Bridging therapy recommendations for patients on warfarin therapy.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"2149",leadTitle:null,fullTitle:"Musculoskeletal Disorder",title:"Musculoskeletal Disorder",subtitle:null,reviewType:"peer-reviewed",abstract:"Work-related musculoskeletal disorders are a significant problem throughout the world. 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\r\n\tThis book will cover the processes of the fungi that attach themselves to plant roots forming mycorrhizae, the mycorrhizal fungi. These fungi are symbiotrophic mutualists, meaning that they grow and feed on living plant tissues without harming the host tissues. Arbuscular mycorrhizae, ectomycorrhizae, and ectoendomycorrhizae will be discussed in more detail. We will cover the taxonomic classification of spore germination and biotrophism. The establishment of mycorrhizae results in a series of events coordinated by the fungus and the plant and their interactions. Therefore we will have the possibility to further explore the molecular and biochemical signals of mycorrhization, its intra and extra root signals, and their occurrence. Furthermore, we want to address the availability of nutrients in the soil according to its characteristics and those of the host plants. Finally, we will address the characteristics, use, and management of the soil for a better symbiotic association between the fungi and the roots. Thus, a better response to the growth of the host plants will be observed in this book.
",isbn:"978-1-83768-090-0",printIsbn:"978-1-83768-089-4",pdfIsbn:"978-1-83768-091-7",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"dddc237ff52d11c9acbfbd488686336b",bookSignature:"Dr. Rodrigo De Sousa",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/12144.jpg",keywords:"Fungi, Glomeromycota, Arbuscular Mycorrhizae, Ectomycorrhiza, Ectoendomycorrhizae, Obligatory Biotrophs, Quiescence, Symbiosis, Occurrence of Mycorrhiza, Stimulation of Plant Growth, Nutrient Use Efficiency, Mycorrhizal Dependence",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 18th 2022",dateEndSecondStepPublish:"July 19th 2022",dateEndThirdStepPublish:"September 17th 2022",dateEndFourthStepPublish:"December 6th 2022",dateEndFifthStepPublish:"February 4th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"19 days",secondStepPassed:!1,areRegistrationsClosed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. de Sousa is a researcher on alternative sources of fertilizers in Brazil. He obtained a Ph.D. in Soil Science and Plant Nutrition from the University of São Paulo (USP), Brazil. Dr. de Sousa completed an internship at the Department of Crop and Soil Sciences, North Carolina State University, USA.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"297508",title:"Dr.",name:"Rodrigo",middleName:null,surname:"De Sousa",slug:"rodrigo-de-sousa",fullName:"Rodrigo De Sousa",profilePictureURL:"https://mts.intechopen.com/storage/users/297508/images/system/297508.jpg",biography:"Rodrigo Nogueira de Sousa obtained an undergraduate degree in Agronomic Engineering and a master’s in Soil Science and Plant Nutrition from the Federal University of Viçosa, Brazil, in 2016 and 2018, respectively. He obtained a Ph.D. in Soil Science and Plant Nutrition from the University of São Paulo (USP). From 2014 to 2015, he studied at North Carolina Agricultural and Technical State University, USA. He also completed an internship at the Department of Crop and Soil Sciences, North Carolina State University, USA, in 2015, for which he studied the management of nitrogen fertilization in corn crops. 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From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Enzymes are able to accelerate chemical reaction dividing it into separate steps. Because each step of enzymatic reaction has a value of activation energy significantly lower than the value of activation energy for the same chemical reaction, enzymes can increase a rate of reaction 106–1018 folds. According to contemporary hypothesis, high conformational mobility of the enzymes allows them to adopt their active sites to substrate(s) and intermediates of the reaction in the best way [1, 2]. Multiple conformers of enzymes with close values of free energy preexist in the solution simultaneously. Along the reaction way, a conformer is picked out, the structure of which can stabilize definite intermediate that makes a reaction more thermodynamically profitable [3].
\nThis hypothesis is supported by unsuccessful attempts to create catalytically effective low molecular enzymes having needed active site (molecular mass should be higher than 10,000 Da) or enzyme with correct active site but with restricted conformational mobility (antibodies with needed active site, so-called
On the other hand, the binding of enzyme activators may lead to the creation of more profitable conformers that can be more effective in carrying out definite steps of the reaction. Therefore, they will accelerate enzymatic reaction. Taking into account this information about enzymes in this chapter, we consider contemporary knowledge about enzyme inhibitors and activators.
Many pharmacological drugs are enzyme inhibitors. The group of well-known pharmaceutical agents with name nonsteroidal antiinflammatory drugs (NSAIDs) includes inhibitors of enzyme cyclooxygenase that catalyzes a first step of synthesis of biologically active compounds prostaglandins that are responsible for the development of pain, inflammation, fever, contraction of smooth muscle, formation of blood clots, and others [5].
\nAll inhibitors may be combined in different groups in accordance with their chemical structure:
In accordance with the mode of action, enzyme inhibitors may be divided into two different groups (
The mechanism of action of enzyme inhibitors includes a step of enzyme-inhibitor complex formation (EI complex) that has no (or low) enzyme activity. An
Irreversible inhibition is different from irreversible enzyme inactivation. Irreversible inhibitors are generally specific for one class of enzymes and do not inactivate all proteins. In contrast to denature agents such as urea, detergents do not destroy protein structure but specifically alter the active site of the target enzyme.
\nConsequently because of tight binding, it is difficult to remove an irreversible inhibitor from the EI complex after its formation [14]. So, we can refer some chemical compound to irreversible enzyme inhibitor, if after the formation of EI complex, the dilution of it with significant amount of water (100–200 excess) does not restore enzyme activity.
\nIrreversible inhibitors display time-dependent loss of enzyme activity. Interaction of irreversible inhibitor with enzyme is a bimolecular reaction:
\nwhere E is enzyme, I is inhibitor, EI is complex of enzyme-inhibitor, and
However, usually the action of irreversible inhibitors is characterized by the constant of observed pseudo-first order reaction under conditions when concentration of inhibitor is significantly higher than concentration of the enzyme. The value of pseudo-first order rate of inhibition may be measured by plotting of the ln of enzyme activity (in % relatively enzyme activity in the absence of inhibitor) vs. time. Tangent of slope angle of straight line obtained by this way will be equal to value of constant of pseudo-first order inhibition. The value of rate constant of bimolecular reaction for irreversible inhibition may be then calculated by dividing the obtained value of constant of pseudo-first order reaction per inhibitor concentration.
\nwhere
Usually
One type of reversible inhibition is called
Kinetic test for reversible inhibitor classification. Double reciprocal plot (1/Vo) vs. (1/s) for competitive (A), uncompetitive (B), noncompetitive (C), and mixed (D) enzyme inhibition [
Another type of reversible inhibition is
The third type of inhibition is
In some cases, we can see
Special case of enzyme inhibition is inhibition by the excess of substrate or by the product. This inhibition may follow the competitive, uncompetitive, or mixed patterns. Inhibition of enzyme by its substrate occurs when a dead-end enzyme-substrate complex forms. Often in the case of substrate inhibition, a molecule of substrate binds to active site in two points (e.g., by the “head” and by the “tail” of molecule). At high concentrations, two substrate molecules bind in active site the following manner: one substrate molecule binds using the “head” and another molecule using the “tail.” This binding is nonproductive and substrate cannot be converted to the product (Figure 2). An example of such inhibition is inhibition of acetyl cholinesterase by the excess of acetylcholine [15].
Enzyme inhibition by substrate. Productive binding of one substrate molecule with two points of enzyme active site (A) and unproductive binding of two substrate molecules with the same site (B).
Competitive inhibitors mainly interact with enzyme active site preventing binding of real substrate. Classical example of competitive inhibition is inhibition of fumarate hydratase by maleate that is a substrate analog (Figure 3). Enzyme is highly stereospecific; it catalyzes the hydration of the trans-double bound of fumarate but not maleate (cis-isomer of fumarate). Maleate binds to active site with high affinity preventing the binding of fumarate. Despite the binding maleate to active site, it cannot be converted into the product of reaction. However, maleate occupies active site making it inaccessible for real substrate and providing by this way the inhibition [16].
Example of enzyme competitive inhibitors. A reaction catalyzing by fumarate hydratase (A) and comparison of structure of fumarate (substrate of reaction) and maleate (enzyme competitive inhibitor) (B) [
Some reversible inhibitors bind so tightly to the enzyme that they are essentially irreversible. It is known that proteolytic enzymes of the gastrointestinal tract are secreted from the pancreas in an inactive form. Their activation is achieved by restricted trypsin digestion of proenzymes. To stop activation of proteolytic enzymes, the pancreas produces trypsin inhibitor. It is a small protein molecule (it consists of 58 amino acid residues) [17]. This inhibitor binds directly to trypsin active site with Kd value that is equal to 0.1 pM. The binding is almost irreversible; complex EI does not dissociate even in solution of 6 M urea. The inhibitor is a very effective analog of trypsin substrates; amino acid residue Lys-15 of inhibitor molecule interacts with aspartic residue located in a pocket of enzyme surface destined for substrate binding, thereby preventing its binding and conversion into the product (Figure 4).
Structure of complex pancreatic trypsin inhibitor—trypsin and free trypsin inhibitor [
To obtain information concerning the mechanism of enzyme reaction, we should determine functional groups that are required for enzyme activity and located in enzyme active site. First approach is to reveal a 3D structure of enzyme with bound substrate using X-ray crystallography. Alternative and/or additional approach is to use group-specific reagent that simultaneously is irreversible inhibitor of the enzyme. It can covalently bind to reactive groups of enzyme active site that allow to elucidate functional amino acid residues of the site. Modified amino acid residues may be found later after achievement of complete enzyme inhibition, enzyme proteolysis, and identification of labeled peptide(s).
\nIrreversible inhibitors that can be used with this aim may be divided into two groups: (1) group-specific reagents for reactive chemical groups and (2) substrate analogs with included functional groups that are able to interact with reactive amino acid residues. These compounds can covalently modify amino acids essential for activity of enzyme active site and in such a manner can label them.
