\r\n\tThe Japanese were revolutionizing quality improvement. As a result, Japan adopted a "total quality" approach to its strategies. In the United States, Total Quality Management (TQM) encompasses not only statistics but also approaches that encompass the entire organization. There were several subsequent quality-management initiatives. \r\n\tIn 1986, Motorola developed Six Sigma to improve its business processes by minimizing defects. A philosophy that views all work as a process, which can be identified, measured, analyzed, improved, and controlled. Generally, "Six Sigma quality" is an indicator that a process is well controlled.
\r\n
\r\n\tLean manufacturing (1988), also known as just-in-time manufacturing, derives from Toyota's 1930 operating model "The Toyota Way." Lean describes a set of management practices that reduce waste and increase productivity. \r\n\tThe ISO 9000 series of quality-control standards appeared in 1987. ISO 9001 integrates a process-oriented approach into enterprise management based on the plan-do-check-act method. The quality movement has matured as we enter the 21st century. ISO 9000 was revised in 2000 to emphasize customer satisfaction. The fifth edition of ISO 9001, published in 2015, emphasizes risk-based thinking to improve the application of the process approach. In addition to the manufacturing sector, quality has moved into service, healthcare, education, and government. For example, through standards such as ISO/IEC 17025 for testing and calibration laboratories and ISO 15189 for medical laboratories. \r\n\tMore recently, it has been recognized that the Fourth Industrial Revolution, Industry 4.0, best defines the present industry model. As its part, "Quality 4.0" refers to the future of quality and organizational excellence.
\r\n
\r\n\tThe book will aim to introduce a comprehensive overview of the up-to-date models used in quality management systems by experts in the field.
",isbn:"978-1-80356-729-7",printIsbn:"978-1-80356-728-0",pdfIsbn:"978-1-80356-730-3",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"7c2744454ba90e8d6cf507e167cc3779",bookSignature:"Dr. Paulo Pereira and Dr. Sandra Xavier",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11527.jpg",keywords:"Leadership, Customer Focus, Improvement, Process Approach, Planning, CAPA, Audit, Management Review, Evaluation, Lean Sigma, DMAIC, DMADV",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 24th 2022",dateEndSecondStepPublish:"June 8th 2022",dateEndThirdStepPublish:"August 7th 2022",dateEndFourthStepPublish:"October 26th 2022",dateEndFifthStepPublish:"December 25th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"12 days",secondStepPassed:!1,areRegistrationsClosed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. Pereira received his Ph.D. from the Catholic University of Portugal. He has over 20 years of experience as a consultant and auditor of quality management systems, and over 16 years of experience as a quality manager. He has been recruited as a quality and laboratory expert for seminars and professional laboratory meetings throughout Europe, Africa, and South America. Currently, he is the head of the R&D Department at the Portuguese Institute of Blood and Transplantation; a CLSI and EURACHEM fellow.",coeditorOneBiosketch:"Dr. Xavier received her Ph.D. from the University of Lisbon, Portugal. She has extensive experience in teaching and managing quality systems, and is a member of several Scientific Commissions and editorial boards.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"178637",title:"Dr.",name:"Paulo",middleName:null,surname:"Pereira",slug:"paulo-pereira",fullName:"Paulo Pereira",profilePictureURL:"https://mts.intechopen.com/storage/users/178637/images/system/178637.jpeg",biography:"Dr. Pereira received his Ph.D. in Biotechnology from the Catholic University of Portugal. He has been recruited as a quality and laboratory expert for seminars and professional laboratory meetings throughout Europe, Africa, and South America. He has more than twenty-five years of experience working in medical laboratories, having held key scientific leadership roles: 15+ years as a senior researcher; 10+ years as a consultant for a metrology laboratory based on ISO/IEC 17025 specifications and related standards; 20+ years as a consultant and auditor of quality management systems based on ISO 9001, ISO/IEC 17025, and ISO 15189 standards; 16+ years as the quality manager in the Portuguese Institute of Blood and Transplantation, including more than 6 years in national coordination; and 6+ years as a professor of Quality Assurance. Currently, he is the head of the R&D Department at the Portuguese Institute of Blood and Transplantation, Lisbon, Portugal. Dr. Pereira is the author of several peer-reviewed scientific articles and indexed books and chapters. He is an editor for several books. He serves as a member of several editorial boards. He is a member of the Clinical Laboratory and Standards Institute and Eurachem. Dr. Pereira is an expert on in vitro diagnostic medical devices at the European Commission / European Medicines Agency.",institutionString:"Portuguese Institute of Blood and Transplantation",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],coeditorOne:{id:"264942",title:"Dr.",name:"Sandra",middleName:null,surname:"Xavier",slug:"sandra-xavier",fullName:"Sandra Xavier",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRZ6mQAG/Profile_Picture_2022-03-25T09:32:37.jpg",biography:"Dr. Xavier received her Ph.D. in Nursing from the University of Lisbon, Portugal. 26+ years professional experience in nursing 15+ years of teaching in a university 4+ years of professional practice as the Head of Nursing 9+ years as a researcher in the different Nursing Research Units , Since 2018 as research in Nursing Research Unit of South and Island (NURSE'IN - UIESA), Portugal. 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She is a member of several Scientific Commissions of various meetings.",institutionString:"School of Nursing of Lisbon",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"11",title:"Engineering",slug:"engineering"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"453622",firstName:"Tea",lastName:"Jurcic",middleName:null,title:"Ms.",imageUrl:"//cdnintech.com/web/frontend/www/assets/author.svg",email:"tea@intechopen.com",biography:null}},relatedBooks:[{type:"book",id:"7710",title:"Quality Management and Quality Control",subtitle:"New Trends and Developments",isOpenForSubmission:!1,hash:"226e5d555cafed8a4d1b410959863661",slug:"quality-management-and-quality-control-new-trends-and-developments",bookSignature:"Paulo Pereira and Sandra Xavier",coverURL:"https://cdn.intechopen.com/books/images_new/7710.jpg",editedByType:"Edited by",editors:[{id:"178637",title:"Dr.",name:"Paulo",surname:"Pereira",slug:"paulo-pereira",fullName:"Paulo Pereira"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10198",title:"Response Surface Methodology in Engineering Science",subtitle:null,isOpenForSubmission:!1,hash:"1942bec30d40572f519327ca7a6d7aae",slug:"response-surface-methodology-in-engineering-science",bookSignature:"Palanikumar Kayaroganam",coverURL:"https://cdn.intechopen.com/books/images_new/10198.jpg",editedByType:"Edited by",editors:[{id:"321730",title:"Prof.",name:"Palanikumar",surname:"Kayaroganam",slug:"palanikumar-kayaroganam",fullName:"Palanikumar Kayaroganam"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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\n\t\t\t
1. Introduction
\n\t\t\t
Driven by the demand of the bioelectronics market, many biosensors need to work in parallel or in a controllable way to achieve complicated biodetections, however the limited scale, speed, cost, complex signal processing, and bulky circuit routing problems prohibit the discrete biosensor solutions (Drummond et al., 2003). Nowaday biosensor are usually integrated on the same substrate to form biosensor array to improved the scale and efficiency, and solve the signal routing difficulties.
\n\t\t\t
CMOS technology emerges since the mid-1960s, and rapidly captured the IC market. The aggressive scaling of CMOS technology following the famous Moore’s Law enables the realization of high-speed digital circuits, analog and mixed-signal circuits, as well as radio-frequency (RF) communication circuits. A single chip monotonically integrating all components of a complex electronics systems or laboratory systems which contain digital, analog, mixed-signal, and RF communication, microelectromechanical systems (MEMS), and other experimental functions, i.e. lab-on-a-chip (LOC) is avidly to be implemented to possess the capabilities of high-efficiency characterization, high-speed complex signal processing and communication, mass production, large scale, low cost, and low power as well. Fortunately, most of the fabrication processes of biosensors are compatible with the standard CMOS technology either directly or via the post-CMOS processes, e.g. DNA sensors fabricated on Si-nanowire (Li et al., 2004) and gold surface (Cheng et al., 2005) etc, which makes it possible to integrate the biosneosr arrays and CMOS IC on a single chip as a CMOS integrated biosensing system (IBS) (Augustyniak et al., 2006; Prakash et al., 2006; Thewes et al., 2005; Han et al., 2007).
\n\t\t\t
The CMOS IBS usually composes of four parts in its system circuitry: integrated biosensor array, interfacing circuits, analog-to-digital (A/D) conversion, and digital signal processor (DSP), as shown in Figure 1(a). In some system requiring feedback controlling during the characterization, digital-to-analog (D/A) converters are also included depending on the applications, as shown in Figure 1(b). In the system architecture of CMOS IBS, the overall performance such as noise, bandwidth, sensitivity etc are mainly governed by the performances of interfacing circuits which controls the electrolyte potential and directly acquires signals from the integrated biosensor array.
\n\t\t\t
The three electrode system, as shown in Figure 2, is the most popular electrode architecture of the integrated biosensor array in nowadays CMOS IBS. The system is composed of reference electrode, working electrode, and counter electrode (it is also called auxiliary electrode sometimes).
\n\t\t\t
Figure 1.
System architectures of CMOS IBS. (a) Feedforward sensing. (b) Feedback controlled sensing.
\n\t\t\t
Reference electrode is an electrode with a stable and well-known electrode potential. There are many types of reference electrode used in electrochemical systems, such as hydrogen electrode, copper-copper(II) sulphate electrode, silver chloride electrode etc, among which the silver chloride (Ag-AgCl) electrode is commonly employed in the IBS. In some systems with feedback stabilization, the reference electrode made from inert metals such as gold (Au), platinum (Pt) etc are also utilized to simplify the fabrication process.
\n\t\t\t
Working electrode is an electrode in the IBS on which reaction of interest is occurring. Common working electrode is usually implemented in inert metals such as Au, Ag, Pt, etc. Most biosensors apply a control voltage on the working electrode in contact with the electrolyte while measuring the current by a signal acquisition circuit, as shown in Figure 2.
\n\t\t\t
Counter electrode is an electrode used in the IBS from which the sensing current is expected to flow and is also made from inert metals in most cases. The potential on this electrode is opposite in sign to that of the working electrode. Counter electrode is usually connected with the reference electrode by a potentiostat in a negative feedback loop to stabilize the electrolyte potential with respect to a reference during the biosensing process, as shown in Figure 2. In some systems, acquisition circuit is combined into the potentiostat, but which is not against the architecture of the interfacing circuits we are discussing here.
\n\t\t\t
Figure 2.
Interfacing circuits in the CMOS IBS.
\n\t\t
\n\t\t
\n\t\t\t
2. Potentiostat
\n\t\t\t
The on-chip potentiostat circuit serving for stabilizations of electrolyte potential and accommodation of electrochemical current (Augustyniak et al., 2006; Prakash et al., 2006; Thewes et al., 2005) is one of the major components in the IBS, which is usually realized as an operational transconductance amplifier (OTA) (\n\t\t\t\t\tZhang et al., 2009\n\t\t\t\t). Table 1 shows the specifications of the potentiostat OTA from a typical biosensor system based on nano-particle assembly.
