More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\n
Our breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n
“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\n
Additionally, each book published by IntechOpen contains original content and research findings.
\\n\\n
We are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\n
Simba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\n
IntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\n
Since the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\n
Our breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n
“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\n
Additionally, each book published by IntechOpen contains original content and research findings.
\n\n
We are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n
\n\n
\n'}],latestNews:[{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"},{slug:"intechopen-s-chapter-awarded-the-guenther-von-pannewitz-preis-2020-20200715",title:"IntechOpen's Chapter Awarded the Günther-von-Pannewitz-Preis 2020"},{slug:"suf-and-intechopen-announce-collaboration-20200331",title:"SUF and IntechOpen Announce Collaboration"}]},book:{item:{type:"book",id:"3857",leadTitle:null,fullTitle:"Glucose Homeostasis",title:"Glucose Homeostasis",subtitle:null,reviewType:"peer-reviewed",abstract:"Most tissues and organs, such as the brain, need glucose constantly, as an important source of energy. The low blood concentrations of glucose (hypoglycemia) can cause seizures, loss of consciousness, and death. On the other hand, long lasting elevation of blood glucose concentrations (hyperglycemia) can result in blindness, renal failure, cardiac and peripheral vascular disease, and neuropathy. Therefore, blood glucose concentrations need to be maintained within narrow limits. The process of maintaining blood glucose at a steady-state level is called glucose homeostasis. This is accomplished by the finely hormone regulation of peripheral glucose uptake (glucose utilization), hepatic glucose production and glucose uptake during carbohydrates ingestion.",isbn:null,printIsbn:"978-953-51-1618-9",pdfIsbn:"978-953-51-7212-3",doi:"10.5772/57190",price:119,priceEur:129,priceUsd:155,slug:"glucose-homeostasis",numberOfPages:176,isOpenForSubmission:!1,isInWos:1,hash:"7d6d19b59871b430fbcfc4bd297e242d",bookSignature:"Leszek Szablewski",publishedDate:"June 18th 2014",coverURL:"https://cdn.intechopen.com/books/images_new/3857.jpg",numberOfDownloads:11257,numberOfWosCitations:30,numberOfCrossrefCitations:13,numberOfDimensionsCitations:37,hasAltmetrics:0,numberOfTotalCitations:80,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"July 31st 2013",dateEndSecondStepPublish:"September 23rd 2013",dateEndThirdStepPublish:"December 18th 2013",dateEndFourthStepPublish:"February 23rd 2014",dateEndFifthStepPublish:"June 11th 2014",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,editors:[{id:"49739",title:"Dr.",name:"Leszek",middleName:null,surname:"Szablewski",slug:"leszek-szablewski",fullName:"Leszek Szablewski",profilePictureURL:"https://mts.intechopen.com/storage/users/49739/images/system/49739.jpg",biography:"Leszek Szablewski is a professor of medical sciences. He received his M.S. in the Faculty of Biology from the University of Warsaw and his PhD degree from the Institute of Experimental Biology Polish Academy of Sciences. He habilitated in the Medical University of Warsaw, and he obtained his degree of Professor from the President of Poland. Professor Szablewski is the Head of Chair and Department of General Biology and Parasitology, Medical University of Warsaw. Professor Szablewski has published over 80 peer-reviewed papers in journals such as Journal of Alzheimer’s Disease, Biochim. Biophys. Acta Reviews of Cancer, Biol. Chem., J. Biomed. Sci., and Diabetes/Metabol. Res. Rev, Endocrine. He is the author of two books and four book chapters. He has edited four books, written 15 scripts for students, is the ad hoc reviewer of over 30 peer-reviewed journals, and editorial member of peer-reviewed journals. Prof. Szablewski’s research focuses on cell physiology, genetics, and pathophysiology. He works on the damage caused by lack of glucose homeostasis and changes in the expression and/or function of glucose transporters due to various diseases. He has given lectures, seminars, and exercises for students at the Medical University.",institutionString:"Medical University of Warsaw",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"5",totalChapterViews:"0",totalEditedBooks:"4",institution:{name:"Medical University of Warsaw",institutionURL:null,country:{name:"Poland"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1013",title:"Pediatric