Patil Biotechnology and Bioinformatics Institute, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India. With 16+ years of trans-disciplinary research experience in Drug Design, development, and pre-clinical validation; 20+ research article publications in journals of repute, 9+ years of teaching experience, trained with cross-disciplinary education, Dr. Basu is a life-long learner and always thrives for new challenges.\r\nHer research area is the design and synthesis of small molecule partial agonists of PPAR-γ in lung cancer. She is also using artificial intelligence and deep learning methods to understand the exosomal miRNA’s role in cancer metastasis. Dr. Basu is the recipient of many awards including the Early Career Research Award from the Department of Science and Technology, Govt. of India. She is a reviewer of many journals like Molecular Biology Reports, Frontiers in Oncology, RSC Advances, PLOS ONE, Journal of Biomolecular Structure & Dynamics, Journal of Molecular Graphics and Modelling, etc. She has edited and authored/co-authored 21 journal papers, 3 book chapters, and 15 abstracts. She is a Board of Studies member at her university. She is a life member of 'The Cytometry Society”-in India and 'All India Cell Biology Society”- in India.",institutionString:"Dr. D.Y. Patil Vidyapeeth, Pune",institution:{name:"Dr. D.Y. Patil Vidyapeeth, Pune",country:{name:"India"}}},{id:"354817",title:"Dr.",name:"Anubhab",middleName:null,surname:"Mukherjee",slug:"anubhab-mukherjee",fullName:"Anubhab Mukherjee",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y0000365PbRQAU/ProfilePicture%202022-04-15%2005%3A11%3A18.480",biography:"A former member of Laboratory of Nanomedicine, Brigham and Women’s Hospital, Harvard University, Boston, USA, Dr. Anubhab Mukherjee is an ardent votary of science who strives to make an impact in the lives of those afflicted with cancer and other chronic/acute ailments. He completed his Ph.D. from CSIR-Indian Institute of Chemical Technology, Hyderabad, India, having been skilled with RNAi, liposomal drug delivery, preclinical cell and animal studies. He pursued post-doctoral research at College of Pharmacy, Health Science Center, Texas A & M University and was involved in another postdoctoral research at Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Santa Monica, California. In 2015, he worked in Harvard-MIT Health Sciences & Technology as a visiting scientist. He has substantial experience in nanotechnology-based formulation development and successfully served various Indian organizations to develop pharmaceuticals and nutraceutical products. He is an inventor in many US patents and an author in many peer-reviewed articles, book chapters and books published in various media of international repute. Dr. Mukherjee is currently serving as Principal Scientist, R&D at Esperer Onco Nutrition (EON) Pvt. Ltd. and heads the Hyderabad R&D center of the organization.",institutionString:"Esperer Onco Nutrition Pvt Ltd.",institution:null},{id:"319365",title:"Assistant Prof.",name:"Manash K.",middleName:null,surname:"Paul",slug:"manash-k.-paul",fullName:"Manash K. Paul",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/319365/images/system/319365.png",biography:"Manash K. Paul is a Principal Investigator and Scientist at the University of California Los Angeles. He has contributed significantly to the fields of stem cell biology, regenerative medicine, and lung cancer. His research focuses on various signaling processes involved in maintaining stem cell homeostasis during the injury-repair process, deciphering lung stem cell niche, pulmonary disease modeling, immuno-oncology, and drug discovery. He is currently investigating the role of extracellular vesicles in premalignant lung cell migration and detecting the metastatic phenotype of lung cancer via machine-learning-based analyses of exosomal signatures. Dr. Paul has published in more than fifty peer-reviewed international journals and is highly cited. He is the recipient of many awards, including the UCLA Vice Chancellor’s award, a senior member of the Institute of Electrical and Electronics Engineers (IEEE), and an editorial board member for several international journals.",institutionString:"University of California Los Angeles",institution:{name:"University of California Los Angeles",country:{name:"United States of America"}}},{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://mts.intechopen.com/storage/users/219081/images/system/219081.