\n\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Typical assembling voltage
\n\t\t\t\t\t\t
1.8 ± 0.2 V
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Min. assembling voltage
\n\t\t\t\t\t\t
~1 V
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Electrolyte potential range
\n\t\t\t\t\t\t
0 to 1.8 V
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Max. potential variation
\n\t\t\t\t\t\t
5 mV
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Assembling current range
\n\t\t\t\t\t\t
~ 10 nA to ~ 100 µA
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Max. signal bandwidth
\n\t\t\t\t\t\t
< 100 kHz
\n\t\t\t\t\t
\n\t\t\t\t
Table 1.
Sepcifications of potentiostat OTA from the experiment.
\n\t\t\t
It can be seen that the assembling voltage range falls in the typical supply voltage range of standard CMOS technology, but due to the aggressive scaling of CMOS technology, typical supply voltage of mainstream CMOS process can barely satisfy the specifications in Table 1. For this reason, a potentiostat OTA with rail-to-rail input common-mode range is highly preferred in the CMOS IBS. On the other hand, considering the loading capability required by the assembling current range, a Class-AB output stage should also be incorporated for its bidirectional loading capability and high power efficiency.
\n\t\t\t
The potentiostat OTA has been designed and illustrated in Figure 3. The potentiostat OTA uses the complimentary folded-cascode input stage composed of transistor M0 to M13 to achieve the rail-to-rail input common-mode range to enable the required assembling voltage, and reduce the input-referred noise to stabilize the potential as well, while incorporates the Class-AB output stage composed of transistor M29 to M32 to provide the maximized loading capability and accommodate the assembling current requirement. Transistors M14 to M21 function as the common-mode feedback circuit and provide biasing voltage for the folded-cascode input stage. M25 to M28 are two source follower to match the DC voltage between stages, while the other biases are served by M22 to M24 from a current IB. Simulation results show that biasing at a current of IB=1 µA the circuit is capable of providing a rail-to-rail input and output dynamic range and a unit gain bandwidth up to 42.7 MHz, while the output current headroom, I\n\t\t\t\tmax, is over 450 µA, which meet the specifications in Table 1.
\n\t\t\t
Figure 3.
Transistor level implementation of the potentiostat OTA with rail-to-rail input common-mode range and Class-AB output stage.
\n\t\t\t
The potential variation is due to: (I) finite transconductance of the potentiostat OTA, (II) input referred noise, and (III) the input referred offset. If Gm\n\t\t\t\t\tDC\n\t\t\t\t is the DC transconductance of the potentiostat OTA, the potential variation, Vft\n\t\t\t\t, due to (I) can be expressed as
According to the noise theory, transistors M0, M1, M5, M6, M7, M8, M12, and M13 in the first stage contribute to the overall noise. The noise power spectral density, SI\n\t\t\t\t, in a MOS transistor is given by (Linares-Barranco et al., 2003; Linares-Barranco et al., 2004)
where γ is the thermal noise parameter, gm\n\t\t\t\t is the transconductance, Ids\n\t\t\t\t is the drain-source current, Cox\n\t\t\t\t, W, and L are the gate capacitance per unit area, transistor width and length, respectively, and k, T, and f are the Boltzman constant, temperature, and frequency, respectively. KF\n\t\t\t\t, AF\n\t\t\t\t, and EF\n\t\t\t\t are flicker noise parameters with the typical values of 2×10-25, 2, and 1, respectively. Since the corner frequency fc\n\t\t\t\t, where thermal noise and flicker noise exhibit the same power density, is calculated as 5.4 Hz by using parameters provided by the foundry, much smaller than the unit gain bandwidth, therefore, flicker noise is negligible in the proposed OTA, and the input referred noise voltage Virn\n\t\t\t\t can be characterized by
where gmj\n\t\t\t\t is the transconductance of transistor Mj, j = 0, 1,…, 32.
\n\t\t\t
\n\t\t\t\tVirn\n\t\t\t\t can be diminished by increasing the biasing currents and aspect ratios of the input differential pairs, but trades off with the power consumption and the physical area. The spectral density input referred noise of proposed OTA on different common-mode input voltages are shown in Table 2.
\n\t\t\t
Monte-Carlo simulation is also performed to characterize the input referred offset by utilizing the mismatch parameters provided by the foundry, and the results are also shown in Table 2. In the worst case with VCM\n\t\t\t\t = 0 V, the overall potential variation due to the above three issues is 4.12 mV, which implies an 8 bit of potential resolution and satisfies the boundary condition in Table 1. The other circuit performances are summarized in Table 2.
\n\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Parameters
\n\t\t\t\t\t\t
V CM = 0 V
\n\t\t\t\t\t\t
V CM = 0.9 V
\n\t\t\t\t\t\t
V CM = 1.8 V
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
DC transconductance
\n\t\t\t\t\t\t
2.22 S
\n\t\t\t\t\t\t
5.43 S
\n\t\t\t\t\t\t
3.90 S
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
3- dB bandwidth
\n\t\t\t\t\t\t
1.97 kHz
\n\t\t\t\t\t\t
2.07 kHz
\n\t\t\t\t\t\t
1.94 kHz
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Phase margin
\n\t\t\t\t\t\t
"/75 o
\n\t\t\t\t\t\t
"/80 o
\n\t\t\t\t\t\t
"/75 o
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Max. output pull current
\n\t\t\t\t\t\t
451 µA
\n\t\t\t\t\t\t
451 µA
\n\t\t\t\t\t\t
-
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Max. output push current
\n\t\t\t\t\t\t
-
\n\t\t\t\t\t\t
459 µA
\n\t\t\t\t\t\t
459 µA
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Input referred offset
\n\t\t\t\t\t\t
3.51 mV
\n\t\t\t\t\t\t
1.60 mV
\n\t\t\t\t\t\t
2.75 mV
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Input referred noise
\n\t\t\t\t\t\t
61.8 nV/µHz
\n\t\t\t\t\t\t
38.2 nV/µHz
\n\t\t\t\t\t\t
57.7 nV/µHz
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Overall potential variation
\n\t\t\t\t\t\t
4.12 mV
\n\t\t\t\t\t\t
1.93 mV
\n\t\t\t\t\t\t
3.24 mV
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Potential resolution
\n\t\t\t\t\t\t
8 bit
\n\t\t\t\t\t\t
9 bit
\n\t\t\t\t\t\t
9 bit
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
DC power dissipation
\n\t\t\t\t\t\t
40.4 µW
\n\t\t\t\t\t\t
50.3 µW
\n\t\t\t\t\t\t
58.0 µW
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t\t
Power supply
\n\t\t\t\t\t\t
1.8 V
\n\t\t\t\t\t\t
1.8 V
\n\t\t\t\t\t\t
1.8 V
\n\t\t\t\t\t
\n\t\t\t\t
Table 2.
Summary of performances of the potentiostat OTA
\n\t\t
\n\t\t
\n\t\t\t
3. Acquisition circuits
\n\t\t\t
The design of acquisition circuits in the IBS is circumscribed by the sensing mechanism of the biosensor. In the electrical biosensing, there are two major schemes in analyte detection: direct current (DC) sensing and alternative current (AC) sensing.
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In the DC sensing, a DC voltage is usually applied to the working electrode in an IBS, and the current flowing from counter electrode to the working electrode is measured (Augustyniak et al., 2006; Thewes et al., 2005). This method suffers from the large background noise in the electrolyte seriously, which prevent it from the applications requiring high sensitivities of biosensing.
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In the AC sensing, the acquisition circuit senses the AC modulation current by applying an AC voltage superimposed on a DC biasing on the working electrode (Huang & Chen, 2008). Since only the background noise within the band-of-interest deteriorates the signal-to-noise ratio, the AC sensing has much better sensitivity than the DC sensing scheme.
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DNA releasing voltage
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0.9 V
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DNA modulation voltage
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±0.5 V
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Current headroom
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±100 nA
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Current sensitivity
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~100 pA
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Max. signal bandwidth
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10 kHz
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Min. sensor impedance
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~5 MΩ
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Table 3.
Specifications of a typical DNA IBS
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A desirable acquisition circuit should usually accommodate both schemes of biosensing, however, as summarized in Table 3, the fastidious requirements, such as sensitivity, bandwidth, input range, etc., for the following circuits make great challenges to analog integrated circuit designers. There are various methods and circuits dealing with the ultralow current in biosensing applications, e.g., current integrator (sometimes it is called as potentiostat) (Ayers et al., 2007; Narula & Harris, 2006), transimpedance amplifiers (Rodriguez-Villegas, 2007; Basu et al., 2007), and ultralow current-mode amplifiers (ULCA) (Zhang et al., 2007; Ramirez-Angulo et al., 2004; Steadman et al., 2006; Zhang et al., 2009). The current integrator is capable of providing sub-picoampere sensitivity, however, the circuit bandwidth is typically below 1 kHz, which cannot fully accommodate the bandwidth of AC sensing. Transimpedance amplifiers possess wider bandwidth and good sensitivity, however, its dynamic range is limited by the supply voltage, which becomes a serious issue along with the scaling of supply voltage in today’s CMOS technology. The ULCA turns out to be a favorable candidate with high sensitivity, sufficient bandwidth, and wide dynamic range for IBS with AC sensing capabilities.
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3.1. Circuit design of ULCA
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In ULCA design, conventional transistor-strong-inversion-based current-mode circuits are out of consideration due to the large noise background induced by the dc quiescent current, and weak-inversion-based (subthreshold) current-mode circuits emerge as the candidates. Since the subthreshold circuits suffer from supply voltage fluctuations and die-to-die process fluctuations (Mead, 1989), they are usually closely integrated with other adjacent stages on a single die and share the same supply voltage, along with careful considerations on the matching, symmetry, and biasing issues (Linares-Barranco et al., 2003; Linares-Barranco et al., 2004; O’Halloran & Sarpeshkar 2004).
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Some ULCA topologies have been reported (Zhang et al., 2007; Ramirez-Angulo et al., 2004; Steadman et al., 2006), as shown in Figure 4. The circuit in Figure 4(a) is working in the Class A mode. It uses a regulated current mirror to achieve the current amplification. The quiescent currents are provided by current sources, whereas the bandwidth is limited by capacitor C\n\t\t\t\t\t0. Although the circuit provides good linearity over the input range, since the quiescent current I\n\t\t\t\t\t0 should be low enough to reduce the noise level and meet the requirement of sensitivity, the specified current headroom (in both positive and negative directions) can hardly be achieved. One can certainly introduce the Class B complementary topology in Figure 4(b) to meet the headroom requirement and increase the sensitivity by removing the noise background induced by I\n\t\t\t\t\t0; however, this comes at the cost of substantially losing bandwidth in the low-input cases.
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Figure 4.
Conventional current-mode amplifier topologies.