Endocrinology",slug:"pediatric-endocrinology"}],chapters:[{id:"46785",title:"Mammalian Sugar Transporters",doi:"10.5772/58325",slug:"mammalian-sugar-transporters",totalDownloads:2356,totalCrossrefCites:5,totalDimensionsCites:15,signatures:"Robert Augustin and Eric Mayoux",downloadPdfUrl:"/chapter/pdf-download/46785",previewPdfUrl:"/chapter/pdf-preview/46785",authors:[{id:"170051",title:"Dr.",name:"Robert",surname:"Augustin",slug:"robert-augustin",fullName:"Robert Augustin"}],corrections:null},{id:"46624",title:"Structural and Functional Evolution of Glucose Transporter 4 (GLUT4): A Look at GLUT4 in Fish",doi:"10.5772/58094",slug:"structural-and-functional-evolution-of-glucose-transporter-4-glut4-a-look-at-glut4-in-fish",totalDownloads:1824,totalCrossrefCites:4,totalDimensionsCites:12,signatures:"Rubén Marín-Juez, Encarnación Capilla, Francisco Carvalho-Simoes,\nMarta Camps and Josep V. Planas",downloadPdfUrl:"/chapter/pdf-download/46624",previewPdfUrl:"/chapter/pdf-preview/46624",authors:[{id:"170055",title:"Dr.",name:"Ruben",surname:"Marin-Juez",slug:"ruben-marin-juez",fullName:"Ruben Marin-Juez"},{id:"170056",title:"Dr.",name:"Francisco",surname:"Carvalho-Simoes",slug:"francisco-carvalho-simoes",fullName:"Francisco Carvalho-Simoes"},{id:"170057",title:"Dr.",name:"Encarnación",surname:"Capilla",slug:"encarnacion-capilla",fullName:"Encarnación Capilla"},{id:"170058",title:"Dr.",name:"Marta",surname:"Camps",slug:"marta-camps",fullName:"Marta Camps"},{id:"170059",title:"Dr.",name:"Josep",surname:"Planas",slug:"josep-planas",fullName:"Josep Planas"}],corrections:null},{id:"46465",title:"The Effects of Energy Intake, Insulin Therapy and Physical Activity on Glucose Homeostasis in Children and Adolescents with Type 1 Diabetes Mellitus",doi:"10.5772/57590",slug:"the-effects-of-energy-intake-insulin-therapy-and-physical-activity-on-glucose-homeostasis-in-childre",totalDownloads:1372,totalCrossrefCites:0,totalDimensionsCites:0,signatures:"Aleksandra Żebrowska, Marcin Sikora, Przemysława Jarosz-Chobot,\nBarbara Głuchowska and Michał Plewa",downloadPdfUrl:"/chapter/pdf-download/46465",previewPdfUrl:"/chapter/pdf-preview/46465",authors:[{id:"170053",title:"Dr.",name:"Aleksandra",surname:"Zebrowska",slug:"aleksandra-zebrowska",fullName:"Aleksandra Zebrowska"}],corrections:null},{id:"46454",title:"Role of Magnesium in the Regulation of Hepatic Glucose Homeostasis",doi:"10.5772/57564",slug:"role-of-magnesium-in-the-regulation-of-hepatic-glucose-homeostasis",totalDownloads:1665,totalCrossrefCites:1,totalDimensionsCites:3,signatures:"Chesinta Voma and Andrea M.P. Romani",downloadPdfUrl:"/chapter/pdf-download/46454",previewPdfUrl:"/chapter/pdf-preview/46454",authors:[{id:"100220",title:"Dr.",name:"Andrea",surname:"Romani",slug:"andrea-romani",fullName:"Andrea Romani"},{id:"170054",title:"Dr.",name:"Chesinta",surname:"Voma",slug:"chesinta-voma",fullName:"Chesinta Voma"}],corrections:null},{id:"46632",title:"Glycemia and Memory",doi:"10.5772/58241",slug:"glycemia-and-memory",totalDownloads:1171,totalCrossrefCites:2,totalDimensionsCites:4,signatures:"M.O. Welcome and V.A. Pereverzev",downloadPdfUrl:"/chapter/pdf-download/46632",previewPdfUrl:"/chapter/pdf-preview/46632",authors:[{id:"145006",title:"Dr.",name:"Menizibeya",surname:"Welcome O.",slug:"menizibeya-welcome-o.",fullName:"Menizibeya Welcome O."}],corrections:null},{id:"46440",title:"Adipokines Involved in Macrophage Recruitment",doi:"10.5772/57558",slug:"adipokines-involved-in-macrophage-recruitment",totalDownloads:1563,totalCrossrefCites:1,totalDimensionsCites:2,signatures:"Dayea Kim, Jong Hyuk Yoon, Jaeyoon Kim and Sung Ho Ryu",downloadPdfUrl:"/chapter/pdf-download/46440",previewPdfUrl:"/chapter/pdf-preview/46440",authors:[{id:"170060",title:"Ms.",name:"Dayea",surname:"Kim",slug:"dayea-kim",fullName:"Dayea Kim"},{id:"170061",title:"Dr.",name:"Jong",surname:"Hyuk Yoon",slug:"jong-hyuk-yoon",fullName:"Jong Hyuk Yoon"},{id:"170062",title:"Dr.",name:"Jaeyoon",surname:"Kim",slug:"jaeyoon-kim",fullName:"Jaeyoon Kim"},{id:"170063",title:"Dr.",name:"Sung Ho",surname:"Ryu",slug:"sung-ho-ryu",fullName:"Sung Ho Ryu"}],corrections:null},{id:"46451",title:"Thyrotropin-Releasing Hormone (TRH) a Small Molecule in Pancreas Promotes Insulin Producing Cell Proliferation",doi:"10.5772/57550",slug:"thyrotropin-releasing-hormone-trh-a-small-molecule-in-pancreas-promotes-insulin-producing-cell-proli",totalDownloads:1306,totalCrossrefCites:0,totalDimensionsCites:1,signatures:"John Z.Q . Luo, Souriya Vang, Zhao Ting, Ivor Jackson and LuGuang\nLuo",downloadPdfUrl:"/chapter/pdf-download/46451",previewPdfUrl:"/chapter/pdf-preview/46451",authors:[{id:"170069",title:"Dr.",name:"Lu