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. He is currently working on the protective activity of phenolic compounds in disorders associated with oxidative stress and inflammation.",institutionString:null,institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Dr.",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:"329248",title:"Dr.",name:"Md. Faheem",middleName:null,surname:"Haider",slug:"md.-faheem-haider",fullName:"Md. Faheem Haider",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329248/images/system/329248.jpg",biography:"Dr. Md. Faheem Haider completed his BPharm in 2012 at Integral University, Lucknow, India. In 2014, he completed his MPharm with specialization in Pharmaceutics at Babasaheb Bhimrao Ambedkar University, Lucknow, India. He received his Ph.D. degree from Jamia Hamdard University, New Delhi, India, in 2018. He was selected for the GPAT six times and his best All India Rank was 34. Currently, he is an assistant professor at Integral University. Previously he was an assistant professor at IIMT University, Meerut, India. He has experience teaching DPharm, Pharm.D, BPharm, and MPharm students. He has more than five publications in reputed journals to his credit. Dr. Faheem’s research area is the development and characterization of nanoformulation for the delivery of drugs to various organs.",institutionString:"Integral University",institution:{name:"Integral University",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/system/329795.png",biography:"Dr. Mohd Aftab Siddiqui is an assistant professor in the Faculty of Pharmacy, Integral University, Lucknow, India, where he obtained a Ph.D. in Pharmacology in 2020. He also obtained a BPharm and MPharm from the same university in 2013 and 2015, respectively. His area of research is the pharmacological screening of herbal drugs/natural products in liver cancer and cardiac diseases. He is a member of many professional bodies and has guided many MPharm and PharmD research projects. Dr. Siddiqui has many national and international publications and one German patent to his credit.",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. from Integral University, Lucknow, India, with his work titled ‘Development and evaluation of silymarin nanoformulation for hepatic carcinoma’. Currently, he is an Assistant Professor of Pharmaceutics, at the Faculty of Pharmacy, Integral University. He has been teaching PharmD, BPharm, and MPharm students and conducting research in the novel drug delivery domain. 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 twenty-four original journal articles, two edited books, four book chapters, and several scientific articles to his credit. He is a member of the American Association for Cancer Research, the 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.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"333824",title:"Dr.",name:"Ahmad Farouk",middleName:null,surname:"Musa",slug:"ahmad-farouk-musa",fullName:"Ahmad Farouk Musa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333824/images/22684_n.jpg",biography:"Dato’ Dr Ahmad Farouk Musa\nMD, MMED (Surgery) (Mal), Fellowship in Cardiothoracic Surgery (Monash Health, Aust), Graduate Certificate in Higher Education (Aust), Academy of Medicine (Mal)\n\n\n\nDato’ Dr Ahmad Farouk Musa obtained his Doctor of Medicine from USM in 1992. He then obtained his Master of Medicine in Surgery from the same university in the year 2000 before subspecialising in Cardiothoracic Surgery at Institut Jantung Negara (IJN), Kuala Lumpur from 2002 until 2005. He then completed his Fellowship in Cardiothoracic Surgery at Monash Health, Melbourne, Australia in 2008. He has served in the Malaysian army as a Medical Officer with the rank of Captain upon completing his Internship before joining USM as a trainee lecturer. He is now serving as an academic and researcher at Monash University Malaysia. He is a life-member of the Malaysian Association of Thoracic & Cardiovascular Surgery (MATCVS) and a committee member of the MATCVS Database. He is also a life-member of the College of Surgeons, Academy of Medicine of Malaysia; a life-member of Malaysian Medical Association (MMA), and a life-member of Islamic Medical Association of Malaysia (IMAM). Recently he was appointed as an Interim Chairperson of Examination & Assessment Subcommittee of the UiTM-IJN Cardiothoracic Surgery Postgraduate Program. As an academic, he has published numerous research papers and book chapters. He has also been appointed to review many scientific manuscripts by established journals such as the British Medical Journal (BMJ). He