\nOne from the most known group-specific reagent that was used to label functional amino acid residue of enzyme active site of protease chymotrypsin was diisopropyl phosphofluoridate [18]. It modified only 1 from 28 serine residues of the enzyme. It means that this serine residue is very reactive. Location of Ser-195 in active site of chymotrypsin was confirmed in investigation carried out later, and the origin of its high reactivity was revealed. Diisopropyl phosphofluoridate was also successfully used for identification of a reactive serine residue in the active site of acetylcholinesterase [12].
\nTo reveal reactive SH-group in active site of various enzymes, different SH-reagents were used, among them 14C-labeled N-ethylmaleimide, iodoacetate, and iodoacetamide. Using these reagents, cysteines were revealed in the active sites of some dehydrogenase, cysteine protease, and other enzymes.
\nThe second approach is the application of reactive substrate analogs. These compounds are structurally similar to the substrate but include chemically reactive groups, which can covalently bind to some amino acid residues. Substrate analogs are more specific than group-specific reagents. Tosyl-L-phenylalanine chloromethyl ketone, a substrate analog for chymotrypsin that is able to bind covalently with histidine residue and irreversibly inhibit enzyme, makes possible identification of Hys-57 in chymotrypsin active site [19].
Many cellular enzyme inhibitors are proteins or peptides that specifically bind to and inhibit target enzymes. Numerous metabolic pathways are controlled by these specific compounds that are synthesized in organisms. Very interesting example of these inhibitors is protein serpins. It is a large family of proteins with similar structures. Most of them are inhibitors of chymotrypsin-like serine protease [20, 21].
\nSerine proteases (e.g., mentioned above chymotrypsin) possess a reactive serine residue in active site and have similar mechanisms of catalysis. Cleavage of peptide bond by these proteases is a two-step process. Reactive serine residue of the protease active site that looses H+ and becomes nucleophilic one in the beginning of catalytic act attacks substrate peptide bond. This results in the release of new N-terminal part of protein substrate (first product) and in the formation of a covalent ester bond between the enzyme and the second part of substrate (see Ref. [16]). The second step of catalysis of usual substrates leads to the hydrolysis of ester bond and to the release of the second product (C-terminal part of protein substrate). If serpin is cleaved by a serine protease, it undergoes conformational transition before the hydrolysis of ester bond between enzyme and the second part of substrate (serpin). The change of serpin conformation leads to the “freezing” of intermediate (complex of enzyme with covalently attached second part of serpin is retained for several days) [21]. Therefore, serpins are irreversible inhibitors with unusual mechanism of action. They have named “suicide inhibitors,” because each serpin molecule can inactivate a single molecule of protease and kills itself during the process of protease inhibition.
\nConsidering enzyme inhibitors we should keep in mind that many living organisms are in the state of “chemical war.” Fungi are fighting with bacteria for food using antibiotics. Most immobile organisms like plants and some sea invertebrates use different poisons to defense themselves from being eaten; some vertebrates (like snakes) and invertebrates (e.g., bee and wasps) use poisons not only for defense but also to get food. If we will analyze the composition of these poisons, we can find in their content a lot of various enzyme inhibitors. They were selected during the evolution to stop many metabolic processes in organisms of victims that lead to their death.
\nPoisons of plants and invertebrates were used as medicine drugs during thousands of years. But only in the twentieth century, it became clear that the poisons contain various enzyme inhibitors as well as the blockers of some other biological molecules (channels, receptors, etc.) For example, bee venom includes melittin, peptide containing 28 amino acids. This peptide can interact with many enzymes suppressing their activities; in particular, it binds with protein calmodulin [22] that are activator of many enzymes. Special studies have shown that melittin structure imitates structure of some proteins (to be exact, some part of protein molecules) that can interact with target enzyme to provide their biological function [23].
\nAnother example of natural inhibitors is cardiotonic steroids that were found initially in plants (digoxin, digitonin, ouabain) and in the mucus of toads (marinobufagenin, bufotoxin, etc.). These compounds are irreversible inhibitors of Na,K-ATPase that is enzyme transporting Na+ and K+ through the plasma membrane of animals against the electrochemical gradients. In the end of the twentieth century, it was shown that cardiotonic steroids are presented in low concentrations in the blood of mammals including human beings. The increase of concentration of these compounds in the blood may be involved in the development of several cardiovascular and renal diseases including volume-expanded hypertension, chronic renal failure, and congestive heart failure [24].
\nNatural poisons are a powerful instrument for investigation of enzyme function, and analysis of their action is necessary for these studies. It might be also a model for design of new inhibitors and activators that will imitate natural compounds with such properties.
We have mentioned above nonsteroidal anti-inflammatory drugs that are the inhibitors of cyclooxygenase. This group of compounds (the most prescribed drugs in the world, the oldest among them is aspirin) was successfully used for more than one century around the whole world for treatment of patients with fever, cardiovascular diseases, joint pain, etc. [5]. Among these drugs are both irreversible and reversible inhibitors that slow down production of prostaglandins that control many aspects of inflammation, smooth muscle contraction, and blood clotting. But there are many other groups of drugs that are by nature of inhibitors of some enzymes; the following groups of enzyme inhibitors are developed now by pharmaceutical companies and have very important therapeutic significances [24].
\nInhibitors of angiotensin-converting enzyme (ACE). ACE catalyzes a conversion of inactive decapeptide angiotensin I into angiotensin II by the removal of a dipeptide from the C-terminus of angiotensin I. Angiotensin II is a powerful vasoconstrictor. Inhibition of ACE results in the decrease of angiotensin I concentration and in the relaxation of smooth muscles of vessels. Inhibitors of ACE are widely used as drugs for treatment of arterial hypertension [25].
\nProton pump inhibitors (PPIs). Proton pump is an enzyme that is located in the plasma membrane of the parietal cells of stomach mucosa. It is a P-type ATPase that provides proton secretion from parietal cells in gastric cavity against the electrochemical gradient using energy of adenosine triphosphate (ATP) cleavage. PPIs are groups of substituted benzopyridines that in acid medium of stomach are converted into active sulfonamides interacting with cysteine residues of pump [26]. Therefore, PPIs are acid-activated prodrugs that are converted into drugs inside the organisms. PPIs are introduced in therapeutic practice in 80th years of the twentieth century. Since this time, the drugs are successfully used for treatment of gastritis, gastric and duodenal ulcer, and gastroesophageal reflux disease.
\nStatins represent a group of compounds that are analogs of mevalonic acid. They are inhibitors of 3-hydroxy-3-methylglutaryl-CoA reductase, an enzyme participating in cholesterol synthesis. Statins are used as drugs preventing or slowing the development of atherosclerosis [27]. Because of the existence of some adverse effects, statins may be recommended for patients that cannot achieve a decrease of cholesterol level in the blood through diet and changes in lifestyle.
\nAntibiotic penicillin covalently modifies the enzyme transpeptidase, thereby preventing the synthesis of bacterial cell walls and thus killing the bacteria [28].
\nMethotrexate is a structural analog of tetrahydrofolate, a coenzyme for the enzyme dihydrofolate reductase, which catalyzes necessarily step in the biosynthesis of purines and pyrimidines. Methotrexate binds to this enzyme approximately 1000-fold more tightly than the substrate and inhibits nucleotide base synthesis. It is used for cancer therapy [29].
\nNew promising direction of anticancer therapy that is connected with suppression of protein kinases controlling the cellular response to DNA damage is now on the step of development. Selective inhibitors of these enzymes are now being tested in clinical trials in cancer patients [30].
\nBreakthrough in treatment of patients with acquired immune deficiency syndrome (AIDS) that is provoked by human immunodeficiency virus (HIV) was achieved recently using two different types of enzyme inhibitors. Nucleoside reverse transcriptase inhibitors and protease inhibitors are now recommended for treatment of patients with this decease. These inhibitors affect also some other viral infections and demonstrated anticancer activity. Presented here list of enzyme inhibitors that are used in therapy of numerous deceases that is far from being complete. But even mentioned above, points demonstrate how useful and important are therapeutic application of theoretical knowledge obtained as result of study of enzyme inhibitors [31].
\nSciences around the world are involved in a search of new inhibitors of known enzymes that have therapeutic significance. An example of this complex research is a work devoted to design, synthesis, and study of new inhibitors of carbonic anhydrase, an enzyme that is involved in the development of such symptoms and deceases as edema, glaucoma, obesity, cancer, epilepsy, and osteoporosis (see Ref. [32]).
Enzyme
There are many enzymes that are specifically and directly activated by small inorganic molecules, mainly by cations such as Ca2+ which is a the second messenger (among enzymes activated by Ca2+, we can find different regulatory enzymes, in particular phospholipases II, protein kinases C, adenylyl cyclases, etc.). These enzymes usually have special site for Ca2+ binding; the binding of Ca2+ with it results in the change of enzyme conformation that increase enzyme activity [33].
\nCations can bind not only with enzyme but also with the substrate increasing its affinity to the enzyme that activate enzyme. For example, magnesium ions interact with ATP or with other nucleotides that are negatively charged molecules, decreasing their charge that provides effective binding of nucleotides in substrate binding site of various enzymes and increasing their activity.
\nIn some cases, activation of enzymes is due to the elimination of enzyme inhibitors. In total this effect looks as enzyme activation. Some cations including heavy metal cations inhibit definite enzymes. Small organic compounds like ethylene glycol-bis(β-aminoethyl ether)-N,N,N′,N′-tetraacetic acid (EGTA) and ethylenediaminetetraacetic acid (EDTA) that are known as chelating agents bind these inhibitory cations and by this way can eliminate their inhibitory effect.
\nSpecial group of activators can produce activation of target enzymes only after the formation of complex with another molecule. This complex, in turn, binds to enzyme and increases the velocity of enzymatic reaction. The most well-known example of such type of activators is Ca-binding protein calmodulin (calcium-modulated protein) that is expressed in all eukaryotic cells. Calmodulin is a small protein containing 148 amino acids (16.7 kDa). Its molecule consists of two symmetrical globular domains each with two Ca-binding motifs (EF-hand) located on N- and C-domains that are jointed by flexible linker. Flexibility of calmodulin molecule and the presence of nonpolar grooves in the middle part of the protein allow it to bind a large variety of proteins [33]. The binding of Ca2+ to calmodulin changes its conformation. These, in turn, make complex calmodulin-Ca2+ suitable for interaction with target enzymes (calmodulin-dependent protein kinases and phosphatases,Ca-ATPase of plasma membrane, etc.), by this manner increasing their activity. Therefore calmodulin is considered as a participant of calcium signal transduction pathway that provides enforcing and prolongation of the effect of Ca2+ as a second messenger [34].