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To meet the specifications in Table 3, a Class AB ULCA aiming at biosensing amplification has been designed and verified in SMIC 0.18-µm CMOS mixed-signal technology (Zhang et al., 2009). The design elaborately considered the issues and tradeoffs over gain, bandwidth, noise, and offset. The experimental results show that the ULCA can completely satisfy the requirements of typical DNA-based IBS and is eligible to serve for the preamplification of ultralow biosensor signals in the IBS.
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The ULCA schematic is shown in Figure 5. In this circuit, the current from DNA biosensors is input to a complementary regulated current mirror consisting of an N-type opamp AN0\n\t\t\t\t\t, a P-type opamp AP0\n\t\t\t\t\t, and transistors M0\n\t\t\t\t\t, M1\n\t\t\t\t\t, M3\n\t\t\t\t\t, and M4\n\t\t\t\t\t, where it is amplified by a factor of 10 (20 dB). The opamps AN1\n\t\t\t\t\t and AP1\n\t\t\t\t\t and the transistors M6−M11\n\t\t\t\t\t compose a voltage limiter.
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Figure 5.
Circuit schematic of the ULCA.
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Due to the “virtual short” mechanism, “IN” is fixed at “REF” by AN0\n\t\t\t\t\t and AP0\n\t\t\t\t\t, and a quiescent current of I\n\t\t\t\t\tref is established in M0\n\t\t\t\t\t and M3\n\t\t\t\t\t by AN1\n\t\t\t\t\t and AP1\n\t\t\t\t\t. When a positive input is applied Vn\n\t\t\t\t\t, the output of the opamp AN1\n\t\t\t\t\t reduces, thus turning off M2\n\t\t\t\t\t. The current of M\n\t\t\t\t\t0 and M\n\t\t\t\t\t1 is sunk by AP0. On the other hand, since Vp tends to drop down, the current provided by AN0 becomes smaller. However, M5 is turned on by AP1 to compensate the current at node Vp, which limits Vp from dropping and maintains the quiescent current of M0 and M3 equal to the reference current Iref provided by M6−M9, even if the input current IIN is much larger than Iref. A similar conclusion can also be made for the negative input cases.
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It can be seen that M2 and M5 alternatively sustain the quiescent current for the current mirror, which in turn keeps a constant bandwidth as the input varies between positive and negative directions. Furthermore, Iref can be designed small enough to achieve the required sensitivity and noise level without being restricted by the current headroom, since the current headroom no longer depends on the magnitude of the quiescent current in the ULCA. Therefore, the circuit can provide an extremely high sensitivity and a large current headroom at the required bandwidth. Due to the variation and pad leakage issues, Iref is unpractical to be provided off-chip. Therefore, three steps of current mirroring are introduced by M12−M16 in the biasing stage, where each step achieves a conversion factor of 0.1. A microampere-level off-chip current is downconverted 1000 times to relax these unwanted impacts. Capacitors C0 and C1 serve for frequency compensation and bandwidth limitation purposes in the circuit.
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Figure 6.
Auxiliary N- and P-type opamps in the ULCA.
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The auxiliary N- and P-type opamps are shown in Figure 6(a) and (b). In the circuit, M0, M1, M3, and M4 consist of a differential input stage. M0 and M1 are biased in their subthreshold regions for the purpose of noise reduction; meanwhile, they are chosen as large dimensions to improve the matching and reduce the offset and flicker noise. Transistors M5 and M6 consist of a transconductance output stage that provides current for the following circuits. Capacitors Cn and Cp represent the load capacitances of the opamp.
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As shown in Figure 5, when a positive input is applied, the gain is provided by the regulated current mirror consisting of M0, M1, and opamp AP0, whereas M3−M5 and opamp AP1 are serving as current sources providing the quiescent current for the stage, which can be simplified to the circuit shown in Figure 7(a). A complementary discussion of the negative input case leads to the topology shown in Figure 7(b).
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3.2. Small signal AC analysis
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The small-signal equivalent circuit for ac analysis is shown in Figure 7(c). In this circuit, gm, gmb, go, and Cgs are the gate transconductance, body transconductance, output conductance, and gate capacitance of the MOSFET, and goa, Cia, and Coa are the output conductance, input capacitance, and output capacitance of the opamp, respectively. Ci is defined as Cgs0 + Cgs1 + C0 (or C1). The transconductance of the opamp is modeled as gma(s), considering the delays introduced by the parasitic capacitances of its internal nodes. As suggested in (Linares-Barranco et al., 1992), gma(s) can be written as
where gma is the DC transconductance, and ωa models the delay.
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Figure 7.
a) Simplified circuit of ULCA when a positive input is applied. (b) Simplified circuit of ULCA when a negative input is applied. (c) Small-signal equivalent circuit of a simplified ULCA.
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Detailed analysis of the equivalent circuit results in the characterization function of as2+bs+c=0, where:
To maintain the ac stability, all the poles of the circuit transfer function must be placed in the left-hand side of the Laplace plane, i.e. a>0, b>0, c>0 must be satisfied, resulting in the conditions of gN\n\t\t\t\t\tma, gP\n\t\t\t\t\tma> gm1, C0> gP\n\t\t\t\t\tma/ωa, and C1> gN\n\t\t\t\t\tma/ωa. Moreover, it can be found that provided the quiescent current Iref, by adjusting C0 and C1, the bandwidth of the ULCA can be confined at the expected value.
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3.3 Noise characterization
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It is known that three kinds of noises are considered in the CMOS circuit: thermal noise and shot noise, which are white noise, and flicker noise or 1/f noise. According to the noise theory and the characterizations in (Linares-Barranco et al., 2003) and (Linares-Barranco et al., 2004), the subthreshold noises in the MOSFET are basically contributed by shot noise and flicker noise, and the noise power density SID is given by
where ID is the drain–source current of the MOSFET, W and L are the channel width and length, Cox is the gate capacitance per unit area, and q, f, and K represent the unit charge, frequency, and a process-dependent parameter, respectively. In the 0.18-µm technology, the typical value of Cox is about 1.08 × 10−2 F/m2, and K is 2 × 10−24 F2/m2 for nMOS and 4 × 10−26 F2/m2 for pMOS.
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By equaling the two terms in (8), one can derive the noise corner frequency as fc = KID/2qWLC2\n\t\t\t\t\tox. In a W = 10 µm and L = 1 µm sized nMOS, fc is around 8 Hz when biased at ID = 1.5 nA, which is no more than 0.1% of the required 10-kHz bandwidth, whereas for pMOS, fc is two orders lower. In the DNA biosensor, the modulation signal is usually band limited with a typical bandwidth of 10 kHz and a lower frequency of 10 Hz; therefore, shot noise dominates over the whole signal band of interest from the above design.
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The noise performance of the ULCA can be characterized by two noise sources vn and in with the corresponding power densities of Svn and Sin, which can be calculated as usual by evaluating the output noise current with the input open or shorted to the ground and dividing by the gain. The simplified expressions are reported as
where A is the current gain of the ULCA, and Sva is the input referred noise power density of the opamp. From (9) and (10), Sin and Svn can be reduced by decreasing the input-referred noise of the opamp and the quiescent current Iref, however trading with the power consumption and the bandwidth of the ULCA.
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3.4. Mismatch considerations
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The performances of the practical circuit also suffer from process fluctuations due to transistor mismatches, e.g., variations of W, L, and threshold voltage VT, which would induce the input-referred offset (IRO) Ioff, gain error δA, and bandwidth variation δBW of the ULCA. More specifically, one can find that Ioff is due to the IROs Voff of opamps AN0 and AP0 and the mismatches of M0, M1, M3, and M4; δA is caused by mismatches of M0, M1, M3, and M4; whereas δBW is mainly induced by Voff of opamps AN1 and AP1. It is known that the variances of W, L, and VT due to process fluctuations are inversely proportional to the area of the MOSFET; therefore, as a first-order approximation, Ioff, δA, and δBW are inversely proportional to √WL, which can be reduced by increasing the sizes of M0, M1, M3, and M4 and the input differential pairs of opamps in the ULCA, provided that the bandwidth specification is satisfied.
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Incorporating the above considerations on stability, noise, and mismatch, HSPICE simulations are made on the circuit to meet the circuit specification in Table 3, and the optimized quiescent current is designed as Iref = 1.5 nA, whereas capacitors C0 and C1 are set to 1 pF. Monte Carlo simulation based on the design kit of SMIC 0.18-µm CMOS technology also shows that Ioff and BW are within −30~120 pA and 12~16 kHz, whereas δA/A is less than ±5%, when the channel length is chosen as L = 1 µm, and the aspect ratios (W/L) of N and P transistor units are 10 and 20, respectively.
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3.5. Experiment and discussions
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The ULCA is realized in the SMIC 0.18-µm CMOS mixed-signal technology, and Figure 8 shows the die micrograph of the chip. The box encloses the ULCA circuitry, which occupies about 230 × 80 µm2 of the chip area. The performance of the ULCA is measured in terms of gain, bandwidth, noise, offset, etc. The results are shown and discussed in this section.
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To test the performance of the ULCA, very large resistors (from 1 to 10 GΩ) are used to convert the voltage into input currents down to the picoampere or sub-nanoampere range, which may further keep the input noise current small since the input noise current spectrum density due to the resistor is inversely proportional to the resistance. The whole circuit is placed in an aluminum box with Bayonet Neill-Concelman (BNC) connectors to shield from unwanted interferences. In the experiment, VREF is biased at 0.9 V to provide maximized input range on both positive and negative directions while satisfying the voltage range specifications in Table 3. The input voltage varies between 1.9 and −0.1 V to provide the positive and negative input currents by replacing the resistors.
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Figure 8.
Die micrograph of the ULCA circuit.
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Figure 9.
DC gain and bandwidth as functions of input currents ranging from −1 to 1 µA. The black squares represent the dc gain, whereas the circles illustrate the bandwidth.
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The DC gain as a function of input currents ranging from −1 to 1 µA is plotted in Figure 9, which is 0.5% lower than the designed value of 20 dB and implies about 2% of the overall mismatch on transistors M0, M1, M3, and M4 due to fabrication variations. The gain error over the input range is less than 0.3%. One can certainly increase the transistor dimensions to further reduce the mismatch and achieve better linearity, however trading with the bandwidth performance.
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The bandwidth has been characterized by analyzing the step response of the ULCA, which is cascaded by a commercial transimpedance amplifier, and the result as a function of input currents is also illustrated in Figure 9. It can be seen that the bandwidth basically linearly increases with the input current levels on both positive and negative directions from around 20 kHz to 1 MHz. The minimal bandwidth of 15 kHz occurs in the low-input cases, satisfying the 10 kHz requirement in the application. The overshoot of the bandwidth is because the offset of opamps AN1 and AP1 and the threshold mismatch shift the actual quiescent current of M0 and M3 up to around 2 nA (estimated value) from the designed value of 1.5 nA. A larger bandwidth may slightly degrade the noise performance and sensitivity, but it could be adjusted by somewhat tuning the biasing current Iref down for compensation.