Guang",surname:"Luo",slug:"lu-guang-luo",fullName:"Lu Guang Luo"},{id:"170070",title:"Dr.",name:"John YZ",surname:"Luo",slug:"john-yz-luo",fullName:"John YZ Luo"},{id:"170582",title:"BSc.",name:"Souriya",surname:"Vang",slug:"souriya-vang",fullName:"Souriya Vang"},{id:"170583",title:"Prof.",name:"Ivor",surname:"Jackson",slug:"ivor-jackson",fullName:"Ivor Jackson"},{id:"170584",title:"Prof.",name:"Ting",surname:"Zhao",slug:"ting-zhao",fullName:"Ting Zhao"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},relatedBooks:[{type:"book",id:"6581",title:"Adipose Tissue",subtitle:null,isOpenForSubmission:!1,hash:"85899eab2d8b01653e1297b168c470d7",slug:"adipose-tissue",bookSignature:"Leszek Szablewski",coverURL:"https://cdn.intechopen.com/books/images_new/6581.jpg",editedByType:"Edited by",editors:[{id:"49739",title:"Dr.",name:"Leszek",surname:"Szablewski",slug:"leszek-szablewski",fullName:"Leszek Szablewski"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7061",title:"Blood Glucose Levels",subtitle:null,isOpenForSubmission:!1,hash:"71d38173067c610b03c51dec97dd031d",slug:"blood-glucose-levels",bookSignature:"Leszek Szablewski",coverURL:"https://cdn.intechopen.com/books/images_new/7061.jpg",editedByType:"Edited by",editors:[{id:"49739",title:"Dr.",name:"Leszek",surname:"Szablewski",slug:"leszek-szablewski",fullName:"Leszek Szablewski"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8797",title:"Adipose Tissue",subtitle:"An Update",isOpenForSubmission:!1,hash:"34880b7b450ef96fa5063c867c028b02",slug:"adipose-tissue-an-update",bookSignature:"Leszek Szablewski",coverURL:"https://cdn.intechopen.com/books/images_new/8797.jpg",editedByType:"Edited by",editors:[{id:"49739",title:"Dr.",name:"Leszek",surname:"Szablewski",slug:"leszek-szablewski",fullName:"Leszek Szablewski"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2666",title:"Diabetes Mellitus",subtitle:"Insights and Perspectives",isOpenForSubmission:!1,hash:"49a714ae0be8a338523befe4ffc9352f",slug:"diabetes-mellitus-insights-and-perspectives",bookSignature:"Oluwafemi O. Oguntibeju",coverURL:"https://cdn.intechopen.com/books/images_new/2666.jpg",editedByType:"Edited by",editors:[{id:"32112",title:"Prof.",name:"Oluwafemi",surname:"Oguntibeju",slug:"oluwafemi-oguntibeju",fullName:"Oluwafemi Oguntibeju"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3829",title:"Antioxidant-Antidiabetic Agents and Human Health",subtitle:null,isOpenForSubmission:!1,hash:"148f7976e4249aa1f0180cca370e36ce",slug:"antioxidant-antidiabetic-agents-and-human-health",bookSignature:"Oluwafemi Oguntibeju",coverURL:"https://cdn.intechopen.com/books/images_new/3829.jpg",editedByType:"Edited by",editors:[{id:"32112",title:"Prof.",name:"Oluwafemi",surname:"Oguntibeju",slug:"oluwafemi-oguntibeju",fullName:"Oluwafemi Oguntibeju"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1035",title:"Type 1 Diabetes",subtitle:"Complications",isOpenForSubmission:!1,hash:"b7ba654e889d323762cc9fb4a014cdbf",slug:"type-1-diabetes-complications",bookSignature:"David Wagner",coverURL:"https://cdn.intechopen.com/books/images_new/1035.jpg",editedByType:"Edited by",editors:[{id:"45994",title:"Dr.",name:"David",surname:"Wagner",slug:"david-wagner",fullName:"David Wagner"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3266",title:"Type 1 Diabetes",subtitle:null,isOpenForSubmission:!1,hash:"21684525ccb8c6acd89bc43ce177f90b",slug:"type-1-diabetes",bookSignature:"Alan P. Escher and Alice Li",coverURL:"https://cdn.intechopen.com/books/images_new/3266.jpg",editedByType:"Edited by",editors:[{id:"46023",title:"Dr.",name:"Alan",surname:"Escher",slug:"alan-escher",fullName:"Alan Escher"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"665",title:"Global Perspective on Diabetic Foot Ulcerations",subtitle:null,isOpenForSubmission:!1,hash:"b702efe619adff42227dadb5b4bda12b",slug:"global-perspective-on-diabetic-foot-ulcerations",bookSignature:"Thanh Dinh",coverURL:"https://cdn.intechopen.com/books/images_new/665.jpg",editedByType:"Edited by",editors:[{id:"69737",title:"Dr.",name:"Thanh",surname:"Dinh",slug:"thanh-dinh",fullName:"Thanh Dinh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1036",title:"Type 1 Diabetes",subtitle:"Complications, Pathogenesis, and Alternative Treatments",isOpenForSubmission:!1,hash:"ccb81d334cd838c9e80f3ebafb63eec0",slug:"type-1-diabetes-complications-pathogenesis-and-alternative-treatments",bookSignature:"Chih-Pin Liu",coverURL:"https://cdn.intechopen.com/books/images_new/1036.jpg",editedByType:"Edited by",editors:[{id:"47141",title:"Prof.",name:"Chih-Pin",surname:"Liu",slug:"chih-pin-liu",fullName:"Chih-Pin