Inhibitors and activators (modulators) that bind to enzymes not in the active site but in special center located far enough from it have name allosteric modulators. Their binding to allosteric sites induces the change of enzyme conformation that affects both the structure of active site and enzyme conformational mobility leading to the decrease or to the increase of enzyme activity. Just as enzyme active site is specific in relation to substrate, the allosteric site is specific to its modulator [16].
\nMany metabolic pathways are regulated through the action of allosteric modulators. Enzymes in metabolic pathways work sequentially, and in such pathways, a product of one reaction becomes a substrate for the next one. The rate of whole pathway is limited by the rate of the lowest reaction. Allosteric regulators often are a final product of whole metabolic pathway that activates enzymes catalyzing a limiting step of the whole pathway. Enzymes in a metabolic pathway can be inhibited or activated by downstream products. This regulation represents negative and positive feedbacks that slow metabolic pathway when the final product is produced in large amounts or accelerate it when a final product is presented in low concentration. Therefore, allosteric modulators are important participants of such negative and positive feedbacks in metabolic pathways or between them making metabolism self-controlled.
\nFor example, ATP and citrate are inhibitors of phosphofructokinase that is a key enzyme of glycolytic pathway. One product of glycolysis is ATP. Another product is pyruvate that after the conversion into acetyl-CoA is condensed with citrate opening cycle of citrate acids (Krebs cycle). Reactions of this cycle produce reduced nicotinamide adenine dinucleotide reduced (NADH) and flavinadeninidinucleotide reduced (FADH2), oxidation of which is coupled with massive production of ATP in mitochondria. Availability of ATP or citrate inhibits glycolysis preventing glucose oxidation (negative feedback). Inhibition of phosphofructokinase by ATP or by citrate occurs by allosteric manner [35]. Described negative feedback control maintains a steady concentration of ATP in the cell. It should be noted also that metabolic pathways are regulated not only through inhibition but also through activation of the key enzymes. Mentioned above phosphofructokinase is activated by adenosine diphosphate (ADP), adenosine monophosphate (AMP), and fructose-2,6-bisphospate that represents positive feedback control.
\nEnzymes that are regulated by allosteric modulators are usually presented by several interacting subunits (they are called oligomers). A very interesting example of regulation of the activity of oligomeric enzymes is c-AMP-dependent protein kinase that is an important regulatory enzyme participating in the phosphorylation of serine and threonine residues of target proteins changing by this way their activity. This enzyme consists of four subunits; two of them are catalytic and two are regulatory. Cyclic AMP (c-AMP) is allosteric activator of this enzyme. Catalytic subunit being bound to the regulatory one is inactive. Binding of two c-AMP molecules to allosteric sites of each regulatory subunit induces their conformation transition that results in dissociation of the tetrameric complex and in activation of catalytic subunits [36]. Decrease of c-AMP concentration leads to its dissociation from the allosteric site and to association of regulatory and catalytic subunits with subsequent inactivation of catalytic subunits. By this way, c-AMP activity depends upon the c-AMP concentration in the cell.
Enzyme inhibitors and activators are a number of various chemical compounds that can slow down (or even stop) and activate enzymes, natural protein catalysts. They include inorganic compounds (often anions), different organic compounds (mainly containing reactive groups that can modify amino acids of protein), natural proteins, lipids, and carbohydrates. Mechanism of inhibitor and activator action on the enzyme activity includes a step of their binding to the enzyme, after which a step of the change of enzyme conformation often follows.
\nInhibitors are a good tool for study of enzyme reaction mechanisms. Many natural inhibitors especially obtained from plants and invertebrates often imitate natural proteins or some of their motifs that participate in the protein-protein interactions in the cell that are important for metabolic regulation. Among enzyme activators and inhibitors, one can highlight a group of allosteric modulators that participate in feedback regulation of metabolic pathways. And finally, we should note a practical significance of enzyme inhibitors that are a base for the design of different classes of pharmaceutical drugs, pesticides, and insecticides.
Orthopedic procedures are among the most common elective and non-elective surgeries performed in the United States every year. Though common, these procedures are associated with excessive bleeding and a high demand for transfusions [1, 2, 3]. Common surgeries where significant blood loss can be expected include total hip and knee replacements, instrumented spinal fusion or deformity correction, wide resection for bone or soft tissue tumors and trauma to long bones, especially those of the lower extremities and pelvis. Maintaining hemostasis in these environments is of utmost importance, but many orthopedic subspecialties have surgical cases which present unique challenges in blood management. During decompression of the spinal canal, surgeons must be vigilant of the effects that hemostatic agents may have on neural structures. Joint arthroplasty procedures are often associated with bleeding from the bony edges which is not amenable to techniques commonly used for hemostasis in soft tissues, and orthopedic traumatologists must frequently manage mangled limbs with multifaceted approaches.
\nTo put the importance of blood management in perspective, one must look at the prevalence of transfusions among orthopedic populations. Though the rate of hip and knee arthroplasty has steadily increased over the last decade, transfusion rates have remained stable, but the type of transfusion has shifted from pre-donated autologous blood to allogenic blood transfusions [1]. Between total hip arthroplasty (THA) and total knee arthroplasty (TKA), it has been demonstrated that THA is associated with higher rates of perioperative transfusions, especially if the patient is anemic pre-operatively. In their study of national trends in transfusion requirements in lower extremity arthroplasty, Yoshihara et al. cited transfusion rates of 18% and 11% for THA and TKA, respectively [1].
\nSimilarly, spine surgery has seen a significant increase in allogenic transfusions, while pre-donated autologous blood transfusion has declined [2]. When translated to the pediatric population, major deformity corrections of the spine have consistently found that 30% of patients will require a transfusion and these rates may increase with the presence of neuromuscular syndromes or non-neuromuscular comorbidities [3]. The PREPARE study performed in 2015 was a large observational study assessing the value of patient blood management (PBM) programs in the context of major joint or spine surgery. This study found that PBM centers not only optimized patients better pre-operatively, but also found that patients who entered surgery anemic had higher complication rates [4].
\nIn the realm of tumor surgery, orthopaedists are often called upon to stabilize compromised long bones in the setting of metastatic disease to avoid pathologic fracture. In this setting, patients are often deconditioned and can be expected to receive an average of 2.5 units of packed red blood cell (PRBC) transfusions in the post-operative period [5].
\nLastly, orthopedic trauma to the lower extremities and pelvis are associated with an extremely high rate of transfusion. Over one-third of the patients who sustain a fracture of the femur will require a transfusion within 48 h with an average transfusion volume of 2 units PRBC [6].
\nWhile transfusions themselves place the patient at risk for transfusion reactions, disease transmission, and increased overall cost of care, there is a preponderance of data which shows that receiving a transfusion in the perioperative period places the patient at risk for post-operative complications. Across all subspecialties, transfusions have been shown to increase length of stay, cardiac events, sepsis, wound infections, and even mortality [7, 8, 9, 10].
\nIt is imperative to develop a comprehensive approach to blood management, as many orthopedic surgical procedures place patients at risk for blood transfusions, leaving both patients and the healthcare system at risk of negative outcomes. The goal of this chapter is to outline several options by which surgeons can optimize patients in the perioperative setting. This includes pre-operative management of anticoagulant and antiplatelet agents, intra-operative techniques, new technology, and use of biosurgical innovations throughout the perioperative period to minimize blood loss.
\nGiven the expected blood loss associated with certain orthopedic surgeries, patients taking prophylactic or therapeutic anticoagulants may require the effects of these medications to be reversed in a controlled fashion. Unfortunately, this reversal can place patients at risk for arterial thromboembolism (ATE) or venous thromboembolism (VTE) due to a rebound hypercoagulability resulting from increased thrombin generation. The risk of ATE is relatively low in patients with mechanical valves or atrial fibrillation (0.6%), but up to 70% of those who develop an ATE can suffer a cerebral embolism which can leave patients with varying degrees of disability [11]. Conversely, patients who do not have the effects of these medications adequately reversed are left at an increased risk of post-operative hemorrhage leading to higher rates of infection and possible compartment syndrome [11].
\nWarfarin is one of the oldest anticoagulation agents on the market and works by inhibiting the reduction of vitamin K into vitamin K epoxide, which is required for gamma carboxylation of many clotting factors including II, V, VII, and X. The advantage of warfarin is that it can be easily measured via international normalized ratio (INR) and has many reversal agents. Troublesome aspects of warfarin include difficulty maintaining proper therapeutic levels which requires frequent testing as well as cross reactivity with many other medications, foods, and supplements. Studies have shown that an INR > 1.8 is an independent risk factor for post-operative hemorrhage, and an INR of >1.4 is a contra-indication to spinal anesthesia as it places the patient at risk for epidural hematoma [12, 13].
\nThe mode of reversal for warfarin can be dictated by the timeframe of surgery. Urgent surgeries (within 24 h) require more aggressive measures than semi-urgent surgeries (24–72 h) and elective surgeries. For cases that require urgent intervention, prothrombin concentrate complex (PCC) and fresh frozen plasma (FFP) are agents that may be utilized. PCC is a balanced mixture of coagulation factors II, V, VII, and X. PCC has the advantage of being administered in small volumes over the course of several minutes and can reverse INR within 3–4 h. Disadvantages of PCC include a lack of intrinsic pathway coagulation factors and increased risk of patient developing thrombosis due to rapid reversal of anticoagulant. FFP contains all coagulation factors except for IX. It is administered in larger volumes over the course of hours. While it does provide a more gradual correction than PCC, the effects can be transient leaving the patient under-corrected at the time of surgery. Furthermore, FFP has a risk of disease transmission and the larger transfusion volumes can contribute to CHF and fluid overload. Key to FFP administration is monitoring INR just prior to surgery [11, 14, 15].