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The IRO is analyzed by keeping the input open while measuring the mean current at the output and dividing by the gain, which is found to be 96.6 pA at VOUT = 0.9 V. The IRO corresponds to the offsets of opamps and mismatches at the output node; however, it is not critical for the application. One can either slightly modify VOUT for compensation or do the calibration after acquisition and analog-to-digital conversion in the digital domain by a simple subtraction.
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Figure 10.
IRNC and SNR as functions of input currents ranging from −1 to 1 µA. The black squares represent the IRNC, whereas the circles illustrate the SNR.
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The noise performance of the ULCA is characterized in terms of the input-referred noise current (IRNC) by measuring the mean-square-root value of the output current fluctuation at each input current level and dividing by the gain. The result is shown in Figure 10. It is noticed that the IRNC of the ULCA starts at 37.6 pArms at zero input and basically remains at the same level for |Iin| < 1 nA, whereas it linearly increases for larger input levels. The target current sensitivity of ~100 pA is satisfied. The signal-to-noise ratio (SNR) increases for |Iin| < 10 nA and gradually saturates at values around 36 dB for larger input levels. The SNR is smaller on the positive input side than on the negative side; this is due to the fact that nMOS exhibits a higher current noise than pMOS. It is worth mentioning that the minimal noise current is larger than the simulated value of 12 pArms but falls in the range provided by Monte Carlo simulation by utilizing parameters from the foundry, which can be explained from two aspects: 1) the actual quiescent current of M0 andM3 is slightly larger than the designed value due to offsets of the opamp; and 2) the mismatches of M0, M1, M3, and M4 degrade the symmetry of the ULCA topology, thus increasing the noise level.
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Linearity is presented by the gain versus input characteristic in Figure 11. The gain approximately remains at 19.9 dB for the input range of −100 to 100 µA and degrades for larger input levels. The maximal input current is estimated to about ±0.4 mA as determined by the 1-dB (or 10% in the linear scale) degrading point of gain, which implies 141 dB of headroom-to-noise ratio or equivalent to 23 bit. Moreover, depending on the electric properties of the DNA sensor and the buffer solution, the minimal impedance from the biosensor electrode is around 5 MΩ. The input impedance of the ULCA is measured as 15.5 kΩ, which is much lower than the biosensor impedance in the application, satisfying the interface condition.
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Figure 11.
Gain versus input current over the entire input range.
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DC gain
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19.9 dB
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3-dB bandwidth
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15 kHz
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Current sensitivity
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37.6 pArms
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Potential variation
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583 nVrms
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Input-referred offset
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96.6 pA
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Input impedance
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15.5 kΩ
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Max. input current
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±0.4 mA
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Input dynamic range
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141 dB
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DC power consumption
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35 µW
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Power supply
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1.8 V
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Table 4.
able 4. Summary of circuit parameter of the ULCA.
A novel subthreshold Class AB ULCA aiming at the application of signal preamplification in the IBS has been demonstrated in SMIC 0.18-µm CMOS technology. Experimental results show that the ULCA completely accommodates the application and can provide a current gain of 19.9 dB, 3-dB bandwidth of 15 kHz, and an input range of −0.4 to 0.4 mA, whereas the IRO and the noise current are less than 96.6 pA and 37.6 pArms, respectively. Table 4 shows the summarized parameters of the circuit. The ULCA can also be used for ultralow current amplification in other types of biosensor interfaces, nanoscale device sensing, and optical sensing in the future.
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4. Discussion
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4.1. A few trade-offs
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In order to accurately acquire signals during the sensing process, CMOS IBS has to work on a stable electrolyte potential, which is precisely controlled by the potentiostat through the reference and counter electrodes from a negative feedback mechanism. The potential variation is mainly due to the offset and noise of the potentiostat OTA. Offset can be reduced by increasing the size of input differential pair of the OTA, or introducing a digital correction circuit via a D/A converter and logics, but trades with the circuit area. On the other hand, noise can be reduced by either increasing the size or biasing current of input differential pair, but trades with the area and power, respectively.
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The sensitivity of CMOS IBS is mainly governed by the acquisition circuits, which translates to the IRNC of ULCA. One can reduce IRNC by reducing the DC quiescent current, but trading with the bandwidth required in the biosensing. In some biosening systems with low electrolyte impedance, noise voltage (potential variation on the working electrode) of ULCA also becomes a concern, which also trades with the power and area of the circuit.
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In general, interfacing circuits is the bottle neck of the CMOS IBS design. A good design comes with various requirements of a specific biosensing system, which differs from one system to another. Various trade-offs must be considered in the circuit design according to the system specifications as well as power and area budgets.
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4.2. Future research
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Future research of CMOS IBS covers a number of directions to further improve the efficiency and performance of the system. One of the methods is to incorporate a preamplification step such as polymerase chain reaction (PCR) or rolling circle amplification (RCA) before the electrical sensing, which increases the analyte concentration in the electrolyte and biosensing current level, thus relaxing the sensitivity requirements of the interfacing circuit. Keeping the same sensitivity, one can further shrink the dimension of electrodes and increase the scale of IBS to improve the throughput and sensing efficiency.
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As the scale of IBS growing up, asymmetry due to the electrode layout also becomes an issue, because the current density distributes from the counter electrode to all the working electrodes in the electrolyte, which could be quite different from each other depending on the positions. Some structures such as multiple counter electrodes, interlacing electrodes, partition, etc are being investigated. Further research also needs to be invested to characterize the current distribution in the electrolyte for a specific electrode layout when the number of electrode scales up.
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From the circuit angle, the sensitivity can be further improved by using the lock-in filtering, which extracts the current only at the vicinity of frequency-of-interest therefore minimizing the background noise contributions and maximizing the signal-to-noise ratio. The challenge part is that a high resolution A/D conversion is required to translate current signals into digital domain before the digital lock-in filtering. Logarithmic transimpedance amplification is another candidate to achieve high sensitivity and satisfying the bandwidth requirements, while ameliorating the dynamic range limitations by compressing output voltage range. The signal decompress can be realized by digital circuits after the voltage digitization.
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5. Conclusion
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The CMOS IBS research and production continue to offer a fertile ground for innovation. In this chapter, design considerations on the CMOS IBS interfacing circuits, including the integrated biosensor array, potentiostat, and acquisition circuits, have been introduced. A number of circuit design trade-offs between potential variation, sensitivity, speed, dynamic range, power, and physical area have also been discussed. Finally, future research directions to further improve the IBS performances in terms of efficiency and sensitivity are reviewed.
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Acknowledgments
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This work was supported by the National Science Foundation of China under Grant 60236020 and Grant 90307016, by a grant from Intel, and by a private research grant from Dr. D. Yang.
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The authors would like to thank Prof. Y. Chen of the Mechanical and Aerospace Engineering Department, University of California, Los Angeles, for the collaboration with his research team.
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\n',keywords:null,chapterPDFUrl:"https://cdn.intechopen.com/pdfs/6922.pdf",chapterXML:"https://mts.intechopen.com/source/xml/6922.xml",downloadPdfUrl:"/chapter/pdf-download/6922",previewPdfUrl:"/chapter/pdf-preview/6922",totalDownloads:4002,totalViews:397,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:0,impactScore:0,impactScorePercentile:20,impactScoreQuartile:1,hasAltmetrics:0,dateSubmitted:null,dateReviewed:null,datePrePublished:null,datePublished:"February 1st 2010",dateFinished:null,readingETA:"0",abstract:null,reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/6922",risUrl:"/chapter/ris/6922",book:{id:"3185",slug:"biosensors"},signatures:"Lei Zhang, Zhiping Yu and Xiangqing He",authors:[{id:"6943",title:"Prof.",name:"Lei",middleName:null,surname:"Zhang",fullName:"Lei Zhang",slug:"lei-zhang",email:"leinper@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Tsinghua University",institutionURL:null,country:{name:"China"}}},{id:"134001",title:"PhD.",name:"Zhiping",middleName:null,surname:"Yu",fullName:"Zhiping Yu",slug:"zhiping-yu",email:"yu@gloworm.Stanford.EDU",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Tsinghua University",institutionURL:null,country:{name:"China"}}}],sections:[{id:"sec_1",title:"1. Introduction ",level:"1"},{id:"sec_2",title:"2. Potentiostat",level:"1"},{id:"sec_3",title:"3. Acquisition circuits",level:"1"},{id:"sec_3_2",title:"3.1. Circuit design of ULCA",level:"2"},{id:"sec_4_2",title:"3.2. Small signal AC analysis",level:"2"},{id:"sec_5_2",title:"3.3 Noise characterization",level:"2"},{id:"sec_5_3",title:"3.4. Mismatch considerations",level:"3"},{id:"sec_6_3",title:"Table 4.",level:"3"},{id:"sec_9",title:"4. Discussion",level:"1"},{id:"sec_9_2",title:"4.1. A few trade-offs",level:"2"},{id:"sec_10_2",title:"4.2. Future research",level:"2"},{id:"sec_12",title:"5. 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Circuits Signal Process., DOI: 10.1007/s10470-009-9342-6, in press.\n\t\t\t'},{id:"B21",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tZhang\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHe\n\t\t\t\t\t\t\tX.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tYu\n\t\t\t\t\t\t\tZ.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2007 Design and implementation of ultra low current sensing amplifier with pico-ampere sensitivity aiming at bio-sensor applications, Chinese J. Electron., 16\n\t\t\t\t\t2 Apr. 2007, (247\n\t\t\t\t\t251 ).\n\t\t\t'},{id:"B22",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tZhang\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tYu\n\t\t\t\t\t\t\tZ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHe\n\t\t\t\t\t\t\tX.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2009 Design and implementation of ultralow current-mode amplifier for biosensor applications, IEEE Trans. Circuits Syst. II, Exp. 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Institute of Microelectronics, Tsinghua UniversityBeijing, 100084, China
Institute of Microelectronics, Tsinghua UniversityBeijing, 100084, China
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1. Introduction
The Codivilla-Putti Institutes has been a strong will of Prof. Vittorio Putti, especially for treating chronic infections; it started its activity in 1930 and had been located in a famous winter sport resort, as it was the case for almost all sanatoriums build in those years to treat septical diseases with “good air” and sun (UV rays), that were then the only therapeutic treatments available to the medical science.
We are now facing in modern therapeutic treatment of chronic osteomyelitis some growing obstacles in using antibiotics, as we find often resistance, principally concerning staphylococcus, which are the major responsible concerning bone infections. The clinician therefore has to dispose not only of surgical knowledge, but he has to be also acquainted with all most recent advances in the field of antibiotic therapies. Moreover, he has to be acquainted with the immunoresponses offered by the body in special circumstances. As a matter of fact the lack of success in such cases induced many scientists to re-evaluate the immunological system by considering its possible deficit.
An immunodeficiency may also show itself in the clinical picture as an increased tendency to chronicize, a reduced phlogistic reaction and an increased frequency of multifocal processes [1].