Liu"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1038",title:"Topics in the Prevention, Treatment and Complications of Type 2 Diabetes",subtitle:null,isOpenForSubmission:!1,hash:"fedb4b227715729de998791e200ef56f",slug:"topics-in-the-prevention-treatment-and-complications-of-type-2-diabetes",bookSignature:"Mark B. Zimering",coverURL:"https://cdn.intechopen.com/books/images_new/1038.jpg",editedByType:"Edited by",editors:[{id:"39545",title:"Prof.",name:"Mark",surname:"Zimering",slug:"mark-zimering",fullName:"Mark Zimering"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],ofsBooks:[]},correction:{item:{id:"69565",slug:"erratum-laser-based-additive-manufacturing-technology-for-fabrication-of-titanium-aluminide-based-co",title:"Erratum - Laser Based Additive Manufacturing Technology for Fabrication of Titanium Aluminide-Based Composites in Aerospace Component Applications",doi:null,correctionPDFUrl:"https://cdn.intechopen.com/pdfs/69565.pdf",downloadPdfUrl:"/chapter/pdf-download/69565",previewPdfUrl:"/chapter/pdf-preview/69565",totalDownloads:null,totalCrossrefCites:null,bibtexUrl:"/chapter/bibtex/69565",risUrl:"/chapter/ris/69565",chapter:{id:"66879",slug:"laser-based-additive-manufacturing-technology-for-fabrication-of-titanium-aluminide-based-composites",signatures:"Sadiq Abiola Raji, Abimbola Patricia Idowu Popoola, Sisa Leslie Pityana, Olawale Muhmmed Popoola, Fatai Olufemi Aramide, Monnamme Tlotleng and Nana Kwamina Kum Arthur",dateSubmitted:"November 7th 2018",dateReviewed:"February 28th 2019",datePrePublished:"September 27th 2019",datePublished:null,book:{id:"8558",title:"Aerodynamics",subtitle:null,fullTitle:"Aerodynamics",slug:null,publishedDate:null,bookSignature:"Prof. Mofid Gorji-Bandpy and Prof. Aly-Mousaad Aly",coverURL:"https://cdn.intechopen.com/books/images_new/8558.jpg",licenceType:"CC BY 3.0",editedByType:null,editors:[{id:"35542",title:"Prof.",name:"Mofid",middleName:null,surname:"Gorji-Bandpy",slug:"mofid-gorji-bandpy",fullName:"Mofid Gorji-Bandpy"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null}},chapter:{id:"66879",slug:"laser-based-additive-manufacturing-technology-for-fabrication-of-titanium-aluminide-based-composites",signatures:"Sadiq Abiola Raji, Abimbola Patricia Idowu Popoola, Sisa Leslie Pityana, Olawale Muhmmed Popoola, Fatai Olufemi Aramide, Monnamme Tlotleng and Nana Kwamina Kum Arthur",dateSubmitted:"November 7th 2018",dateReviewed:"February 28th 2019",datePrePublished:"September 27th 2019",datePublished:null,book:{id:"8558",title:"Aerodynamics",subtitle:null,fullTitle:"Aerodynamics",slug:null,publishedDate:null,bookSignature:"Prof. Mofid Gorji-Bandpy and Prof. Aly-Mousaad Aly",coverURL:"https://cdn.intechopen.com/books/images_new/8558.jpg",licenceType:"CC BY 3.0",editedByType:null,editors:[{id:"35542",title:"Prof.",name:"Mofid",middleName:null,surname:"Gorji-Bandpy",slug:"mofid-gorji-bandpy",fullName:"Mofid Gorji-Bandpy"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null},book:{id:"8558",title:"Aerodynamics",subtitle:null,fullTitle:"Aerodynamics",slug:null,publishedDate:null,bookSignature:"Prof. Mofid Gorji-Bandpy and Prof. Aly-Mousaad Aly",coverURL:"https://cdn.intechopen.com/books/images_new/8558.jpg",licenceType:"CC BY 3.0",editedByType:null,editors:[{id:"35542",title:"Prof.",name:"Mofid",middleName:null,surname:"Gorji-Bandpy",slug:"mofid-gorji-bandpy",fullName:"Mofid Gorji-Bandpy"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},ofsBook:{item:{type:"book",id:"10633",leadTitle:null,title:"Biotechnology to Combat COVID-19",subtitle:null,reviewType:"peer-reviewed",abstract:"
\r\n\tThe recent emergence of a novel, pathogenic coronavirus known as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2, officially COVID-19) and its subsequent rapid spread across the world has put the global health at risk. The ongoing efforts are focused on gaining insights into the epidemiology along with the discovered genome structure and important viral factors of SARS-CoV-2. Biotechnology-based innovative solutions are being sought to develop new rapid methods including point-of-care diagnostics and surveillance technologies to detect SARS-CoV-2 early in order to control the disease and mitigate it in a timely fashion. These efforts have also focused on investigating therapeutics including significant breakthroughs in clinical trials on antiviral drugs and vaccines to alleviate the challenges of COVID-19.
\r\n
\r\n\tThis book intends to provide a comprehensive overview of the current state-of-the-art in epidemiology, transmission and genome structure along with the latest breakthroughs in diagnostics, therapeutics and vaccines to combat COVID-19.