\nIn the case of semi-urgent surgery, vitamin K has the safest side-effect profile. This method of anticoagulant reversal works by providing more vitamin K substrate for reduction by vitamin K epoxide and eventual gamma carboxylation of factors II, V, VII, and X. Though studies have shown intravenous (IV), intramuscular (IM), and per-oral (PO) vitamin K to be effective, each has its advantages. IV and IM vitamin K effects are more rapid when compared to oral administration, but are associated with higher rates of anaphylaxis in IV forms and cutaneous reactions with IM administration. For oral dosing, 2.5–5 mg of vitamin K is given and INR is measured until the goal is reached. Depending on the formulation, 73–93% of patients with presenting INR > 4.0 can achieve an INR < 2 within 24 h of PO vitamin K administration [16].
\nIn elective surgery, patients can be allowed to drift down to a safe INR. Over 90% of patients with INR levels >2.0 can fall below 1.5 after 5 days [17]. It is recommended that patients undergoing major orthopedic surgery should have an INR of <1.3. Patients at high risk for thrombosis may be transitioned to bridging therapy with unfractionated heparin or low molecular weight heparin. Table 1 outlines recommendations for bridging therapy based on thrombosis risk. Pneumatic compression stockings should be employed whenever possible [11].
\nThrombosis risk | \nStop WF | \nBegin LMWH bridge | \nRestart WF | \nStop LMWH bridge | \n
---|---|---|---|---|
High | \n5 days pre-op | \nOnce INR <1.8 until 24 h prior to surgery | \nEvening s/p Surgery | \nOnce INR is therapeutic | \n
Intermediate | \nIndividualized, multidisciplinary approach | \nEvening s/p Surgery | \nOnce INR is therapeutic | \n|
Low | \n5 days pre-op | \nNo need for bridging Tx | \nEvening s/p Surgery | \nN/A | \n
Bridging therapy recommendations for patients on warfarin therapy.
WF—warfarin; INR—international normalized ratio; LMWH—low molecular weight heparin.
Perioperative management of direct oral antocoaculants (DOAC), formerly known as novel anticoagulants, varies by agent. While they provide an advantage over warfarin with dosing consistency, they lack a means of reliable point-of-care measurement. While no standard protocol exists for the management of DOACs in urgent orthopedic surgery, some studies suggest that surgery is safe to perform within 24 h as long as the treating teams remain vigilant of blood loss and transfusion requirements [18, 19, 20]. In the semi-urgent or elective setting, patients may be allowed to safely drift to subtherapeutic levels according to the medication half-life. Pre-operative recommendations for DOAC management as well as availability of reversal agents are listed in Table 2.
\nAgent | \nDuration of pre-op ATI | \nCrCl correction | \nReversal agent | \n
---|---|---|---|
Dabigatran (Pradaxa) | \n2 days | \n4 days w/CrCl <50 mL/min | \nidarucizumab (Praxbind) | \n
Rivaroxaban (Xeralto) | \n2 days | \n3 days w/CrCl <30 mL/min | \nRecombinanat factor Xa (Andexxa) | \n
Apixaban (Eliquis) | \n2 days | \n3 days w/CrCl <30 mL/min | \nRecombinanat factor Xa (Andexxa) | \n
Endoxaban (Savaysa) | \n2 days | \n3 days w/ CrCl <30 mL/min | \nNone | \n
Aspirin | \n7–10 days | \nN/A | \nPooled platelets | \n
Clopidogrel (Plavix) | \n7–10 days | \nN/A | \nPooled platelets | \n
Duel antiplatelet Tx | \nClopidogrel 7-10d Aspirin 5d | \nN/A | \nPooled platelets | \n
Pre-operative management of direct oral anticoagulants (DOAC) and antiplatelet agents.
ATI—antithrombotic interruption; CrCl—creatine clearance
Lastly, in reference to anti-platelet agents, no standardized protocol has been developed. Aspirin has been heavily studied in the pre-operative setting, but evidence has been conflicting in relation to intra-operative bleeding or post-operative complications. Newer agents, such as clopidogrel or prasugrel, have limited high-quality, randomized controlled trial (RCT) data in non-cardiac surgery. A Cochrane review article in 2018 evaluated evidence available in the form of RCT for continuing antiplatelet therapy in non-cardiac surgery. They found no evidence of increased mortality or ischemic events (Grade: Low certainty) post-operatively and no evidence of increased bleeding requiring a transfusion (Grade: Moderate certainty) [21]. Historically, pooled platelets, desmopressin, and recombinant factor VII have been used to acutely counteract the effects of irreversible antiplatelet agents, though no prospective studies have been conducted to evaluate effectiveness in orthopedic surgery [11]. When possible, surgery should be avoided in patients within 6 months of cardiac stent placement with an ideal delay of 1 year. Table 2 contains recommendations for management of antiplatelet agents in elective orthopedic surgery.
\nHip and knee arthroplasty are among the most commonly performed orthopedic procedures in the United States and they carry a unique set of challenges related to hemostasis. When cutting bony surfaces, surgeons are left with a bleeding bone edge which is recalcitrant to many soft tissue hemostatic techniques such as direct electrocautery. These bleeding edges, if not addressed, can contribute to both total measured blood loss as well as hidden blood loss. Below will outline biosurgical, mechanical, and technical methods for controlling blood loss during arthroplasty.
\nPerhaps, the most heavily studied agents for reducing blood loss is tranexamic acid (TXA). TXA is a synthetically derived analog of the amino acid lysine, and works by competitively binding the lysine binding site of plasminogen. This prevents plasmin from cleaving fibrin, thereby decreasing fibrinolysis and allowing for stable clot formation [22, 23]. The primary advantage of TXA is the minimal side-effect profile and plurality dosing routes including topical, intravenous, and oral.
\nTopical TXA is an unconventional mode of administration but carries several advantages including direct application to the source of bleeding, very little systemic absorption, and the ability to deliver the agent in higher concentrations. While no standard protocol exists for topical TXA in joint arthroplasty, the method used by Konig et al. has been replicated in several RCTs. For THA, 3 g of TXA is diluted in saline to make 150 mL of TXA concentrate. First, a 25 × 25 cm gauze is soaked in 50 mL of concentrate and packed into the acetabulum after reaming where it is left for 3 min. A second gauze soaked with 50 mL of TXA is packed into the femoral canal after broaching ×3 min. The final 50 mL of TXA concentrate is injected into the hip joint after fascial closure [24]. The results by Konig et al. were supported in a double-blind RCT by Yue et al. showing that topical TXA significantly decreases intra-operative blood loss, drainage rates, transfusions and hemoglobin drop on post-operative days 1 and 3 [25]. In a meta-analysis including over 2500 patients, Chen et al. found similar results without a reciprocal increase in the rate of DVT [26].
\nKonig et al. also developed a protocol for topical TXA in TKA, which involves diluting 3 g of TXA in 100 mL of saline and injecting it into the knee after closure [24]. The drain remains clamped for 1 h, after which it is placed to suction. This protocol was supported in a prospective RCT by Hamlin et al. who showed lower rates of transfusion and blood loss compared to IV TXA [27]. An alternative method described in a prospective RCT by Abdel et al. dilutes 3 g TXA in 45 mL of saline. The wound is irrigated with this solution after cementation and allowed to sit for 5 min before being suctioned away. This study found equivalence of topical TXA to IV TXA [28].
\nIntravenous TXA is the most common route of administration and also the most studied. Notwithstanding, there are a number of dosing protocols with no studies showing superiority of one dosing regimen over another. Low-dose TXA studies may use a weight-based protocol of 10–20 mg/kg pre-operatively, while higher dose protocols use up to 20 mg/kg administered pre-, intra-, and post-operatively. Other institutions use a standard 1 g of TXA IV pre-operatively before tourniquet deflation. As of yet, there has been no significant difference between protocols in relation to blood loss, transfusion rates of drain output. Some evidence does exist showing that TXA administered 10 min prior to incision is more effective than TXA given 10 min prior to tourniquet deflation in TKA [29, 30]. Fillingham et al. has published two large meta-analyses evaluating IV TXA in TKA and THA. In TKA, evidence does support use, but could not come to a conclusion regarding formulation, dose, or re-dosing. It did suggest that TXA should be administered pre-incision [31]. For THA, TXA was clearly effective in improving blood loss, transfusion rates, and hemoglobin drops, but no conclusion could be reached in regard to formulation, dosing, re-dosing, or timing [32].
\nThe last route of administration for TXA is PO. The primary advantage of oral TXA over IV formulations is cost. Several studies have shown equivalence between intravenous and oral TXA in both THA and TKA [33, 34, 35]. The most commonly studied dose is 1.95 g, which is commercially available and is taken 2 h prior to incision. It is unclear whether multiple PO doses of TXA offer any advantage over a single dose. A full list of protocols and recommendations regarding TXA can be found in Table 3.
\n\n | Dose | \nTiming | \n
---|---|---|
THA | \n\n | \n |
IV | \n10–20 mg/kg | \n10 min pre-incision | \n
Oral | \n1.95 g | \n2 h pre-incision | \n
Topical | \n3 g in 150 mL saline | \n50 mL w/acetabular ream 50 mL w/femoral broach 50 mL s/p fascial closure | \n
TKA | \n\n | \n |
IV | \n10–20 mg/kg | \n10 min pre-incision | \n
Oral | \n1.95 g | \n2 h pre-incision | \n
Topical | \n3 g in 45–100 mL saline | \nAfter cement polymerization or after closure | \n
IV | \n10–20 mg/kg bolus 10–20 mg/kg/h infusion | \n10 min prior to incision through closure | \n
Oral | \n1.95 g | \n2 h pre-incision | \n
Topical | \n1 g in 100 mL saline | \nIrrigate wound for 2–5 min prior to closure | \n
IV | \n1 g bolus 1 g infusion | \nBolus w/i 8 hours of injury over 10 min Infusion over 8 h | \n
Oral | \nNo current literature | \n|
Topical | \n3 g in 30 mL saline | \nInjected after fascial closure | \n
IV | \n15 mg/kg/h bolus 15 mg/kg/h infusion | \nBolus at induction Infusion over 8 h | \n
Oral | \nNo current literature | \n|
Topical | \n1 g in 10 mL saline | \nSprayed over wound bed before closure | \n
Tranexamic acid recommendations by subspecialty.