has presented his research works at numerous local and international conferences such as the European Association for Cardiothoracic Surgery (EACTS) and the European Society of Cardiovascular Surgery (ESCVS), to name a few. He has also won many awards for his research presentations at meetings and conferences like the prestigious International Invention, Innovation & Technology Exhibition (ITEX); Design, Research and Innovation Exhibition, the National Conference on Medical Sciences and the Annual Scientific Meetings of the Malaysian Association for Thoracic and Cardiovascular Surgery. He was awarded the Darjah Setia Pangkuan Negeri (DSPN) by the Governor of Penang in July, 2015.",institutionString:null,institution:{name:"Monash University Malaysia",country:{name:"Malaysia"}}},{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. 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Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"July 5th, 2022",hasOnlineFirst:!0,numberOfOpenTopics:4,numberOfPublishedChapters:319,numberOfPublishedBooks:32,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"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"}}},subseries:[{id:"14",title:"Cell and Molecular Biology",keywords:"Omics (Transcriptomics; Proteomics; Metabolomics), Molecular Biology, Cell Biology, Signal Transduction and Regulation, Cell Growth and Differentiation, Apoptosis, Necroptosis, Ferroptosis, Autophagy, Cell Cycle, Macromolecules and Complexes, Gene Expression",scope:"The Cell and Molecular Biology topic within the IntechOpen Biochemistry Series aims to rapidly publish contributions on all aspects of cell and molecular biology, including aspects related to biochemical and genetic research (not only in humans but all living beings). We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics include, but are not limited to: Advanced techniques of cellular and molecular biology (Molecular methodologies, imaging techniques, and bioinformatics); Biological activities at the molecular level; Biological processes of cell functions, cell division, senescence, maintenance, and cell death; Biomolecules interactions; Cancer; Cell biology; Chemical biology; Computational biology; Cytochemistry; Developmental biology; Disease mechanisms and therapeutics; DNA, and RNA metabolism; Gene functions, genetics, and genomics; Genetics; Immunology; Medical microbiology; Molecular biology; Molecular genetics; Molecular processes of cell and organelle dynamics; Neuroscience; Protein biosynthesis, degradation, and functions; Regulation of molecular interactions in a cell; Signalling networks and system biology; Structural biology; Virology and microbiology.",annualVolume:11410,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"79367",title:"Dr.",name:"Ana Isabel",middleName:null,surname:"Flores",fullName:"Ana Isabel Flores",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRpIOQA0/Profile_Picture_1632418099564",institutionString:null,institution:{name:"Hospital Universitario 12 De Octubre",institutionURL:null,country:{name:"Spain"}}},{id:"328234",title:"Ph.D.",name:"Christian",middleName:null,surname:"Palavecino",fullName:"Christian Palavecino",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000030DhEhQAK/Profile_Picture_1628835318625",institutionString:null,institution:{name:"Central University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"186585",title:"Dr.",name:"Francisco Javier",middleName:null,surname:"Martin-Romero",fullName:"Francisco Javier Martin-Romero",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSB3HQAW/Profile_Picture_1631258137641",institutionString:null,institution:{name:"University of Extremadura",institutionURL:null,country:{name:"Spain"}}}]},{id:"15",title:"Chemical Biology",keywords:"Phenolic Compounds, Essential Oils, Modification of Biomolecules, Glycobiology, Combinatorial Chemistry, Therapeutic peptides, Enzyme Inhibitors",scope:"Chemical biology spans the fields of chemistry and biology involving the application of biological and chemical molecules and techniques. In recent years, the application of chemistry to biological molecules has gained significant interest in medicinal and pharmacological studies. This topic will be devoted to understanding the interplay between biomolecules and chemical compounds, their structure and function, and their potential applications in related fields. Being a part of the biochemistry discipline, the ideas and concepts that have emerged from Chemical Biology have affected other related areas. This topic will