",isbn:"978-1-83968-627-6",printIsbn:"978-1-83968-626-9",pdfIsbn:"978-1-83968-628-3",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"d834c746c5b159a201a9cdadfc473486",bookSignature:"Dr. Megha Agrawal and Dr. Shyamasri Biswas",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10633.jpg",keywords:"Biological Transmission, Infectious Agent, Viral Protein, Crystal Structure, Sequencing, PCR, Microfluidics, Therapeutics, Anti-viral Drugs, Therapeutic Targets, Vaccines, Protein Engineering",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 14th 2020",dateEndSecondStepPublish:"December 28th 2020",dateEndThirdStepPublish:"February 23rd 2021",dateEndFourthStepPublish:"May 14th 2021",dateEndFifthStepPublish:"July 13th 2021",remainingDaysToSecondStep:"20 days",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Co-founder and executive publisher of Biotechnology Kiosk, an international scientific magazine in the USA. She held senior academic positions at top-tier US institutions including the University of Florida at Gainesville, Children’s National Medical Center in Washington, and the University of Illinois.",coeditorOneBiosketch:"Co-founder and executive publisher of Biotechnology Kiosk and Chairman of USA PRIME BIOTECH. LLC. who worked as a scientist in several labs which include the University of Massachusetts, North Carolina State University and the University of Florida at Gainesville.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"193723",title:"Dr.",name:"Megha",middleName:null,surname:"Agrawal",slug:"megha-agrawal",fullName:"Megha Agrawal",profilePictureURL:"https://mts.intechopen.com/storage/users/193723/images/system/193723.jpg",biography:"Dr. Megha Agrawal is co-founder and executive publisher of Biotechnology Kiosk, an international scientific magazine in the USA. She has held senior academic positions at top-tier US institutions including University of Florida at Gainesville, Children’s National Medical Center in Washington DC and the University of Illinois at Chicago, where she was a research faculty and principal investigator. She received her Ph.D. in Biotechnology from the Indian Institute of Technology at Roorkee, which is one of the premier institutions in India with an outstanding reputation across the globe. Dr. Agrawal’s research has impacted significantly to initiate new areas in neurodegeneration, neuroprotection and novel approaches to treat cerebral stroke related injuries and prevention. She has published in internationally prestigious scientific journals in the field of biotechnology, neuroscience, stroke and molecular biology. Dr. Agrawal also serves as an Associate Editor for the international journal ‘Frontiers in Molecular Bioscience (Molecular Diagnostics and Therapeutics)’, a Nature-Frontier publication. In addition, she is on the editorial board of Drug and Metabolism Reviews and a contributing editor in Vacuum Advances in Biotechnology for Vacuum Technology and Coating Magazine and writes a monthly column in biotechnology.",institutionString:"Biotechnology Kiosk, formerly University of Illinois at Chicago",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Illinois at Chicago",institutionURL:null,country:{name:"United States of America"}}}],coeditorOne:{id:"329553",title:"Dr.",name:"Shyamasri",middleName:null,surname:"Biswas",slug:"shyamasri-biswas",fullName:"Shyamasri Biswas",profilePictureURL:"https://mts.intechopen.com/storage/users/329553/images/system/329553.jpg",biography:"Dr Shyamasri Biswas is co-founder and executive publisher of Biotechnology Kiosk. She received her PhD in biotechnology jointly from Banaras Hindu University, Varanasi, India and University of Potsdam, Germany. During her PhD, she received the prestigious DAAD sandwich research fellowship to carry out her PhD work on a collaborative research project in Germany. After her PhD, she was a scientist in several labs in the United States that include University of Massachusetts, Worcester MA, North Carolina State University and the University of Florida at Gainesville. She has published her research works in numerous prestigious international journals including Nature Structural and Molecular Biology, Biochemistry and Journal of Biological Chemistry to name a few. Dr. Biswas is a contributing editor in Vacuum Advances in Biotechnology for Vacuum Technology & Coating Magazine and writes a monthly column in biotechnology. In addition, she is a reviewer for many biochemistry and biotechnology journals. She gave several invited talks at national and international meetings in Biotechnology. Presently, Dr Biswas is the Chairman of a startup company (USA PRIME BIOTECH. LLC), registered in the state of Florida",institutionString:"Biotechnology Kiosk, formerly University of Florida",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Florida",institutionURL:null,country:{name:"United States of America"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"297737",firstName:"Mateo",lastName:"Pulko",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/297737/images/8492_n.png",email:"mateo.p@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"6550",title:"Cohort Studies in Health Sciences",subtitle:null,isOpenForSubmission:!1,hash:"01df5aba4fff1a84b37a2fdafa809660",slug:"cohort-studies-in-health-sciences",bookSignature:"R. Mauricio Barría",coverURL:"https://cdn.intechopen.com/books/images_new/6550.jpg",editedByType:"Edited by",editors:[{id:"88861",title:"Dr.",name:"René Mauricio",surname:"Barría",slug:"rene-mauricio-barria",fullName:"René Mauricio Barría"}],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:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],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:"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:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],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. Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"18292",title:"Utilization of Functional Tests Prior to and Adherence to Guidelines on Coronary Angiography",doi:"10.5772/19365",slug:"utilization-of-functional-tests-prior-to-and-adherence-to-guidelines-on-coronary-angiography",body:'\n\t\t
\n\t\t\t
1. Introduction
\n\t\t\t
Coronary angiography is one of the most commonly performed investigations in clinical cardiology and remains the “gold standard” in the anatomical diagnosis of coronary artery disease. It is often required to establish the diagnosis of coronary disease and to provide a map of a patient’s coronary artery anatomy prior to percutaneous coronary intervention or coronary artery bypass surgery.
\n\t\t\t
Despite its importance, invasive coronary angiography should not be performed in all patients suspected to have coronary artery disease. Functional tests, such as stress ECG, echo or nuclear perfusion imaging, are often recommended as initial tests for many of these patients. These functional tests are widely available and practised. In addition to their diagnostic value, functional tests provide independent and additional prognostic information (Marwick et al., 1997). Furthermore, functional tests are often required to guide management of patients with intermediate lesions on invasive coronary angiography. According to the Bayesian theorem, the impact of a screening test is most significant in patients with intermediate pre-test probability of disease. Furthermore, cost-effectiveness analyses often reveal that the use of screening tests in these patients is the most favourable approach. Despite the established roles of functional tests and their extensive incorporation in best practice guidelines, there is little data on the extent of their use and on how the results of such tests are utilised prior to referral to coronary angiography in patients with low to intermediate pre-test probabilities of coronary disease.