The use of the so-called “immunotherapy” started at the beginning of the 20th century and is still a field of investigation (Table 1) [1, 2, 3].
1884
Leucotoxin
Van de Velde
1901
Anti-Staphylolysin
Neisser, Wechsberg
1925
Anti-Staphylococcus-Sera
Baker, Shands
1936
Anatoxin-Therapy
Ramon
1938
Exp. Allergic Osteomyelitis
Derizanov
1939
Autovaccination
Schoolfield
1953
Sensitisation and Osteomyelitis
Grundmann
1968
Opsonin Activity
Williams
1971
Prophylactic Immunisation
Weber
1972
Anti-Staphylolysin-titre
Queneau, Bertoye
1973
Anti-Nuclear Factors
Hierholzer
1973
Wound-Specific Antibodies
Ring, Seifert
1976
The Staphylococci
Cohen
Table 1.
Historical list of work on immunotherapy in osteomyelitis.
2. Definition of chronic
Chronic osteomyelitis as all forms of bone inflammatory lesions, sustained by pyogenic germs, who selectively involved from the start bone marrow and intratrabecular spaces and therefore are not healing anyhow, as they brought about a suppuration process, but engender foci in the internal part of bones, who maintain themselves active or more or less weakened [4].
Chronicizing may be:
The consequence of initially acute osteomyelitis (hematogenous, post-traumatic, iatrogenous), that passes gradually into the chronic phase (reduced reaction by the patient owing to the symbiosis guest-host through a progressive reduction in acuteness;
Induced by rapid evolution from the acute form into the chronical form (it happens sometimes as an effect of the antibiotic’s administration);
A chronic form “ab initio” without any initial acuteness or a generalisation of the process.
3. Characteristics of the Staphylococcus
Staphylococci are the most important micro-organisms in the Microccaceae family: they have been denominated by Ogston, as in microscopic slides their elements dispose themselves in clusters. They have a spherical form and are asporigenic and normally non-capsulated, gram-positive, aerobic and optionally anaerobic. It is easy to grow them on common culture media; optimal temperature is 37°C. They are among the most resistant germs to heating and disinfectants. With reference to the colony colours they are classed in aureus, albus, citreus and aurantiacus.
More recently they have been divided in aureus and epidermidis, as the former produces coagulasis and is able to ferment mannitol in anaerobic conditions. By phagic typisation 4 groups have been ascertained, whose major representatives in chronic bone pathologies are type 5 and type 8 [5].
Staphylococcus produces many extracellular substances that show almost all antigenic properties. The most interesting is coagulase that fosters a fibrin barrier around the staphylococcus that might oppose the action of phagocytes and opsonins [6].
It can also induce in the host a form of “allergy” that further reduces his defences [2, 3, 4]. It seems moreover that the bacterial resistance develops proportionally to its capacity to produce para-aminobenzoic acid, necessary to its metabolism, or producing its precursor folic acid. It is supposed that para-aminobenzensulfonamide displaces para-aminobenzoic acid from the bacterial body, i.e. owing to the antibiotic action the bacterial bodies may lose their strong cellular wall transforming themselves in sferoblasts with a weakened antigenic function or without any antigenic function, who are responsible for some infections with a chronic evolution.
4. Some immunological information
Before discussing this point some general knowledge concerning immunology is required. We do not refer to immunology as a whole (as the matter covers very wide aspects), but only to infection resistance.
The host defence to bacterial infections happens through two classical mechanisms, i.e.:
natural non-specific immunoresistance (humoral and cellular factors mainly related to phagocyte reactions) [7].
acquired specific immunity (specific antibodies production and Ag-Ab reaction).
We shall mainly focus on the former mechanism, as its deficiency is considered as the major cause of chronic septical forms; it is the fastest and it arises through humoral and cellular factors (in order to summarise we shall treat the matter in very schematic terms).
Humoral factors may be divided principally in three species.
The complement (C) (a biological entity showing itself through the concomitant action of several constituents, some of which are thermolabile) comprehends a group of known substances, that are present in fresh serum and able to interact, in clearly defined sequence, with all possible kind of Ag-Ab combination.
The C does not show any antibody activity and there is no evidence that its blood levels increase as a consequence of immunisation processes. It has been however evidenced (Lopow, Beker) that at least some C components have enzymatic activity against the bacterial cellular walls, that therefore are opsonised and become weaker to the phagocyte action.
The bacteriocidines are produced mainly by leukocytes and in their majority thermostable. They are principally active against Gram+.
Lysozime is an enzyme discovered by Fleming in 1922 and it has been confirmed in many body fluids and tissues and in the internal parts of neutrophile granulocytes. It is constituted by a protein that should be able to depolymerise some polysaccharides contained in many bacterial species. Moreover it should stimulate: phagocytosis, bacterial suspensions agglutinations (Ferrina), phlogistic processes inhibition (Matracia).
Opsonins [8] act on micro-organisms by making them easier to be phagocitated. Generally neutrophyles are able to phagocytate aggressive micro-organisms only after a specific Opsonin has covered (opsonisation) the micro-organisms. Their action fosters also the elimination of micro-organisms from blood by means of the reticuloendothelial system.
As far as the non-specific cellular immunity is concerned, it is mainly related to phagocytosis, i.e. the capacity showed by some cells to take up corpuscular matter of different nature and origin; the cells are part of the so-called reticulohistocytic system (R.H.S).
Metchnikoff considers that cells with the capability to phagocitate are essentially:
The macrophages [9], classed in fixed and mobile, are the reticular cells in the spleen and in the lymphonodules and the Küpfer cells in the liver, the fixed osteoclasts and the histiocytes, which pass from the tissues into circulation (mobile) (see macrophages origin in Figure 1).
Microphages are represented by the blood polymorphonucleic leukocytes, essentially by neutrophyles.
Figure 1.
Genesis of the immunolgical cells.
With reference to specific activity brought about by the production of most often Permanent Ab, it does not seem that staphylococci infections have such characteristics. A study by Ring shows indeed that only 26 cases on 112 have an increased antistaphylolysinic level.
It has been observed that the staphylococci pathogenicity appears on one side as an increased resistance to the defensive powers of the patient and on the other side as a capacity to establish a kind of allergy that further reduces body defences. The production of toxins might have only a minor role in the pathogenicity (Zironi) [2]; as a matter of fact there is no parallelism between germ virulence and the seriousness of the illness. It has been observed that the two factors provoking allergy (hypersensitivity against the germ or its products and increased reaction capacity) do not always evolve in parallel but may show different evolution.
Sensitivity to the micro-organism and its antigens, without variation of the host reactivity may beobserved and such a mechanism induces a very dangerous condition, called by immunologists “specific hyperreceptivity”. Such a mechanism could account as an explication how this state may grow by inappropriate use of antibiotics.
Insufficient immunitary system predisposition to the entrance of the germ inadequate microbial sterilisation (inappropriate antibiotics – dosage – choice) bacterial persistence, even only latent stimulation repeated in the time hyper-receptivity (Figure 2).
Figure 2.
The cascade for arrive to the hyper-receptivity.
We have many actions in the aspecific immunological activity but one of the most important action is the activity of the Macrofages to fight staphylococcus and the action is the opsonization (Figures 3 and 4) [10].
Figure 3.
Summary opsonization-phagocytosis of the “macrophages”.
Figure 4.
Phagocytosis of the staphylococci from “macrophagis”.
5. Specific bacterial immunotherapy (S.B.I.T)
The immunological experience is treating osteomyelitis chronic forms at the Istituto Putti in Cortina starts in 1963 [11, 12, 13] by introducing immunotherapy, applied by the progressive administration in growing doses of a staphylococci pool, that had been collected from some patients with bone infections by the same germ and then inactivated in an aqueous solution suspension. At that time also autologous immunostimulation was carried out, i.e. a therapy prepared by isolating the responsible bacterial agent directly in the patient’s exudate.
Also experiences with a Pseudomonas aeruginosa autologous immunotherapy have been carried out, but we abandoned it, as we saw that this bacterium wasn’t the principal pathogenic agent, which provoked bone infections.
Nowadays only the isolation of Staphylococcus strains 5 and 8 is carried out, as only these strains are responsible for 98% of the bone infections. This aspect has been showed by a joint research with Institut Pasteur in Paris. We are working now only with these kinds of staphylococci and were able to better the general characteristics.
As already mentioned, administration is performed at growing dosages according to patterns adopted since long avoiding that too approached stimulation may exhaust the capacity responses as a consequence of a too prolonged stress.
The preparation is inoculated subcutaneously, and the therapy lasts about three months. After at least one month stop treatment may be repeated (Figure 5).
Figure 5.
Increasing subcutaneous injections of doses, according to a widely scheme (since 1963) of an inactivated staphylococci pool of type 5 and 8.
With reference to the above said we tried, together with “Immuno” in Vienna, to find out whether among chronic osteomyelitis patients there was some immunological deficit. We did not consider this evaluation had to be made on acute forms, as they show different characteristics while the host reactivity is still within the norm.
We evaluated therefore about 150 cases, with different ages and causes (hematogenic, post-traumatical and iatrogenous) and referred to following parameters:
Antibody titre
Complement (fraction 3)
Phagocytic activity
Opsonisation capacity
Bactericidal reaction
Bacterial agglutinins
“T” lymphocyte count
This study ascertained indeed a reduction of the phagocytic activity as a whole, and especially the opsonisation activity.
Opsonisation capacity deficit
62%
Antibody activity deficit
34%
“T” lymphocytes decrease
4%
It has been thought therefore that in immunotherapy more factors are involved; their principal property is to reduce the allergising effect and therefore to desensitise vs. the germ proteins and to increase the phagocytic activity.
This condition, neither whose entity nor its lasting may be defined, does not appear to be unlimited.
Obviously, this desensitisation can be obtained also by the right antibiotic choice that, as already said mainly in acute forms, may develop their bactericidal properties and sterilise the focus.
In the chronic forms it is possible to provoke this mechanism by carrying out a surgical toilette that restores the vascularization and stimulation conditions needed for a correct antibiotic action.
Checks upon immuno-stimulation treatment termination clearly showed corresponding results between laboratory deficit clinical conditions bettering laboratory bettering.
6. Laboratory
Parameters normalisation
35%
Minor increases
34%
No variations
25%
7. Clinical
Good
50%
Reduced
28%
Bad
22%
8. Another immunological evaluation in the use of S.B.I.T
Dr. G. Mastrorillo Work Bari’s School (Tables 2 and 3) [14].
LIF: inhibition of the leucocytic migration in percentage
^: Relevant statistic values
Patients
Phagocytosis*
LIF**
PMN
Monocyte
19 Non-responders
60.6 ± 19.1^
52.6 ± 11.7^
30.5 ± 9.3^
3 responders
87.0 ± 3.2
87.6 ± 5.3
54.3 ± 12.4
40 (controllo)
86.9 ± 4.45
87.1 ± 4.2
48.3 ± 6.9
Table 2.