While TXA is generally deemed safe for a vast majority of patients, those with a history of pulmonary embolism, venous thromboembolism, stroke, cardiac stents, cardiac bypass, or pro-coagulation disorders have been historically contra-indicated for TXA. These recommendations have been precautionary in nature, but several studies have found that even in these “high risk” patients, TXA has not been associated with increased thromboembolic (TE) complications. In a small retrospective study, 240 patients with one of the seven comorbidities listed above were given IV TXA and found to have no increased risk for TE event compared to controls [36]. In a larger retrospective cohort study, Madsen et al. compared 2766 patients receiving TXA treatment to 393 patients who did not. Among patients with ASA scores III/IV, type II diabetes mellitus, or cardiovascular disease, there was no increased rate of TE events [37]. Further large-scale, prospective studies need to be performed to define risks of TXA.
\nAprotinin is a nonspecific serine protease inhibitor which decreases concentrations of fibrinolytic proteases such as cathepsins, kallikrein, protein C, plasmin, and thrombin. Inhibiting these serine proteases promotes clot formation. It is excreted renally and has a biphasic half-life. The rapid phase half-life is 40 min and the slow phase half-life is 7 h. A biphasic half-life lowers the risk of unwanted thrombosis and DVT formation [38].
\nNo standardized protocol exists, but a double-blind prospective RCT performed by Colwell et al. in THA gave patients a loading dose of 2 million kallikrein inhibiting units (KIU) followed by a continuous infusion of 0.5 million KIU until the conclusion of surgery. They found that this significantly reduced blood transfusion rates [39]. In a study of bilateral TKA, Kinzel et al. employed a weight-based protocol infused over 30 min during the closing stages of the first knee arthroplasty. Patients weighing <75 kg were administered 1million KIU, 75–100 kg were given 1.5 million KIU, and those weighing >100 kg were given 2 million KIU. Patients had significantly lower transfusion rates and drain outputs compared to controls with no complications [40]. These results have been repeated in a small series of patients undergoing revision THA, TKA, or sarcoma resection [41]. Unfortunately, aprotinin was removed from the US market in 2007 for concerns for renal toxicity, though it does remain an active ingredient in some of the topical compounds listed below [42]. Further RCT may be needed to explore the risks of aprotinin.
\nThrombin (also known as clotting factor IIa) is converted from the inactive pro-enzyme, prothrombin, by factor Xa. Thrombin then cleaves fibrinogen into fibrin to cross link platelets in a sort of brick-and-mortar structure. Topical thrombin-based agents combine a high viscosity gel, often composed of engineered collagen granules, mixed with bovine derived thrombin. These agents are more commonly used in arenas of soft tissue procedures, but questions have been raised about their utility in arthroplasty. Again, no standardized protocol exists for use of thrombin-based gels in orthopedics, but two high-quality prospective RCTs used similar methods in TKA. The protocol involves applying 10 cc of gel to the exposed bone edges after the components have been placed and cement has polymerized. One study also applied gel to the surrounding soft tissues. The thrombin gel is allowed to sit for 2 min and is irrigated away [43, 44]. The most recent meta-analysis to date, Wang et al. found that these agents can significantly decrease mean calculated total blood loss, drain output, and drops in hemoglobin with minimal risk of side effects. Unfortunately, this meta-analysis only included five studies and further work must be done to support this practice as standard [45]. To date, no studies have evaluated the effectiveness of thrombin-based agents in THA.
\nAs described above, fibrin is a coagulation cascade end product necessary for stable clot formation. Topical fibrin sealants seek to reproduce this final step of the coagulation cascade by providing exogenous clotting reagents to induce clot formation. While there are many proprietary fibrin sealants on the market, most are a combination of fibrinogen, thrombin, factor XIII, and an antifibrinolytic such as aprotinin or TXA. Early iterations of fibrin sealants were animal derived, but modern preparations are obtained via donated autologous platelet-poor plasma or pooled human plasma [46]. These preparations are stored as separate mixtures in a two chamber (or syringe) system. One chamber typically contains thrombin activated with calcium chloride, and the second chamber contains fibrinogen and an antifibrinolytic. The contents of these two chambers are sprayed in a fine mist allowing for the reagents to mix and commence the clotting cascade.
\nTwo high-quality randomized controlled trials have evaluated the effects of fibrin sealants in total knee arthroplasty. These studies concluded that fibrin sealants significantly reduce perioperative blood loss, transfusion requirements, hemoglobin drop, and drain output [47, 48]. The protocol for the use of fibrin sealant in TKA is as follows: after final components have been placed and cement polymerized, the joint is thoroughly irrigated. About 10–20 mL of sealant (1–2 kits) is then sprayed into the wound bed evenly coating exposed boney edges, muscle, tendon and “hidden pouches.” A drain is placed as per institutional protocol and layered closure was performed [47, 48].
\nEvidence for the use of fibrin sealants in total hip arthroplasty is also strongly supported in the literature. Crawford et al., in a retrospective case-control study, found that fibrin sealants in THA can reduce perioperative blood loss and transfusion rates. These results were later echoed by the work of Wang et al. in a prospective controlled trial [49, 50]. In these studies, cemented components were used and 10 mL of sealant was sprayed over the tissues after cement polymerization [49].
\nPlease refer to Table 4 for the complete list of topical hemostatic agents used in hip and knee arthroplasty.
\nAgent | \nMechanism | \nRisks | \n
---|---|---|
Bone Wax | \nIntercalation within bony trabeculae | \nImpeds bone fusion, anaphylaxis, pro-inflammatory | \n
Gelatin Sponge/Powders | \nLocal tamponade | \nMass effect near neural elements, DIC (powders) | \n
Oxidized Regenerated Cellulose | \nLocal tamponade | \nMass effect near neural elements | \n
Chitosan | \nIon based muco-adherent activation of RBCs | \nNone reported | \n
Zeolite | \nClot scaffold, H2O sieve | \nExothermic reaction can cause burns | \n
Fibrin sealants | \nCoaguation lattice for clot formation | \nHypersensitivity reaction for brands containing aprotinin | \n
Topical thrombin-based agents | \nCoaguation lattice for clot formation | \nNone reported | \n
Aprotinin | \nAntifibrinolytic serine protease inhibitor | \nRenal toxicity | \n
Microfibrillar collagen agents | \nCollagen scaffold for fibrin | \nInhibits PMMAC interdigitation, possible hypersensitivity | \n
List of topical hemostatic agents used in orthopedic surgery and their mechanism.
DIC—diffuse intravascular coagulation; PMMAC—polymethylmethacrylate cement; RBCs—red blood cells.
Hemostasis in major spine surgery presents many unique challenges. As with arthroplasty, bone bleeding composes a significant portion of blood loss; but unlike arthroplasty, the surgeon must be continuously aware of the proximity of neural elements in the surgical field. Post-operative hematomas may also lead to neurologic complications. The presence of neural elements often precludes use of certain technologies such as bipolar sealers, but these challenges have also spurred innovation. Some of the more specific methods of hemostasis in spine surgery are outlined below.
\nAs with lower extremity arthroplasty, tranexamic acid is one of the most heavily researched adjuncts for hemostasis in spine surgery. All three modes of administration have been studied and are outlined below:
\nIV TXA remains the most common route of TXA administration in spine surgery. To date, the most comprehensive meta-analysis outlining the effectiveness of IV TXA in spine surgery includes 18 RCTs and 18 non-RCTs. This analysis included cervical, thoracic, and lumbar spine surgery regardless of anterior or posterior approach. The type of surgery (discectomy, laminectomy, fusion, deformity correction, etc.) was not specified, but the authors did stratify studies by low-dose or high-dose administration of TXA. Low dose was considered a bolus of ≤10 mg/kg followed by ≤10 mg/kg/h infusion, and high dose was defined as a bolus ranging from >10 to 100 mg/kg followed by a maintenance infusion of >10 mg/kg/h thereafter. All studies had control groups receiving either a placebo of saline or no TXA at all. Pooled data was able to demonstrate that IV TXA reduced blood loss at every point of the operative cycle compared to controls regardless of dose. Interestingly, there was a dose-dependent response of IV TXA in decreasing intra-operative and perioperative allogenic blood transfusions as well as operative times. Furthermore, there was no increase in the rate of post-operative complications or thromboembolic complications compared to control groups regardless of dose [51].
\nWhile a definitive statement on IV dosing protocol in spine surgery cannot be made, the data would suggest that patients may benefit from higher dose regimens in respects to transfusion rates and operative times. This comes with the caveat that more studies need to be performed to add context.
\nOverall, there is a paucity of data evaluating the efficacy of oral TXA in major spine surgery. Thus far, a singular prospective RCT has been conducted comparing PO administration of TXA to IV TXA in thoracolumbar spinal surgery. Patients randomized to the oral TXA group were given 1.95 g 2 h prior to surgery. The IV TXA arm was administered 1 g IV TXA as a bolus prior to incision and 1 g IV TXA before wound closure. The authors were able to establish equivalency of PO TXA to IV TXA according to calculated bloods loss, transfusion rates, post-operative hemoglobin drops, and rates of thromboembolic events [52]. While preliminary data regarding PO TXA in spine surgery is promising, more high qualities need to be performed to establish efficacy compared to placebo controls and established IV TXA protocols.
\nThe best evidence outlining the efficacy of topical TXA in spine surgery compared to placebo controls has been published in two meta-analyses by Yerneni et al. and Luo et al. They were able to conclude that topical TXA can decrease total blood loss, post-operative hemoglobin drops, and drain outputs compared to placebo controls. Several protocols for the use of topical TXA were outlined, but the most common method was 1 g of TXA diluted in 100 mL of saline. The surgical wound was irrigated with this solution prior to closure and was allowed to sit for 2–5 min before being suctioned away [53, 54].
\nIn an effort to compare topical TXA in spine surgery to the more commonly used IV TXA, Xiong et al. conducted a meta-analysis including eight Chinese RCTs. A compilation of 333 patients received IV TXA while 327 had topical TXA. They demonstrated no significant differences in blood loss, hemoglobin, hematocrit, fibrinogen concentrations, post-operative PT or APTT, drainage volume, and blood transfusions. Of note, this meta-analysis was limited to non-deformity correction surgeries, primarily lumbar and thoracolumbar decompression and fusions.