\n\t\t\t
Guidelines have proliferated in cardiology in recent years. Major professional bodies like the American College of Cardiology, American Heart Association and the European Society of Cardiology have published guidelines on a wide range of cardiovascular disorders and cardiovascular investigations. These guidelines incorporate the latest evidence base and provide recommendations, which are intended to improve the quality of patient care and clinical outcomes whilst minimising costs. These recommendations are based on the most effective and evidence-based strategies. The American College of Cardiology and American Heart Association have published comprehensive guidelines on the use of coronary angiography (Scanlon et al., 1999). The guidelines were initially published in 1987 and were revised in May of 1999. These guidelines provide recommendations for coronary angiography in clinical scenarios such as patients with known or suspected coronary artery disease, stable or unstable angina pectoris, acute coronary syndromes, recurrence of symptoms after revascularization, congestive heart failure or other conditions.
\n\t\t\t
There has been considerable interest in evaluating compliance with guidelines in clinical practice. This is particularly pertinent as improved compliance with treatment guidelines is associated with better clinical outcomes in patients with acute coronary syndromes (Schiele et al., 2005). Despite the widespread dissemination of the guidelines on coronary angiography, the compliance rate with these guidelines in clinical practice and the relationship between compliance and results of angiography has not been prospectively evaluated.
\n\t\t\t
As discussed in other chapters, computed tomography (CT) coronary angiography is now increasingly being used to evaluate patients with suspected coronary artery disease. The American College of Cardiology, together with other professional bodies, has published criteria for the appropriate use of CT coronary angiography (Hendel et al., 2006). CT coronary angiography will increasingly be incorporated into clinical practice as an important imaging modality for the evaluation of patients suspected to be suffering from coronary artery disease. An important consideration for clinicians and administrators will be the diagnostic value of imaging tests and their cost effectiveness in these patients. More data has recently become available regarding the incremental value of functional testing and other imaging modalities like CT coronary angiography in patients with suspected coronary artery disease. In particular, the incremental value of non-invasive testing in risk stratification and the prediction of adverse events in these patients will be of interest in guiding practice and, more importantly, health care policy.
\n\t\t
\n\t\t
\n\t\t\t
2. Utilisation of functional tests prior to coronary angiography
\n\t\t\t
As discussed earlier, despite their well-documented clinical usefulness, there is little information on the pattern of use of functional tests in patients prior to undergoing invasive coronary angiography. In particular, for patients who are subsequently found to have no significant coronary artery disease on coronary angiography, it will be interesting to examine how and why they ended up having invasive coronary angiography. It may be argued that, for these patients, a “failure” of the investigative algorithms led them to undergo an invasive test, which may not have been indicated and should not have been performed. These tests should have been avoided as they exposed the patient to needless risks and might have been unnecessary monetary, resource and manpower wastes. By examining where the process has “failed”, one will hopefully be able to learn how to minimise future such “failures”. The purpose of our study was to analyse the patterns of use and the results of functional tests in patients found to have normal coronary arteries on invasive coronary angiography.
\n\t\t\t
\n\t\t\t\t
2.1. The study - methods
\n\t\t\t\t
Over a 7 and a half-year period, a total of 6,409 patients underwent 8,069 coronary procedures at our hospital. Our hospital is the only tertiary referral centre serving a population of about 800,000 people. Only patients referred for coronary angiography for evaluation of coronary artery disease were included in the analysis. Angiographic studies on patients referred for valvular or haemodynamic indications were excluded from the analysis. Patients with documented coronary artery disease referred for coronary angioplasty or other percutaneous intervention were also excluded. Therefore, the study included 6,053 patients who underwent a total of 6,830 coronary angiographic procedures.
\n\t\t\t\t
Of the 6,830 procedures, 4,610 were for male patients and 2,220 were for female patients. The mean age of the patients was 60.9 ± 11 years. Clinical information, including age and gender, referrer details, indications for angiography, type of the study and subsequent results, was prospectively collected and entered into a computerised database.
\n\t\t\t\t
Coronary angiography was performed according to standard techniques via either the femoral, brachial or radial approaches. Patients with no angiographically detectable disease or irregularities in any of the epicardial coronary arteries were considered to have normal coronary arteries on angiography. Patients who had previously undergone coronary artery bypass surgery and who were found to have patent bypass grafts on angiography were not considered to have normal coronary arteries.
\n\t\t\t\t
Patients who were subsequently found to have normal coronary arteries on angiography were identified. The clinical records of these patients were then reviewed. Their clinical characteristics and presenting symptoms, including risk factors for coronary artery disease, were analysed. Chest pain as the main presenting symptom was characterized on retrospective chart review as typical, atypical or non-anginal/non-specific pain. Five risk factors were considered: diabetes mellitus, cigarette smoking, hypertension, hypercholesterolemia and family history of coronary artery disease. Patients’ pre-test probabilities of coronary artery disease were estimated from age, gender and presenting symptoms (Diamond & Forrester, 1979).
\n\t\t\t\t
The types and results of functional tests, if performed for these patients, were recorded and analysed. Results of functional tests including exercise ECG, exercise or pharmacologic stress echocardiogram or nuclear myocardial perfusion studies were sought. None of the patients had CT coronary angiography as it was not available at the time of the study. Functional tests were considered negative if no evidence of inducible ischaemia was detected on testing and if the level of the stress was considered adequate. Functional tests were considered inconclusive if there was equivocal evidence of inducible ischaemia or if there was no inducible ischaemia at inadequate levels of stress.