The phagocytosis: Is valued as percentage of cells that englobe the specific Bacterias. *Description of the study.
Patients
Phagocytosis*
PMN
Monocyte
LIF**
Before
After
Before
After
Before
After
19 Non-responders
65.7 ± 19.1
72.4 ± 12.4
30.6 ± 8.9
70.4 ± 8.9
25.8 ± 8.1
30.6 ± 8.9
3 Responders
87.0 ± 3.1
85.3 ± 6.1
87.3 ± 5.3
85.2 ± 4.7
54.3 ± 12.4
60.3 ± 11.2
Table 3.
The valuation was repeated after the soministration of S.B.I.T and the results were significant, as you can see on the table, between the beginning and the end of treatment. *The results.
This work considers the immunological effects of S.B.I.T.
In 22 patients with chronic osteomyelitis with a follow up of 20 months the Authors valued:
The phagocytosis of polymorphonucleate and monocytes versus some bacteria that were identified in at least two samples on three.
The dosage of LIF (inhibition of the leukocytes migration in percentage).
The patients were divided in two categories and compared with 40 volunteers.
The responders (3) who had almost normal parameters.
The non responders (19) who were immuno-compromised.
From this valuation, we understand that in chronic osteomyelitis there is unimportant immunological compromise.
9. Clinical effect with the S.B.I.T. treatment
We clinically evaluated the results obtained by using immunotherapy and we observed different facts recorded on about 7,500 cases treated since 1963 till 2016.
Spontaneous elimination of sequestra,
Demarcation or resorption,
Output colour change,
Trend to fistula healing,
Reduction of congestive facts,
Less frequent reacutisation,
Reduced articular rigidity,
Stimulation of bone reparation,
Reduction of soft tissues calcification.
Some of these effects (sequestrum resorption or demarcation, reduced articular rigidity, increased repairing capacity) may be explained only by hypothesising a stimulating action on the reticuloendothelial cells that are able to differentiate themselves in different tissues [9].
We studied also possible differences between children, known for their evolutive receptive potentiality, and adults leaving the kind pf suffered infection out of consideration.
10. Result
The results on 100 adults and 100 children have been compared by referring to following parameters:
100 adults
♂:90
♀:10
100 children
♂:80
♀:20
11. Form
Children
Adults
Hematogen
66
19
Post-traumatic
30
40
Iatrogenic
4
4
12. Stabilisation
Time
Children
Adults
1–6 months
36
15
6–12 months
30
26
> 1 year
31
37
Non attained
3
22
13. Healing
Children
Adults
Obtained
90
73
Not obtained
10
27
Whereas healed are the patients who do not show any restart at least after 1 year from stabilisation, stabilised are those, who do not show any clinical, radiographic or bio-humoral sign of inflammation. As however chronic infections may show restarts, even after more than 1 year from stabilisation, the word “healing” has been adopted by us only to quantitize the research results and we have to evidence that it is more a language term than a truth, as it is well known to our colleagues who deal with these pathologies [15].
Another study has been made by us in order to define the Immunotherapy potentiality concerning both hematogenic and post-traumatic forms.
14. The casuistry
The casuistic is based on 50 patients with hematogenous osteomyelitis, all less than 16 years old, age at which the growth cartilage knit, and 117 post-traumatic infective pseudoarthroses, where this term has been adopted for cases who showed a lack of non-solidification at 6 months after trauma.
We expressly made a distinction between hematogenic and post-traumatic forms, as the relations bacterial count vs. host response do differ. Let us first consider the hematogenic form with all patients infected by coagulase positive Staphylococcus aureus.
Males were infected most often (78%); the prevailing age were between 10 and 16 years old.
Lower limbs were involved three times more than arms, while there was no difference between proximal diaphyseal and distal diaphyseal localisation. In 30% of cases the lesion involved the whole bone segment (panostytis), while the remaining 70% showed a localisation at the diaphysis half (42%) or at the diaphysis (28%).
In males diffused forms are more frequent, while in females the same applies to localised forms.
Patients have been checked with a following-up lasting from 1 till 10 years after healing (where healing has already been defined).
With the depicted criteria we obtained 86% of healing (88.5% when considering localisation), of which 74% already from the first treatment, and only 12% after possible recurrences. Of these relapses only the half involved a bone, while in the other cases they were the periodical opening of abscesses and fistulae, without any bone involvement. 50% of the patients healed by adopting only immunotherapy; in 38% immunotherapy complemented a surgical intervention, and remaining 11.5% did not heal.
As far as time elapsed from treatment beginning till healing is concerned, we observed 46% healing within 6 months, 30% between 6 months and 1 year, and 24% between 1 and 5 years with an average duration of 9.6 months.
With reference to radiographic belated evidences 20 patients showed the damaged bone segments fully leaked, whereas in later checks 33 patients showed a bone rearrangement (residual osteosclerosis without periostal reaction or osteolytic area).
In 7 cases there were still traces of active infection.
In 3 cases the later checks showed growth disturbs higher than 2.5 cm (in 2 cases there had been a contraction owing to growth cartilage lesions and in 1 case there was a lengthening). In 5 further cases, that initially showed limb lengthening, such dysmetrias disappeared afterwards.
In 5 cases the later checks showed a limitation in movements concerning the articulation near the focus; in 4 cases such limitation was already ascertained at the first control and imputable to the treatment with plaster. The joint limitation has never been imputable to joint involvement by the inflammation process (osteoarthritis).
In 3 cases there were deformities of the bone segments (coxa varia, femur procurvation).
We discuss now the data concerning the 147 cases of post-traumatic infective pseudoarthrosis.
The higher percentage of 75.5% concerns pseudoarthrosis subsequent to osteosynthesis.
In this percentage there were 118 males (83.3%) and 29 female patients (19.7%). Mean age has been 32 years and 5 months; the youngest patient was 18 years old, whereas the oldest was 68 years old. The most frequently interested bone has been the shinbone with 99 cases and secondarily the femur with 35 cases.
25 cases were a two bone fractures and there were exactly 19 tibia and fibula and 6 radius and ulna fractures.
We had 7 cases concerning radius and ulna, 3 cases collar bone, 1 case humerus and 1 case hand. The time elapsed between trauma and infection beginning has been in the male 30 days with 7 days in the shortest case and 5 months in the most belated.
The tome between infection initial and our therapy start has been on an average 8 months, varying from minimal 6 months till maximal 4 years. Our treatment allowed almost always precocious weight bearing; as a matter of fact only the most serious cases had to wait 6 months before being in condition to use the sick limb.
At first hospitalisation already 89.1% of the patients showed a fistula.
In all cases therapy has been immunotherapy+antibioticotherapy. In 11 cases immunotherapy has been repeated and in 5 cases it has been administered 3 times.
We carried out 98 surgical toilets and sequestrectomies, of which 22 cases were more than once. In 4 cases we carried out Paltrinieri parafocal osteotomy (all tibial). In 45 cases the Ilizarof system has been adopted with resection of the focus and compactotomy. We had to amputate only in 1 case. Solidification rimes vary according to the involved bone. On the tibiae they vary from at least 3 till maximal 36 months, on average 9.9 months.
More frequently (76.8% of cases) healing was attained within 1 year from therapy start, 26 cases (equalling 26%) did not attain solidification, of which 18 cases are still under treatment.
Very similar times have been observed on femurs, from 3 till 35 months with 9.2 months average duration.
Also for the femur the 84% of cases heals after 12 months therapy, whereas the non consolidated cases are 10 equalling 28.6%, of which 6 cases are still under treatment.
The forearm does not show substantial differences concerning ulna and radius; the same results indeed have been obtained for both bone segments; in 2 cases on 7 we observed a lack of solidification with bone material loss/this happened in the pre-microsurgical period of our experience).
Fistulae closed fairly fast 6 months in 53.48 of cases. The main check control has been 15 months, varying from 4 months at least up to 7 years.
Belated consequences have been:
Articular rigidity. Patients who have been treated with immunotherapy and submitted to plaster casts, both cylinder or valve casts, and precocious walking showed significant articular functional limitations only in 26 cases, equalling 17.6%. 14 cases concerned the talocrural articulation, 8 cases the knee and 4 cases on 7 concerned the elbow.
Shortenings have been significant (more than 4 cm) only in 2% of cases, whereas there have been 30.5% with less than 4 cm. In the whole 102 cases showed shortenings, that were compatible with a good functionality of the sick limb with good walking.
Axial deviations appeared in 18.3% of cases: 15 cases in varus dislocation, 12 in valgus dislocation, 17 in recordation and 10 in procurvation. Calcification of soft parts have been only 3.4%, whereas they were very frequent before systematically introducing immunotherapy.
Relapses concern 26.5% of our patients, i.e. about 39 cases. In 15 cases (10.2%) it was a simple reopening of the fistula that healed soon, in 13 cases the restart of the infective focus was associated with a new relaxation of the fracture. Afterwards 9 cases healed and these have been the precocious relapses (within 1 year from healing), the belated ones have been 11 cases (7.5%) with 10 healings.
15. Final considerations of the results
The efficacy of immunotherapy is certainly higher in children, as it is confirmed by a lower number of surgical interventions and by the stabilisation and healing results. We analysed 50 cases of hematogenous osteomyelitis in order to consider which factors might have influenced the prognoses.
No negative influences have been brought about by age.
The same applied to sex, though males showed major lesions. Daoud and Martin consider the female sex a favourable prognostic factor.
Prognoses are more difficult in cases with lesions, that are localised on the femur (21% without healing, whereas these reduce themselves to 5–6% in other localisation).
Also the extension (pandiaphysis) and the deep localisation (diaphysis) of the infection adversely influence the illness evolution.
Finally the prognoses is very sensible to the lesion chronicity. As a matter of fact the healing frequency is adversely proportional to the lesion duration (94%, 77%, 36%, 5%). The failures have been observed only with symptoms that has been lasted more than 1 year. Immunotherapy has to be started as soon as possible.
Another analysis with similar considerations has been made by us on 147 cases of infected pseudoarthrose:
Healing is significantly influenced by the fistula healing. As a matter of fact we found 86% healing when fistula closes within 6 months. Healing frequency is lower when fistula has staid open for longer times.
the contrary recovery is not influenced by time elapsed from trauma till infection beginning.
Presence of a fistula upon hospitalisation did not affect healing.
Very important has been time elapsed from infection beginning and immunological treatment. With times less than 6 months recoveries show satisfactory percentages that reduce themselves to 50.6% when elapsed times are more than 1 year.
Localisation influences results. Whereas hands recover soon, times are on an average when tibiae are involved to become long lasting on femurs.
Male patients are more frequent than women (118 cases vs. 29 cases).
16. Conclusions
By comparing the results obtained in chronic osteomyelitis (both hematogenous and post-traumatic) before introducing immunotherapy and reconsidered afterwards, after having acquired a long experience in its administration, we feel following conclusions have to be drawn.