closely deal with all emerging trends in this discipline.",annualVolume:11411,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",institutionString:null,institution:{name:"Ondokuz Mayıs University",institutionURL:null,country:{name:"Turkey"}}},editorThree:null,editorialBoard:[{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",fullName:"Abdulsamed Kükürt",profilePictureURL:"https://mts.intechopen.com/storage/users/219081/images/system/219081.png",institutionString:null,institution:{name:"Kafkas University",institutionURL:null,country:{name:"Turkey"}}},{id:"241413",title:"Dr.",name:"Azhar",middleName:null,surname:"Rasul",fullName:"Azhar Rasul",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRT1oQAG/Profile_Picture_1635251978933",institutionString:null,institution:{name:"Government College University, Faisalabad",institutionURL:null,country:{name:"Pakistan"}}},{id:"178316",title:"Ph.D.",name:"Sergey",middleName:null,surname:"Sedykh",fullName:"Sergey Sedykh",profilePictureURL:"https://mts.intechopen.com/storage/users/178316/images/system/178316.jfif",institutionString:null,institution:{name:"Novosibirsk State University",institutionURL:null,country:{name:"Russia"}}}]},{id:"17",title:"Metabolism",keywords:"Biomolecules Metabolism, Energy Metabolism, Metabolic Pathways, Key Metabolic Enzymes, Metabolic Adaptation",scope:"Metabolism is frequently defined in biochemistry textbooks as the overall process that allows living systems to acquire and use the free energy they need for their vital functions or the chemical processes that occur within a living organism to maintain life. Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. Thus all studies on metabolism will be considered for publication.",annualVolume:11413,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",fullName:"Anca Pantea Stoian",profilePictureURL:"https://mts.intechopen.com/storage/users/243049/images/system/243049.jpg",institutionString:null,institution:{name:"Carol Davila University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"203824",title:"Dr.",name:"Attilio",middleName:null,surname:"Rigotti",fullName:"Attilio Rigotti",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institutionString:null,institution:{name:"Pontifical Catholic University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"300470",title:"Dr.",name:"Yanfei (Jacob)",middleName:null,surname:"Qi",fullName:"Yanfei (Jacob) Qi",profilePictureURL:"https://mts.intechopen.com/storage/users/300470/images/system/300470.jpg",institutionString:null,institution:{name:"Centenary Institute of Cancer Medicine and Cell Biology",institutionURL:null,country:{name:"Australia"}}}]},{id:"18",title:"Proteomics",keywords:"Mono- and Two-Dimensional Gel Electrophoresis (1-and 2-DE), Liquid Chromatography (LC), Mass Spectrometry/Tandem Mass Spectrometry (MS; MS/MS), Proteins",scope:"With the recognition that the human genome cannot provide answers to the etiology of a disorder, changes in the proteins expressed by a genome became a focus in research. Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. The Proteomics topic aims to attract contributions on all aspects of MS-based proteomics that, by pushing the boundaries of MS capabilities, may address biological problems that have not been resolved yet.",annualVolume:11414,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null,editorialBoard:[{id:"72288",title:"Dr.",name:"Arli Aditya",middleName:null,surname:"Parikesit",fullName:"Arli Aditya Parikesit",profilePictureURL:"https://mts.intechopen.com/storage/users/72288/images/system/72288.jpg",institutionString:null,institution:{name:"Indonesia International Institute for Life Sciences",institutionURL:null,country:{name:"Indonesia"}}},{id:"40928",title:"Dr.",name:"Cesar",middleName:null,surname:"Lopez-Camarillo",fullName:"Cesar Lopez-Camarillo",profilePictureURL:"https://mts.intechopen.com/storage/users/40928/images/3884_n.png",institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",institutionURL:null,country:{name:"Mexico"}}},{id:"81926",title:"Dr.",name:"Shymaa",middleName:null,surname:"Enany",fullName:"Shymaa Enany",profilePictureURL:"https://mts.intechopen.com/storage/users/81926/images/system/81926.png",institutionString:"Suez Canal University",institution:{name:"Suez Canal University",institutionURL:null,country:{name:"Egypt"}}}]}]}},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"chapter.detail",path:"/chapters/45475",hash:"",query:{},params:{id:"45475"},fullPath:"/chapters/45475",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)}()