\nWhile more high-quality data needs to be obtained to confirm the efficacy of topical TXA in major spine surgery, the current body of evidence suggests that PO TXA is effective in decreasing blood loss, transfusion requirements, and drain outputs when compared to placebo and preliminary evidence shows that this route of administration may be equivalent to the more costly IV TXA.
\nTo see a complete list of the protocols and recommendations for TXA in major spine surgery, please refer to Table 3.
\nNot uncommonly in major spine surgery, patients can lose the equivalent of one entire blood volume or more. This situation can lead to difficulty in clot formation secondary to consumptive and dilutional coagulopathies. A consumptive coagulopathy exists as a result of coagulation factors and platelets appropriately being consumed at the surgical site, while a dilutional coagulopathy results from replacement of blood volume with non-plasma fluids. Traditional methods of addressing the relative shortage of coagulation factors and platelets is replacement therapy with allogenic pooled platelets or fresh frozen plasma, but these methods can be fairly nonspecific in their mechanism [55].
\nRecombinant clotting factor VIIa (rFVIIa) was originally developed to address intra-operative bleeding in patients with disorders of coagulation such as congenital hemophilia, acquired hemophilia, or antibodies to clotting factors VIII or IX. The theory behind using rFVIIa in patients with excessive blood loss is as follows: FVIIa normally works by combining with tissue factor (TF) to create FVIIa-TF complex which activates downstream clotting factors II, IX, and X eventually resulting in a thrombin burst. This thrombin burst is essential for creating a stable fibrin plug resistant to fibrinolysis. In situations of excessive blood loss, exogenously administering rFVIIa will selectively complex with TF at the site of injury, activating the clotting cascade, and leading a thrombin burst with local hemostasis [55, 56].
\nThus far, limited data exists for the use of rFVIIa in major spine surgery. The studies available suggest that rFVIIa effectively reduces intra-operative blood loss, intra-operative transfusion requirements and has a sustained effect on reducing PT and INR [56, 57]. No standard protocol exists for dosing or timing given the limited patient data. One study randomized patients undergoing deformity correction surgery to a treatment arm receiving 23 μg/kg beginning 30 min prior to incision, while another study randomized patients undergoing major spine surgery to treatment arms of 30, 60, or 120 μg/kg given in three separate doses only after an estimated 10% of blood volume had been lost [56, 57]. Of these studies, no increased complications were observed in the treatment groups compared to control groups suggesting that this treatment is safe. Further prospective studies are needed to determine efficacy, dosing, and timing of rFVIIa but preliminary results are promising for use in spine surgery where major blood loss is expected.
\nThe category of topical hemostatic agents in spine surgery is vast and can be split into passive and active agents. Both classes are discussed below. See Table 4 for a complete list of topical hemostatic agents used in spine surgery and their mechanism.
\nPerhaps the oldest topical hemostatic agent in orthopedic surgery is bone wax. In modern times, it is employed less frequently, but it remains a mainstay in spine surgery and during certain approaches of the pelvis where bone bleeding is encountered frequently. Bone wax is derived from a combination of bees wax and petroleum jelly and works via mechanical intercalation within bony trabeculae to tamponade bleeding. Currently, no RCT has been performed to tests the overall effects of bone wax on blood loss in spine surgery, yet it remains a staple for many surgeons. One caveat of bone wax is that it can be a physical impediment to bone healing leading to possible pseudoarthrosis of fusion segments if used in excess. Bone wax can also illicit an allergic reaction in patients allergic to bee venom and has a local pro-inflammatory effect [58].
\nGelatin sponges are hydrophilic compounds that, when exposed to moisture, will expand several times their size. In the context of surgery, these sponges can be placed into a cavity or can be rubbed vigorously onto the surface of a bleeding bone while powder is simply applied topically to a site of bleeding. Once deployed, the gelatin expands creating a tamponade effect. The effect of these sponges can be augmented with the addition of thrombin to encourage clot formation [59]. One benefit of gelatin-derived agents is that they do not serve as a physical impediment to bone healing like bone waxes. Currently, there are no RCTs exploring gelatin sponges/powders as they relate to blood loss in spine surgery. One important caveat to the use of gelatin sponges, especially in the arena of spine surgery, is that their expansion can cause a mass effect resulting in compression of neural elements. While mass effect has not been demonstrated by powdered gelatin agents, there has been a case report of powdered gelatin being inadvertently introduced intravascularly causing DIC. Given the possible complications, it is recommended that gelatin sponges be removed, and powders irrigated away [58].
\nOxidized regenerated cellulose (ORC) is produced in a sponge-like form and works in a similar mechanism to gelatin sponges. No RCTs exploring the effect of ORC agents on blood loss in spine surgery has been performed. Similar cautions should be applied to these compounds as gelatin sponges [58, 59].
\nSection 2.4 outlines the mechanism of action for fibrin sealants. While the primary use of fibrin sealants in spine surgery is aimed at augmenting dural repairs, these compounds have also been shown to promote hemostasis. In a 2008 study of 3+ level anterior cervical decompression and fusion, 2 mL of fibrin sealant was sprayed as a fine mist over the surgical bed before closure and a drain was placed as per institutional protocol. This study found that fibrin sealants significantly reduced post-operative drain output and length of stay [60].
\nThe mechanism for topical thrombin-based agents is outlined above in the section on arthroplasty. Thus far, only one landmark study has been performed as it relates to topical thrombin-based agents and hemostasis in spine surgery. The multicenter, randomized controlled trial compared a novel thrombin-based agent to gelatin sponges soaked in thrombin. Compared to the gelatin sponge group, the novel thrombin-based agent was able to control bleeding within 10 min in a greater proportion of patients, and time to hemostasis was significantly shorter [61]. While this data is promising, further exploration of thrombin-based topical agents should be performed to determine effects on intra-operative and post-operative blood loss, drops in hemoglobin, etc.
\nPlease refer to Table 4 for the complete list of topical hemostatic agents used in major spine surgery.
\nThe surgical timeframe in orthopedic trauma varies greatly ranging from emergent to elective. As a result, hemostatic principles must also reflect this level of plasticity as the mangled extremity is managed much differently in the emergent setting than an ankle fracture is in the elective setting. Often, the task of achieving hemostatis has started in the pre-hospital setting and it is the responsibility of the surgeon and the acute trauma medical colleagues to swiftly enact some of the methods described below to avoid downstream complications.
\nWhile previously discussed topical hemostatic agent can be utilized in the trauma setting, this section will focus on novel agents specifically designed for major extremity trauma. These agents have primarily been used in battlefield settings and are not currently FDA approved, but may translate to civilian first responders in the future.
\nChitosan is a freeze-dried, deacetylated form of chitin which is applied as a bandage to an exsanguinating wound. The positive surface charge of the chitin bandage attracts negatively charged red blood cells causing muco-adherent activation. The original formulation of this product was stiff and did not lend itself to being easily packed into wounds, but newer, more flexible iterations are now in use [62].
\nZeolite is composed of biologically inert mineral granules, which act at local water sieves and exerts its mechanism of action in three different ways. First, by decreasing local concentrations of water, relative concentrations of platelets, and clotting factors increases. Second, the granular surface of the mineral serves as a medium for clot formation. Lastly, the hydration reaction of the granules is exothermic creating a thermal environment ideal for clot formation. The exothermic properties of these agents can be exuberant and cause chemical burns. They should therefore be used with irrigation [62].
\nPlease refer to Table 4 for the complete list of topical hemostatic agents used in orthopedic trauma surgery.
\nTXA has much less robust utilization in orthopedic trauma than it does in arthroplasty or major spine surgery. Nonetheless, high-quality evidence exist showing efficacy of TXA in trauma. The 2010 Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage 2 (CRASH-2) study was a placebo-controlled trial, which enrolled over 20,000 trauma patients from 40 different trauma facilities around the world. The study included patients who presented with, or had significant risk of, major hemorrhage. Those randomized to the treatment arm were administered 1 g of intravenous TXA over 10 min within 8 h of the initial injury and an additional 1 g of IV TXA was infused over 8 h. The authors found this IV TXA protocol significantly decreased all-cause mortality secondary to bleeding [63]. While this data is not specific to extremity trauma, it does show efficacy in critically ill patients.
\nSeveral RCTs have translated the exploration of TXA in general trauma to the world of lower extremity trauma. Two recent meta-analyses have demonstrated that TXA can decrease perioperative blood loss, transfusions, and drops in hemoglobin without reciprocal increased in thromboembolic events. All patients in these studies had suffered femoral neck fractures, intertrochanteic femur fractures, and one study included calcaneus fractures. As with the data presented previously, several routes of administration were utilized with some studies included combination therapies (e.g., IV and topical TXA) [64, 65]. Interestingly, while these meta-analyses found TXA to be effective in lowering transfusion rates and blood loss in lower energy trauma, a recent prospective trial by Spitler et al. found minimal effect of TXA in higher energy trauma including pelvic, acetabular, and femur fractures in younger patients [66].
\nSuperiority of one method over another has not been demonstrated, but a complete list of suggested TXA protocols can be referred to in Table 3.
\nOrthopedic intervention in the world of oncology covers a vast array of procedures which have a significant degree of overlap with the subspecialties listed above. Often, the goal of the orthopedic surgeon is to decrease or eliminate tumor burden through marginal resection, wide resection, and even amputation. These surgeries can be stand-alone, definitive treatments in the algorithm of patient care, or they can serve as adjuvant treatments to be used in addition to chemotherapy or radiation. Orthopedic oncology also extends to the world of palliative medicine, where patients with metastatic disease may present with lesions of impending fracture that benefit from surgical stabilization.
\nWhile many of the strategies above may be employed during orthopedic tumor surgery, some have limited evidence. The sections below focus on techniques, technologies, or biosurgical applications that have not been addressed in the sections above, and that are specific to tumor surgery or have a preponderance of evidence in orthopedic oncology literature.
\nAs outlined above, TXA is a heavily studied compound that has demonstrated efficacy in decreasing blood loss across nearly all orthopedic subspecialties. Unfortunately, far fewer studies have explored the effects of TXA in major tumor surgery. One of the primary reasons for the lag in supporting data is that oncologic patients are often hypercoagulable at baseline and may have other secondary comorbidities induced by tumor burden or chemotherapeutic agents.