Immunotherapy (eventually associated to surgical therapy) ensures high recovery percentages (among the lightest mentioned in the scientific literature) [16, 17, 18, 19, 20, 21, 22].
Such therapy notably reduces recurrences (12% instead of 40% mentioned in the literature), as it fosters natural defences.
Immunological therapy is somewhat more efficacious (and certainly less toxic) than antibioticotherapy. The two approaches have to be associated, as immunotherapy does not substitute antibioticotherapy (only 15% of patients affected by chronic osteomyelitis fully recover by administering only antibiotics).
We may conclude that Specific Bacterial Immunotherapy (S.B.I.T.) has to be considered an important defence, that does not exclude, but has to be associated to antibiotico therapy and even more to surgery. The obtained positive results shall be studied with complex research methods, as the concept “immunity messenger” opens therapeutical approaches, still difficult to evaluate.
17. Some cases
A case of hemathogenous osteomyelitis of radio in the young patient, 3 year old treated with only S.B.I.T (doses reduction) and antibiotics of course.
X-ray control after 13 years. Completed reconstruction of the bone. The infection health after 6 months of treatement with immunotherapy and antibiotics.
Heavy hematogenic pandiaphysitis in a 10 years old child, who has been treated only with S.B.I.T. according to a reduced therapeutical scheme.
After 2 months of treatment the whole diaphysis partially recovers there are still sequestrum of wich one is postero cortical. Fistulae closed.
After 2 months reabitation of big sequestrum. (The arrow indicates bone sequestrum and its revitalization)
Rx control after 15 months after the beginning of the treatment
Rx control one year after the previous one, please note the complete reconstruction of the bones of the leg, absence of flogosi markers (clinical and laboratory)
45 years old man after an open fracture of the leg. Arrived to our hospital after 12 months; he had two fistulae and two focuses of non union and a wide sequestrum was presented.
Rx control after 3 months of treatment with S.B.I.T. and you can see the reabitation of the central sequestrum and the beginning of callification on the two focuses (of non union
Rx control after removal plate, screw e a debridment and 3 months in plaster.
\n',keywords:"immunotherapy, osteomyelitis, non union, psudoarthritis, vaccine",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/77791.pdf",chapterXML:"https://mts.intechopen.com/source/xml/77791.xml",downloadPdfUrl:"/chapter/pdf-download/77791",previewPdfUrl:"/chapter/pdf-preview/77791",totalDownloads:114,totalViews:0,totalCrossrefCites:0,dateSubmitted:"February 26th 2021",dateReviewed:"June 7th 2021",datePrePublished:"August 2nd 2021",datePublished:"October 27th 2021",dateFinished:"August 2nd 2021",readingETA:"0",abstract:"The immunological experience is treating osteomyelitis chronic forms at the Istituto Putti in Cortina starts in 1963 by introducing immunotherapy, applied by the progressive administration in growing doses of a staphylococci pool, that had been collected from some patients with bone infections by the same germ and then inactivated in an aqueous solution suspension. This therapy is coadjutant of antibiotics, surgical and hyperbaric therapy and not substitutive of these. This study ascertained indeed a reduction of the phagocytic activity as a whole, and especially the opsonisation activity It has been thought therefore that in immunotherapy more factors are involved; their principal property is to reduce the allergising effect and therefore to desensitise vs. the germ proteins and to increase the phagocytic activity. This condition, neither whose entity nor its lasting may be defined, does not appear to be unlimited. Obviously this desensitisation can be obtained also by the right antibiotic choice that, as already said mainly in acute forms, may develop their bactericidal properties and sterilise the focus. In the chronic forms it is possible to provoke this mechanism by carrying out a surgical toilette that restores the vascularization and stimulation conditions needed for a correct antibiotic action. Checks upon immuno-stimulation treatment termination clearly showed corresponding results between laboratory deficit corrected and clinical conditions bettering. The casuistry is based on 50 patients with hematogenic osteomyelitis, all under the age of 16, age at which the growth plate is still active, and 117 post-traumatic septic non-union, where this term was adopted for cases that showed a lack of non-solidification at 6 months after trauma. We have expressly made a distinction between hematogenic and post-traumatic forms, since the relationships between bacterial counts vs. host response do differ.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/77791",risUrl:"/chapter/ris/77791",signatures:"Ferdinando Da Rin de Lorenzo",book:{id:"10729",type:"book",title:"Infections and Sepsis Development",subtitle:null,fullTitle:"Infections and Sepsis Development",slug:"infections-and-sepsis-development",publishedDate:"October 27th 2021",bookSignature:"Vincenzo Neri, Lixing Huang and Jie Li",coverURL:"https://cdn.intechopen.com/books/images_new/10729.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83969-458-5",printIsbn:"978-1-83969-457-8",pdfIsbn:"978-1-83969-459-2",isAvailableForWebshopOrdering:!0,editors:[{id:"170938",title:"Prof.",name:"Vincenzo",middleName:null,surname:"Neri",slug:"vincenzo-neri",fullName:"Vincenzo Neri"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"350650",title:"Prof.",name:"Ferdinando",middleName:null,surname:"Da Rin de Lorenzo",fullName:"Ferdinando Da Rin de Lorenzo",slug:"ferdinando-da-rin-de-lorenzo",email:"darin.ferdinando@iol.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Definition of chronic",level:"1"},{id:"sec_3",title:"3. Characteristics of the Staphylococcus",level:"1"},{id:"sec_4",title:"4. Some immunological information",level:"1"},{id:"sec_5",title:"5. Specific bacterial immunotherapy (S.B.I.T)",level:"1"},{id:"sec_6",title:"6. Laboratory",level:"1"},{id:"sec_7",title:"7. Clinical",level:"1"},{id:"sec_8",title:"8. Another immunological evaluation in the use of S.B.I.T",level:"1"},{id:"sec_9",title:"9. Clinical effect with the S.B.I.T. treatment",level:"1"},{id:"sec_10",title:"10. Result",level:"1"},{id:"sec_11",title:"11. Form",level:"1"},{id:"sec_12",title:"12. Stabilisation",level:"1"},{id:"sec_13",title:"13. Healing",level:"1"},{id:"sec_14",title:"14. The casuistry",level:"1"},{id:"sec_15",title:"15. Final considerations of the results",level:"1"},{id:"sec_16",title:"16. Conclusions",level:"1"},{id:"sec_17",title:"17. Some cases",level:"1"}],chapterReferences:[{id:"B1",body:'Eisen H. Immunologia. Piccin Editore, Padova 1977 Stookey P.F., Scarpellino L.a., Weavar J.B.: Immunology of osteomyelitis. Arch. Surg., 32, 494-505, 1935'},{id:"B2",body:'Zironi A.: L’allergia nelle malattie infettive – Es. Ist. Sier. Milanese – Milano – 1951.)'},{id:"B3",body:'Meloni C. A.: Nozioni di Microbiologia. Libreria Cortina Ed., Padova, 1970'},{id:"B4",body:'Sorice F., Ortona L.: L’infezione Stafilococcica. – Ed. Scient. It. – Napoli – 1955'},{id:"B5",body:'Fournier J.M., K. Hannon, M. Moreau, W. W. Karakawa, and W. F. Vann. 1987. Isolation of type 5 capsular polysaccharide from Staphylococcus aureus. Ann. Inst. Pasteur Microbiol. 138:561-567'},{id:"B6",body:'Tager M., Drumond M. C. Staphylocoagulase; Ann. N. Y. Acad. Sci.; 1965, 128, 92'},{id:"B7",body:'Savoini E., Capanna R., Gherlinzoni F.: Immunità umorale ed osteomielite cronica. COM, 66 (4), 511-515, 1980'},{id:"B8",body:'Pozzi C, Wilk K, Lee JC, Gening M, Nifantiev N, Pier GB. 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Vol. XVII magg.-giu, 1965 Fasc. III'},{id:"B12",body:'Savoini E., Capanna R., Mercuri M., Stilli S.: Risultati nel trattamento immunoterapico e chirurgico nelle osteomieliti croniche dell’infanzia. COM, 67 (4), 397-404, 1981'},{id:"B13",body:'Ciotti M., Argazzi M., Bergami P.L.: La vaccinoterapia nell’osteomelite cronica. Atti S.E.R.T.O.T., Vol. XXXIV – Fasc. 2, 1992'},{id:"B14",body:'Mastrorillo G., Minoia L., Jirillo E., De Vito D.: “Il vaccino autogeno antistafilococcico, trattamento delle osteomieliti croniche: basi scientifiche”. Quad. Inf. Osteoart. Apr. 2001, 23-30 Ed. Masson'},{id:"B15",body:'Morrey B.F.: Hematogenus osteomyelitis at uncommon sites in children. Mayo Clin. Proc. 53: 707, 1978'},{id:"B16",body:'Halasa J., Giedrys-Galant S., Podkowinska I., Braun J., Strzelecka G. and Dabrowski W.: Evaluation of certain immunological parameters in the course of autovaccine treatement in patients with chronic ostitis and carbunculosis. Arch. Immunol. Ter. Exp. 26: 589-593, 1978'},{id:"B17",body:'Fattom A., Schneerson R., C. Szu S., F. Vann W. Shiloach J., W. Karakawa W. and Robbins J.B.: Synthesis and Immunologic properties in mice of vaccines composed of Staphylococcus aureus type 5 and type 8 capsular polysaccharides conjugated to Pseudomonas aeruginosa exotoxin A. Infection and Immunity July 1990, p. 2367-2374'},{id:"B18",body:'Ing-Marie Nilsson,* Joseph M. Patti,‡ Tomas Bremell,* Magnus Höök,‡ and Andrzej Tarkowski* Department of Rheumatology, University of Göteborg, Sweden; Center for Extracellular Matrix Biology, Institute of Biosciences and Technology, Texas a&M University, Houston, Texas 77030 vaccination with a recombinant fragment of collagen Adhesin provides protection against Staphylococcus aureus-mediated septic death. The American society for clinical investigation, Inc. Volume 101, Number 12, June 1998, 2640-2649'},{id:"B19",body:'Foster TJ. Potential for vaccination against infections caused by Staphylococcus aureus. Vaccine. 1991 Apr;9(4):221-227'},{id:"B20",body:'Nilsson IM, Verdrengh M, Ulrich RG, Bavari S, Tarkowski A. Source Department of Rheumatology, S-41346 Göteborg, Sweden. Ing-Marie. Nilsson@immuno.gu.se protection against Staphylococcus aureus sepsis by vaccination with recombinant staphylococcal enterotoxin a devoid of superantigenicity. Department of Rheumatology, S-41346 Göteborg, Sweden. Ing-Marie. J Infect Dis. 1999 Oct;180(4):1370-1373'},{id:"B21",body:'Bagnoli, F., Bertholet, S., and Grandi, G. (2012). Inferring reasons for the failure of Staphylococcus aureus vac-cines in clinical trials. Front. Cell. Infect. Microbiol. 2:16. doi:10.3389/fcimb.2012.00016'},{id:"B22",body:'R.A. Proctor.: Recent developments for Staphylococcus aureus vaccines: clinical and basic science challenges. European Cells and Materials Vol. 30 2015 (pages 315-326) DOI: 10.22203/eCM. V030a22 ISSN 1473-2262. University of Wisconsin – Medical Microbiology/Immunology 835 Asa Gray, Ann Arbor, Michigan 48105, USA'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Ferdinando Da Rin de Lorenzo",address:"darin.ferdinando@iol.it",affiliation:'
National Center of Reference for the Bone Infections, Codivilla-Putti Institutes, Cortina d’Ampezzo, Italy
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Definition of Terms:
\n\n
Book - collection of Works distributed in a book format, whose selection, coordination, preparation, and arrangement has been performed and published by IntechOpen, and in which the Work is included in its entirety in an unmodified form along with one or more other contributions, each constituting separate and independent sections, but together assembled into a collective whole.