\n\t\t\t\t
Information on the physicians who referred these patients (referrers) for coronary angiography was also recorded. Referrers were classified into cardiologists or other physicians according to the field of specialisation. In particular, for cardiologist referrers, those who performed coronary angiography were considered proceduralists whilst cardiologists who do not perform angiography were considered non-proceduralists.
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
2.2. Results
\n\t\t\t\t
\n\t\t\t\t\t
2.2.1. Patients
\n\t\t\t\t\t
Seven hundred and fifty six patients undergoing 762 procedures were found to have normal epicardial coronary arteries on angiography. This means that 11.2% of the coronary angiograms performed were for patients with normal coronary arteries. The mean age of these patients was 54.9 ± 11.5 years with female patients comprising 54.9%. Clinical information was obtainable in all but 4 patients (99.5%). The mean number of coronary risk factors was 1.5 ± 1. The mean pre-test probability of coronary artery disease was 41.7 ± 30% (median 46.1%, inter-quartile range 14.1 - 58.9%). Three hundred and thirteen patients underwent coronary angiography as hospital inpatients while 445 patients underwent coronary angiography as a day-only procedure on an outpatient basis. There were no significant differences in gender distribution, number of coronary risk factors and pre-test probability of coronary artery disease between patients who underwent coronary angiography as inpatients and those who underwent the procedure as day-only patients. However, patients who underwent coronary angiography as inpatients were significantly younger and more likely to have presented with non-anginal chest pain (Table 1).
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Parameters
\n\t\t\t\t\t\t\t\t
Inpatient procedure (n=313)
\n\t\t\t\t\t\t\t\t
Day-only procedure (n=445)
\n\t\t\t\t\t\t\t\t
p
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Men/Women
\n\t\t\t\t\t\t\t\t
149/164
\n\t\t\t\t\t\t\t\t
199/246
\n\t\t\t\t\t\t\t\t
0.43
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Age (years)
\n\t\t\t\t\t\t\t\t
53.6 12.5
\n\t\t\t\t\t\t\t\t
55.8 10.8
\n\t\t\t\t\t\t\t\t
0.01
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Number of risk factors
\n\t\t\t\t\t\t\t\t
1.48 1.1
\n\t\t\t\t\t\t\t\t
1.49 1
\n\t\t\t\t\t\t\t\t
0.73
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Presenting symptom n (%)
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
<0.001
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Typical angina
\n\t\t\t\t\t\t\t\t
62 (19.8%)
\n\t\t\t\t\t\t\t\t
99 (22.2%)
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Atypical angina
\n\t\t\t\t\t\t\t\t
110 (35.1%)
\n\t\t\t\t\t\t\t\t
172 (38.7%)
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Non anginal chest pain
\n\t\t\t\t\t\t\t\t
85 (27.2%)
\n\t\t\t\t\t\t\t\t
71 (15.9%)
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Dyspnea
\n\t\t\t\t\t\t\t\t
23 (7.3%)
\n\t\t\t\t\t\t\t\t
48 (10.8%)
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Others
\n\t\t\t\t\t\t\t\t
26 (8.3%)
\n\t\t\t\t\t\t\t\t
34 (7.6%)
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Asymptomatic
\n\t\t\t\t\t\t\t\t
2 (0.6%)
\n\t\t\t\t\t\t\t\t
16 (3.6%)
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Pre-test probability ofcoronary disease (%)
\n\t\t\t\t\t\t\t\t
39.6 30
\n\t\t\t\t\t\t\t\t
43.2 29.8
\n\t\t\t\t\t\t\t\t
0.11
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 1.
Clinical characteristics of patients who were subsequently found to have angiographically normal coronary arteries divided according to whether they were hospital inpatients or not at the time of angiography. (Reproduced with permission from: Leung DY, Lo ST, Liew CT, Wong A, Hopkins AP, Juergens CJ. Utilization of functional tests prior to coronary angiography in patients with angiographically normal coronary arteries. International Journal of Cardiology 2005; 104(3):326 – 331. Elsevier Limited)
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
2.2.2. Utilization of functional tests
\n\t\t\t\t\t
Only 483 of the 758 patients (63.7%) had undergone functional tests as part of the diagnostic workup prior to coronary angiography. Two hundred and fifty three patients (33.4%) underwent exercise electrocardiography, 140 underwent stress nuclear perfusion imaging (18.5%), 9 underwent stress echocardiography (1.2%) and 81 underwent more than one functional test (10.7%). There were no significant differences in gender distribution, age, number of coronary risk factors and pre-test probability of coronary disease between patients who had undergone functional tests and those who had not. However, inpatients were significantly less likely to have undergone functional tests prior to angiography compared to day-only patients (Table 2).
\n\t\t\t\t\t
Multiple logistic regression analysis identified inpatient status as the only independent predictor of undergoing functional tests prior to coronary angiography in these patients (OR 5.9, 95% confidence interval 5.0 - 7.0, p <0.001).