\nEndoprosthetic reconstruction is one arena of orthopedic oncology which has some supporting data. In a recent study by Haase et al., patients undergoing proximal femoral replacement, distal femoral replacement, or proximal tibial replacement were given topical TXA intra-operatively. Compared to patients undergoing endoprothetic reconstruction without TXA, the TXA treatment group had lower perioperative blood loss, transfusion rates, and overall length of stay without increasing overall VTE rates. The authors cited a theoretical increased risk of thromboembolic complications as the reason for using topical TXA as opposed to IV or oral. The protocol involved diluting 1 g of TXA in 10 mL of normal saline which was then sprayed as a fine mist over the wound bed [67].
\nOnly one study has evaluated the effects of intravenous TXA in orthopedic tumor resection. Damade et al. performed a retrospective case series on patients undergoing posterior laminectomy and fusion for metastatic spine disease. A 15 mg/kg dose of TXA was infused at induction and 15 mg/kg/h was continuously infused for the next 8 h. Patients undergoing this treatment did have significantly lower transfusion rates compared to controls and, once adjusted for the number of fusion levels, also had lower perioperative blood loss [68].
\nA summary of the TXA protocols in orthopedic oncology can be found in Table 3. While the preliminary data is promising, there is a significant gap in the literature supporting safety and efficacy of TXA in this patient population.
\nNot uncommonly, orthopedic tumor surgery requires the use of bone graft to fill defects left behind from local or marginal resections. Autograft harvested from the iliac crest has many advantages over allograft counterparts, but can be associated with donor site morbidity including bleeding. Microfibrillar collagens (MFC) are bovine collagen derivatives that have used primarily to provide hemostasis at iliac crest donor sites. Though the exact mechanism of MFC agents is not fully understood, at least two theories have been supported by the literature. First, MFCs enhance platelet activity in a way similar to that of natural collagen, facilitating platelet adhesion to fibrin, platelet aggregation, and degranulation. Second, MFC agents complex with fibrin via the clot stabilizing factor XIIIa. It has been shown that even in thrombocytopenic environments, MFC agents can increase clot formation over controls [69].
\nUse of MFC agents in orthopedics is extremely limited and most of the data hails from spine literature where iliac crest autograft was formally the gold standard before modern grafting methods were developed. Craig et al. have the first reported human study of MFC agents in the orthopedic literature. Here, MFC agents were found to be equivalent to thrombin-soaked gel-foam in reducing hemovac output in the post-operative setting with no clinical evidence of immune reaction [70]. Intra-operatively, MFC agents have been shown to be better at reducing bone bleeding than control groups receiving no hemostatic agents, but does not reach the same level of effectiveness as gelatin paste of thrombin-soaked gel-foam [71]. More modern formulations combine MFCs, bovine-derived thrombin, and patient plasma into a composite gel applied to sites of bony bleeding. The patient’s plasma provides fibrinogen which is cleaved by the bovine thrombin into fibrin. This fibrin is then able to complex with the MFC’s creating a collagen-fibrin matrix. This self-contained mixture has been shown to significantly reduce total intra-operative blood loss compared to controls and may also decrease operative time [72].
\nThough several small, prospective case-control studies support the use of MFC agents for topical hemostasis, no large-scale RCT has evaluated its efficacy.
\nPlease refer to Table 4 for the complete list of topical hemostatic agents used in orthopedic tumor surgery.
\nOn occasion, surgeons can take advantage of tumor composition prior to operative intervention. For tumors which are highly vascular in nature, interventional radiologists may be able to ablate the blood supply, thus shrinking the tumor and decreasing the risk of hemorrhage in regions which are difficult to reach operatively. The most common embolizing agents are polyvinyl alcohol (PVA) and microcoils, and the most common metastatic lesions susceptible to embolization are renal cell carcinoma, thyroid carcinoma, and multiple myeloma. In extremity tumors, definitive orthopedic intervention performed within 48 h of embolization can decrease transfusion requirements as well as perioperative blood loss in direct correlation to tumor size [73].
\nIR embolization can be especially helpful prior to decompressive spine surgery, but reliable data is difficult to decipher. Two RCTs with similar methodological criteria came to differing conclusions on the effects of embolization on intra-operative blood loss, transfusion requirements, and blood loss [74, 75]. A separate study found that decreases in blood loss only became significant if arterial supply was completely embolized versus partial or subtotal embolization [76].
\nGiven that most evidence exploring pre-operative embolization of tumors prior to orthopedic intervention is level III or IV, no definitive conclusions can be made regarding efficacy. Despite this, there are certain circumstances where embolization is likely beneficial including large tumors, highly vascular tumors, and tumors requiring large areas of resection. If the surgeon decides to pursue pre-operative embolization, it should be done within 24–72 h of planned orthopedic intervention and the surgeon should have a discussion with the interventional radiologist to determine if complete arterial occlusion can be achieved [77].
\nThe topic of hemostasis in orthopedic surgery is immense, and the evidence behind certain principles is frequently limited. The sections above take a subspecialized approach to hemostasis encompassing technological breakthroughs, evolutions in surgical techniques, and novel biosurgical agents which can be used synergistically. Each subspecialty presents specific challenges when it comes to hemostasis, and even specific procedures may lend themselves to a high potential for blood loss. By remaining up to date with the most recent tools and techniques, as well as the evidence behind them, surgeons can continue to make informed decisions to minimize the risk of perioperative blood loss and thereby limit risk of post-operative complications.
\nNone of the authors listed have financial conflicts to disclose.
\n"Open access contributes to scientific excellence and integrity. It opens up research results to wider analysis. It allows research results to be reused for new discoveries. And it enables the multi-disciplinary research that is needed to solve global 21st century problems. Open access connects science with society. It allows the public to engage with research. To go behind the headlines. And look at the scientific evidence. And it enables policy makers to draw on innovative solutions to societal challenges".
\n\nCarlos Moedas, the European Commissioner for Research Science and Innovation at the STM Annual Frankfurt Conference, October 2016.
",metaTitle:"About Open Access",metaDescription:"Open access contributes to scientific excellence and integrity. It opens up research results to wider analysis. It allows research results to be reused for new discoveries. And it enables the multi-disciplinary research that is needed to solve global 21st century problems. Open access connects science with society. It allows the public to engage with research. To go behind the headlines. And look at the scientific evidence. And it enables policy makers to draw on innovative solutions to societal challenges.\n\nCarlos Moedas, the European Commissioner for Research Science and Innovation at the STM Annual Frankfurt Conference, October 2016.",metaKeywords:null,canonicalURL:"about-open-access",contentRaw:'[{"type":"htmlEditorComponent","content":"The Open Access publishing movement started in the early 2000s when academic leaders from around the world participated in the formation of the Budapest Initiative. They developed recommendations for an Open Access publishing process, “which has worked for the past decade to provide the public with unrestricted, free access to scholarly research—much of which is publicly funded. Making the research publicly available to everyone—free of charge and without most copyright and licensing restrictions—will accelerate scientific research efforts and allow authors to reach a larger number of readers” (reference: http://www.budapestopenaccessinitiative.org)
\\n\\nIntechOpen’s co-founders, both scientists themselves, created the company while undertaking research in robotics at Vienna University. Their goal was to spread research freely “for scientists, by scientists’ to the rest of the world via the Open Access publishing model. The company soon became a signatory of the Budapest Initiative, which currently has more than 1000 supporting organizations worldwide, ranging from universities to funders.
\\n\\nAt IntechOpen today, we are still as committed to working with organizations and people who care about scientific discovery, to putting the academic needs of the scientific community first, and to providing an Open Access environment where scientists can maximize their contribution to scientific advancement. By opening up access to the world’s scientific research articles and book chapters, we aim to facilitate greater opportunity for collaboration, scientific discovery and progress. We subscribe wholeheartedly to the Open Access definition:
\\n\\n“By “open access” to [peer-reviewed research literature], we mean its free availability on the public internet, permitting any users to read, download, copy, distribute, print, search, or link to the full texts of these articles, crawl them for indexing, pass them as data to software, or use them for any other lawful purpose, without financial, legal, or technical barriers other than those inseparable from gaining access to the internet itself. The only constraint on reproduction and distribution, and the only role for copyright in this domain, should be to give authors control over the integrity of their work and the right to be properly acknowledged and cited” (reference: http://www.budapestopenaccessinitiative.org)
\\n\\nOAI-PMH
\\n\\nAs a firm believer in the wider dissemination of knowledge, IntechOpen supports the Open Access Initiative Protocol for Metadata Harvesting (OAI-PMH Version 2.0). Read more
\\n\\nLicense
\\n\\nBook chapters published in edited volumes are distributed under the Creative Commons Attribution 3.0 Unported License (CC BY 3.0). IntechOpen upholds a very flexible Copyright Policy. There is no copyright transfer to the publisher and Authors retain exclusive copyright to their work. All Monographs/Compacts are distributed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). Read more
\\n\\nPeer Review Policies
\\n\\nAll scientific works are Peer Reviewed prior to publishing. Read more
\\n\\nOA Publishing Fees
\\n\\nThe Open Access publishing model employed by IntechOpen eliminates subscription charges and pay-per-view fees, enabling readers to access research at no cost. In order to sustain operations and keep our publications freely accessible we levy an Open Access Publishing Fee for manuscripts, which helps us cover the costs of editorial work and the production of books. Read more
\\n\\nDigital Archiving Policy
\\n\\nIntechOpen is committed to ensuring the long-term preservation and the availability of all scholarly research we publish. We employ a variety of means to enable us to deliver on our commitments to the scientific community. Apart from preservation by the Croatian National Library (for publications prior to April 18, 2018) and the British Library (for publications after April 18, 2018), our entire catalogue is preserved in the CLOCKSS archive.
\\n\\nOpen Science is transparent and accessible knowledge that is shared and developed through collaborative networks.
\\n\\nOpen Science is about increased rigour, accountability, and reproducibility for research. It is based on the principles of inclusion, fairness, equity, and sharing, and ultimately seeks to change the way research is done, who is involved and how it is valued. It aims to make research more open to participation, review/refutation, improvement and (re)use for the world to benefit.