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Work - a book Chapter (as well as Conference Papers), including any and all content, graphics, images and/or other materials forming part of, or accompanying, the Chapter/Conference Paper.
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Attribution – appropriate credit for the used Work or book.
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Creative Commons licenses – enable licensors to retain copyright while allowing others to use their Works in an appropriate way.
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Rules of Attribution for Works Published by IntechOpen
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With the purpose of protecting Authors' copyright and the transparent reuse of OA (Open Access) content, IntechOpen has developed Rules of Attribution of Works licensed under Creative Commons licenses.
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\\n\\t
All Chapters published in IntechOpen books prior to October 2011 are licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported license (CC BY-NC-SA 3.0);
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All Chapters published in IntechOpen books after October 2011 are licensed under the Creative Commons Attribution 3.0 Unported license (CC BY 3.0);
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In case you reuse or republish any of the Works licensed under CC licenses, you must abide by the guidelines outlined below:
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1. Rules for reusing of books in their entirety or significant parts of books
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All rights to Books and other compilations published on the IntechOpen platform and in print are reserved by IntechOpen. The Copyright to Books and other compilations is subject to a separate Copyright from any that exists in the included Works.
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A Book in its entirety or a significant part of a Book cannot be translated freely without specific written consent by the publisher. Further information can be obtained at permissions@intechopen.com.
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In instances where permission is obtained from the publisher for reusing or republishing the Book, or significant parts of the Book, all of the following conditions apply:
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\\n\\t
Information about the first publisher must be provided – please note the fact that the material was originally published by IntechOpen as an OA (Open Access) publication must be acknowledged;
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All original Academic Editor(s) must be credited;
\\n\\t
Since you are reusing content that someone else created and allowed you to use freely, you must credit all Authors involved;
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The type of license that is available for the Works must be indicated, as well as a link to the license provided, so that others can investigate the terms of the license. You will be aware that the material can be used for free in consequence of the CC license attribution, so you must acknowledge that fact. It is not sufficient that the material is Creative Commons, because that says nothing about how the material can actually be used. There are different CC licenses and you have to identify the specific license that is being used;
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Any original Copyright Notices associated, with the Works which constitute the Book must be kept intact;
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Provision of the original title of the Book, as well as the original titles of any individual Works;
\\n\\t
Provision of the URL where the Book is hosted, with a notice to the effect that the Book is an OA (Open Access) publication;
\\n\\t
Provision of the URL to every individual Work which constitutes the Book with a notice that the Work is an OA (Open Access) publication. As the material has been accessed for free, it is incumbent upon you to provide the source so that others can also access it for free.
\\n
\\n\\n
Every single Work that is used has to be attributed in the way described. If you are unsure about proper attribution, please write to permissions@intechopen.com.
\\n\\n
2. Rules of attribution for works published by IntechOpen
\\n\\n
Individual Works originally published in IntechOpen books are licensed under Creative Commons licenses and can be freely used under terms of the respective CC license, if properly attributed. In order to properly attribute the Work you must respect all the conditions outlined below:
\\n\\n
\\n\\t
Credit all Authors – since you are reusing contents that someone created and allowed you to use freely, you have to acknowledge authorship;
\\n\\t
Indicate the type of license under which the Work is available and provide the URL to the license so others can find out the license terms. Preferably keep intact any original Copyright Notice associated with the Chapter (if any). You will be aware that the material can be used for free in consequence of the CC license attribution, so you must acknowledge that fact. It is not sufficient that the material is Creative Commons, because that says nothing about how the material can actually be used. There are different CC licenses and you have to identify the specific license that is being used;
\\n\\t
Provide the URL where the Work is hosted, preferably providing the original title of the Work, as well as the original title of the Book with a notification that the Work is an OA (Open Access) publication. As the material has been accessed for free, it is incumbent upon you to provide the source so that others can also access it for free;
\\n\\t
Provide information about the first publisher – please note the fact that the material was originally published by IntechOpen as an OA (Open Access) Work must be acknowledged.
\\n
\\n\\n
Every single Work that is used has to be attributed in the way as described. If you are unsure about proper attribution, please contact Us at permissions@intechopen.com.
\\n\\n
In the event that you use more than one of IntechOpen's Works published in one or more books (but not a significant part of the book that is under separate Copyright), each of these have to be properly attributed in the way described.
\\n\\n
IntechOpen does not have any claims on newly created copyrighted Works, but the Works originally published by IntechOpen must be properly attributed.
\\n\\n
All these rules apply to BOTH online and offline use.
\\n\\n
Parts of the Rules of Attribution are based on Work Attributing Creative Commons Materials published by the Australian Research Council Centre of Excellence for Creative Industries and Innovation, in partnership with Creative Commons Australia, which can be found at creativecommons.org.au licensed under Creative Commons Attribution 2.5 Australia license, and Best practices for attribution published by Creative Commons, which can be found at wiki.creativecommons.org under the Creative Commons Attribution 4.0 license.
\\n\\n
All the above rules are subject to change, IntechOpen reserves the right to take appropriate action if any of the conditions outlined above are not met.
Work - a book Chapter (as well as Conference Papers), including any and all content, graphics, images and/or other materials forming part of, or accompanying, the Chapter/Conference Paper.
\n\n
Attribution – appropriate credit for the used Work or book.
\n\n
Creative Commons licenses – enable licensors to retain copyright while allowing others to use their Works in an appropriate way.
\n\n
Rules of Attribution for Works Published by IntechOpen
\n\n
With the purpose of protecting Authors' copyright and the transparent reuse of OA (Open Access) content, IntechOpen has developed Rules of Attribution of Works licensed under Creative Commons licenses.
\n\n
\n\t
All Chapters published in IntechOpen books prior to October 2011 are licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported license (CC BY-NC-SA 3.0);
\n\t
All Chapters published in IntechOpen books after October 2011 are licensed under the Creative Commons Attribution 3.0 Unported license (CC BY 3.0);
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\n\n
In case you reuse or republish any of the Works licensed under CC licenses, you must abide by the guidelines outlined below:
\n\n
1. Rules for reusing of books in their entirety or significant parts of books
\n\n
All rights to Books and other compilations published on the IntechOpen platform and in print are reserved by IntechOpen. The Copyright to Books and other compilations is subject to a separate Copyright from any that exists in the included Works.
\n\n
A Book in its entirety or a significant part of a Book cannot be translated freely without specific written consent by the publisher. Further information can be obtained at permissions@intechopen.com.
\n\n
In instances where permission is obtained from the publisher for reusing or republishing the Book, or significant parts of the Book, all of the following conditions apply:
\n\n
\n\t
Information about the first publisher must be provided – please note the fact that the material was originally published by IntechOpen as an OA (Open Access) publication must be acknowledged;
\n\t
All original Academic Editor(s) must be credited;
\n\t
Since you are reusing content that someone else created and allowed you to use freely, you must credit all Authors involved;
\n\t
The type of license that is available for the Works must be indicated, as well as a link to the license provided, so that others can investigate the terms of the license. You will be aware that the material can be used for free in consequence of the CC license attribution, so you must acknowledge that fact. It is not sufficient that the material is Creative Commons, because that says nothing about how the material can actually be used. There are different CC licenses and you have to identify the specific license that is being used;
\n\t
Any original Copyright Notices associated, with the Works which constitute the Book must be kept intact;
\n\t
Provision of the original title of the Book, as well as the original titles of any individual Works;
\n\t
Provision of the URL where the Book is hosted, with a notice to the effect that the Book is an OA (Open Access) publication;
\n\t
Provision of the URL to every individual Work which constitutes the Book with a notice that the Work is an OA (Open Access) publication. As the material has been accessed for free, it is incumbent upon you to provide the source so that others can also access it for free.
\n
\n\n
Every single Work that is used has to be attributed in the way described. If you are unsure about proper attribution, please write to permissions@intechopen.com.
\n\n
2. Rules of attribution for works published by IntechOpen
\n\n
Individual Works originally published in IntechOpen books are licensed under Creative Commons licenses and can be freely used under terms of the respective CC license, if properly attributed. In order to properly attribute the Work you must respect all the conditions outlined below:
\n\n
\n\t
Credit all Authors – since you are reusing contents that someone created and allowed you to use freely, you have to acknowledge authorship;
\n\t
Indicate the type of license under which the Work is available and provide the URL to the license so others can find out the license terms. Preferably keep intact any original Copyright Notice associated with the Chapter (if any). You will be aware that the material can be used for free in consequence of the CC license attribution, so you must acknowledge that fact. It is not sufficient that the material is Creative Commons, because that says nothing about how the material can actually be used. There are different CC licenses and you have to identify the specific license that is being used;
\n\t
Provide the URL where the Work is hosted, preferably providing the original title of the Work, as well as the original title of the Book with a notification that the Work is an OA (Open Access) publication. As the material has been accessed for free, it is incumbent upon you to provide the source so that others can also access it for free;
\n\t
Provide information about the first publisher – please note the fact that the material was originally published by IntechOpen as an OA (Open Access) Work must be acknowledged.
\n
\n\n
Every single Work that is used has to be attributed in the way as described. If you are unsure about proper attribution, please contact Us at permissions@intechopen.com.
\n\n
In the event that you use more than one of IntechOpen's Works published in one or more books (but not a significant part of the book that is under separate Copyright), each of these have to be properly attributed in the way described.
\n\n
IntechOpen does not have any claims on newly created copyrighted Works, but the Works originally published by IntechOpen must be properly attributed.
\n\n
All these rules apply to BOTH online and offline use.
\n\n
Parts of the Rules of Attribution are based on Work Attributing Creative Commons Materials published by the Australian Research Council Centre of Excellence for Creative Industries and Innovation, in partnership with Creative Commons Australia, which can be found at creativecommons.org.au licensed under Creative Commons Attribution 2.5 Australia license, and Best practices for attribution published by Creative Commons, which can be found at wiki.creativecommons.org under the Creative Commons Attribution 4.0 license.
\n\n
All the above rules are subject to change, IntechOpen reserves the right to take appropriate action if any of the conditions outlined above are not met.
\n\n
Policy last updated: 2016-06-09
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