\\n\\nOpen Science refers to doing traditional science with more transparency involved at various stages, for example by openly sharing code and data. It implies a growing set of practices - within different disciplines - aiming at:
\\n\\nWe aim at improving the quality and availability of scholarly communication by promoting and practicing:
\\n\\n\\n"}]'},components:[{type:"htmlEditorComponent",content:'
The Open Access publishing movement started in the early 2000s when academic leaders from around the world participated in the formation of the Budapest Initiative. They developed recommendations for an Open Access publishing process, “which has worked for the past decade to provide the public with unrestricted, free access to scholarly research—much of which is publicly funded. Making the research publicly available to everyone—free of charge and without most copyright and licensing restrictions—will accelerate scientific research efforts and allow authors to reach a larger number of readers” (reference: http://www.budapestopenaccessinitiative.org)
\n\nIntechOpen’s co-founders, both scientists themselves, created the company while undertaking research in robotics at Vienna University. Their goal was to spread research freely “for scientists, by scientists’ to the rest of the world via the Open Access publishing model. The company soon became a signatory of the Budapest Initiative, which currently has more than 1000 supporting organizations worldwide, ranging from universities to funders.
\n\nAt IntechOpen today, we are still as committed to working with organizations and people who care about scientific discovery, to putting the academic needs of the scientific community first, and to providing an Open Access environment where scientists can maximize their contribution to scientific advancement. By opening up access to the world’s scientific research articles and book chapters, we aim to facilitate greater opportunity for collaboration, scientific discovery and progress. We subscribe wholeheartedly to the Open Access definition:
\n\n“By “open access” to [peer-reviewed research literature], we mean its free availability on the public internet, permitting any users to read, download, copy, distribute, print, search, or link to the full texts of these articles, crawl them for indexing, pass them as data to software, or use them for any other lawful purpose, without financial, legal, or technical barriers other than those inseparable from gaining access to the internet itself. The only constraint on reproduction and distribution, and the only role for copyright in this domain, should be to give authors control over the integrity of their work and the right to be properly acknowledged and cited” (reference: http://www.budapestopenaccessinitiative.org)
\n\nOAI-PMH
\n\nAs a firm believer in the wider dissemination of knowledge, IntechOpen supports the Open Access Initiative Protocol for Metadata Harvesting (OAI-PMH Version 2.0). Read more
\n\nLicense
\n\nBook chapters published in edited volumes are distributed under the Creative Commons Attribution 3.0 Unported License (CC BY 3.0). IntechOpen upholds a very flexible Copyright Policy. There is no copyright transfer to the publisher and Authors retain exclusive copyright to their work. All Monographs/Compacts are distributed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). Read more
\n\nPeer Review Policies
\n\nAll scientific works are Peer Reviewed prior to publishing. Read more
\n\nOA Publishing Fees
\n\nThe Open Access publishing model employed by IntechOpen eliminates subscription charges and pay-per-view fees, enabling readers to access research at no cost. In order to sustain operations and keep our publications freely accessible we levy an Open Access Publishing Fee for manuscripts, which helps us cover the costs of editorial work and the production of books. Read more
\n\nDigital Archiving Policy
\n\nIntechOpen is committed to ensuring the long-term preservation and the availability of all scholarly research we publish. We employ a variety of means to enable us to deliver on our commitments to the scientific community. Apart from preservation by the Croatian National Library (for publications prior to April 18, 2018) and the British Library (for publications after April 18, 2018), our entire catalogue is preserved in the CLOCKSS archive.
\n\nOpen Science is transparent and accessible knowledge that is shared and developed through collaborative networks.
\n\nOpen Science is about increased rigour, accountability, and reproducibility for research. It is based on the principles of inclusion, fairness, equity, and sharing, and ultimately seeks to change the way research is done, who is involved and how it is valued. It aims to make research more open to participation, review/refutation, improvement and (re)use for the world to benefit.
\n\nOpen Science refers to doing traditional science with more transparency involved at various stages, for example by openly sharing code and data. It implies a growing set of practices - within different disciplines - aiming at:
\n\nWe aim at improving the quality and availability of scholarly communication by promoting and practicing:
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I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. 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After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). 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It provides a novel ALIZA Canvas and ALIZA Process supported by a comprehensive ALIZA Toolset. This output is derived from observed, tangible deficiencies in contemporary functional communications in manufacturing. This study proposes an innovative approach with robust methodologies for strategic alignment of the technical and business components in manufacturing. The requirement for a supplementary educational infrastructure, to address the pronounced educational shortcomings and knowledge gaps in the transition to Industry 4.0 is outlined. An explanation is provided of how E-Cubers (our own educational organization) will design, develop, and deliver educational programmes on Topics relevant to achieving Industry 4.0 Equipment Engineering Excellence. It defines and tests the novel concept of the E-Cubers Eight Ps; encompassing prioritized problem solving, via portfolios and projects, through peer collaboration within a defined technology playground with emphasis on learning and playing with passion. The E-Cubers Eight Ps is combined with The E-Cubers Library to deliver a truly comprehensive specialist, national learning framework. This holistic approach will ultimately enable Ireland to lead the way in Industry 4.0 by doing what we do best “ag spraoi agus ag imirt” (Gaelic – playing by having fun and competing).",book:{id:"7436",slug:"new-trends-in-industrial-automation",title:"New Trends in Industrial Automation",fullTitle:"New Trends in Industrial Automation"},signatures:"Shane Loughlin",authors:null}],onlineFirstChaptersFilter:{topicId:"119",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:106,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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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. 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Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"14",title:"Cell and Molecular Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",isOpenForSubmission:!0,editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",slug:"rosa-maria-martinez-espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",biography:"Dr. Rosa María Martínez-Espinosa has been a Spanish Full Professor since 2020 (Biochemistry and Molecular Biology) and is currently Vice-President of International Relations and Cooperation development and leader of the research group 'Applied Biochemistry” (University of Alicante, Spain). Other positions she has held at the university include Vice-Dean of Master Programs, Vice-Dean of the Degree in Biology and Vice-Dean for Mobility and Enterprise and Engagement at the Faculty of Science (University of Alicante). She received her Bachelor in Biology in 1998 (University of Alicante) and her PhD in 2003 (Biochemistry, University of Alicante). She undertook post-doctoral research at the University of East Anglia (Norwich, U.K. 2004-2005; 2007-2008).\nHer multidisciplinary research focuses on investigating archaea and their potential applications in biotechnology. She has an H-index of 21. She has authored one patent and has published more than 70 indexed papers and around 60 book chapters.\nShe has contributed to more than 150 national and international meetings during the last 15 years. Her research interests include archaea metabolism, enzymes purification and characterization, gene regulation, carotenoids and bioplastics production, antioxidant\ncompounds, waste water treatments, and brines bioremediation.\nRosa María’s other roles include editorial board member for several journals related\nto biochemistry, reviewer for more than 60 journals (biochemistry, molecular biology, biotechnology, chemistry and microbiology) and president of several organizing committees in international meetings related to the N-cycle or respiratory processes.",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"15",title:"Chemical Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",isOpenForSubmission:!0,editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",slug:"sukru-beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",biography:"Dr. Şükrü Beydemir obtained a BSc in Chemistry in 1995 from Yüzüncü Yıl University, MSc in Biochemistry in 1998, and PhD in Biochemistry in 2002 from Atatürk University, Turkey. He performed post-doctoral studies at Max-Planck Institute, Germany, and University of Florence, Italy in addition to making several scientific visits abroad. He currently works as a Full Professor of Biochemistry in the Faculty of Pharmacy, Anadolu University, Turkey. Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. Dr. Beydemir is also Rector of Bilecik Şeyh Edebali University, Turkey.",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",slug:"deniz-ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",biography:"Dr. Deniz Ekinci obtained a BSc in Chemistry in 2004, MSc in Biochemistry in 2006, and PhD in Biochemistry in 2009 from Atatürk University, Turkey. He studied at Stetson University, USA, in 2007-2008 and at the Max Planck Institute of Molecular Cell Biology and Genetics, Germany, in 2009-2010. Dr. Ekinci currently works as a Full Professor of Biochemistry in the Faculty of Agriculture and is the Head of the Enzyme and Microbial Biotechnology Division, Ondokuz Mayıs University, Turkey. He is a member of the Turkish Biochemical Society, American Chemical Society, and German Genetics society. Dr. Ekinci published around ninety scientific papers, reviews and book chapters, and presented several conferences to scientists. He has received numerous publication awards from several scientific councils. Dr. Ekinci serves as the Editor in Chief of four international books and is involved in the Editorial Board of several international journals.",institutionString:null,institution:{name:"Ondokuz Mayıs University",institutionURL:null,country:{name:"Turkey"}}},editorThree:null},{id:"17",title:"Metabolism",coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",isOpenForSubmission:!0,editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",slug:"yannis-karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",biography:"Yannis Karamanos, born in Greece in 1953, completed his pre-graduate studies at the Université Pierre et Marie Curie, Paris, then his Masters and Doctoral degree at the Université de Lille (1983). He was associate professor at the University of Limoges (1987) before becoming full professor of biochemistry at the Université d’Artois (1996). He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. His teaching areas are energy metabolism and regulation, integration and organ specialization and metabolic adaptation.",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null},{id:"18",title:"Proteomics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",isOpenForSubmission:!0,editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",slug:"paolo-iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",biography:"Paolo Iadarola graduated with a degree in Chemistry from the University of Pavia (Italy) in July 1972. He then worked as an Assistant Professor at the Faculty of Science of the same University until 1984. In 1985, Prof. Iadarola became Associate Professor at the Department of Biology and Biotechnologies of the University of Pavia and retired in October 2017. Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. 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She gained considerable experience in developing and validating new methodologies whose applications allowed her to determine both the amount of biomarkers (Desmosine and Isodesmosine) in the urine of patients affected by COPD, and the activity of proteolytic enzymes (HNE, Cathepsin G, Pseudomonas aeruginosa elastase) in the sputa of these patients. Simona Viglio was also involved in research dealing with the supplementation of amino acids in patients with brain injury and chronic heart failure. She is presently engaged in the development of 2-DE and LC-MS techniques for the study of proteomics in biological fluids. The aim of this research is the identification of potential biomarkers of lung diseases. 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