\n\t\t\t\t\t
Of the 483 patients who underwent functional tests prior to coronary angiography, inducible ischaemia was detectable in only 241 patients (49.6%). Therefore less than half of the performed tests were positive. Functional tests were reported negative for inducible
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Parameters
\n\t\t\t\t\t\t\t\t
Functional tests (n = 483)
\n\t\t\t\t\t\t\t\t
No functional tests (n=275)
\n\t\t\t\t\t\t\t\t
p
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Men/Women
\n\t\t\t\t\t\t\t\t
218/265
\n\t\t\t\t\t\t\t\t
130/145
\n\t\t\t\t\t\t\t\t
0.57
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Age (years)
\n\t\t\t\t\t\t\t\t
55.3 10.7
\n\t\t\t\t\t\t\t\t
54.2 12.8
\n\t\t\t\t\t\t\t\t
0.2
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Number of coronary risk factors
\n\t\t\t\t\t\t\t\t
1.5 1.1
\n\t\t\t\t\t\t\t\t
1.45 1.1
\n\t\t\t\t\t\t\t\t
0.52
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Pre-test probability of coronary disease (%)
\n\t\t\t\t\t\t\t\t
42.5 29
\n\t\t\t\t\t\t\t\t
40.2 31
\n\t\t\t\t\t\t\t\t
0.32
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Inpatient/day-only patient (n)
\n\t\t\t\t\t\t\t\t
126/357
\n\t\t\t\t\t\t\t\t
187/88
\n\t\t\t\t\t\t\t\t
<0.001
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 2.
Clinical characteristics of the patients when subdivided according to whether they had undergone functional testing prior to coronary angiography. (Reproduced with permission from: Leung DY, Lo ST, Liew CT, Wong A, Hopkins AP, Juergens CJ. Utilization of functional tests prior to coronary angiography in patients with angiographically normal coronary arteries. International Journal of Cardiology 2005; 104(3):326 – 331. Elsevier Limited)
\n\t\t\t\t\t
ischaemia for 245 patients. Of these, 151 patients achieved adequate stress levels whilst in 91 cases the results were inconclusive. Of the 151 patients with negative functional tests, 114 (75.5%) underwent coronary angiography as outpatients and 37 as inpatients. Only 22 patients (14.5%) had history of previous admission to hospital with chest pain prior to angiography.
\n\t\t\t\t\t
Patients were further divided into 3 subgroups according to their pre-test probability of coronary disease: low risk (pre-test probability <20%), intermediate risk (pre-test probability 20% to <80%) and high risk (pre-test probability ≥ 80%). There were no significant differences in the utilisation and the results of functional tests across the clinical risk subgroups for day-only patients (Figure 1, p = 0.2) or for inpatients (Figure 2, p = 0.76). However, a higher proportion of day-only patients underwent functional tests prior to angiography irrespective of pre-test probability of disease compared to inpatients.
\n\t\t\t\t\t
Figure 1.
Use and results of functional tests in patients undergoing coronary angiography as a day-only procedure. (Reproduced with permission from: Leung DY, Lo ST, Liew CT, Wong A, Hopkins AP, Juergens CJ. Utilization of functional tests prior to coronary angiography in patients with angiographically normal coronary arteries. International Journal of Cardiology 2005; 104(3):326 – 331. Elsevier Limited)
\n\t\t\t\t\t
A total of 33 physicians referred these patients to our institution for coronary angiography. Twenty (60.6%) were cardiologists and 13 (39.4%) were other physicians. Patients referred by cardiologists were significantly more likely to have undergone functional tests compared
\n\t\t\t\t\t
Figure 2.
Use and results of functional tests in patients undergoing coronary angiography as inpatients. (Reproduced with permission from: Leung DY, Lo ST, Liew CT, Wong A, Hopkins AP, Juergens CJ. Utilization of functional tests prior to coronary angiography in patients with angiographically normal coronary arteries. International Journal of Cardiology 2005; 104(3):326 – 331. Elsevier Limited)
\n\t\t\t\t\t
with those referred by other physicians (66% vs 50.8%, p = 0.001). Of the cardiologists, 9 were proceduralists and 11 were non-proceduralists. There was no significant difference between procedural cardiologists and non-procedural cardiologists in the use of functional tests in patients prior to coronary angiography (68% vs 64%, p = 0.28).
\n\t\t\t\t
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
2.3. Discussion
\n\t\t\t\t
This study examined the use and results of functional tests in a large consecutive series of patients who were subsequently found to have angiographically normal coronary arteries at our institution over the study period. The overall utilisation of functional tests in our patients was only modest and a significant proportion of patients either had no functional tests done prior to angiography or proceeded directly to coronary angiography despite negative functional tests. Referrer characteristics and patient status, rather than pre-test probability of coronary artery disease, appeared to have a greater impact on the use of functional tests prior to angiography.
\n\t\t\t\t
Functional tests have established and pivotal roles in the investigation and management of patients with suspected or confirmed coronary artery disease. They have a high sensitivity and specificity in the non-invasive diagnosis of coronary artery disease in patients with suggestive symptoms. Information like blood pressure, exercise capacity and heart rate response to exercise are of further prognostic value. The addition of cardiac imaging during functional tests provides incremental prognostic information (Marwick et al., 1999). Therefore, functional tests not only allow diagnosis of coronary artery disease but also allow clinicians to risk-stratify patients. Higher risk patients should be referred onto coronary angiography whilst lower risk patients can safely be managed without expensive and invasive investigations. In the American College of Cardiology/American Heart Association guidelines for coronary angiography, functional tests play a central role (Scanlon et al., 1999).
\n\t\t\t\t
It has been suggested that the diagnostic as well as the follow up costs were lower for those who had undergone functional tests prior to coronary angiography, irrespective of the pre-test probability of coronary disease, without significant differences in the medium term outcome (Shaw et al., 1999a). The cost differences between the two strategies may reflect a decreased need for coronary angiography in patients with normal perfusion scan results (Shaw et al., 1999b). Functional tests, therefore, have the potential to accrue cost savings by acting as a "gate-keeper" for coronary angiography by excluding those with normal results who have no significant coronary disease and excellent short to medium term outcome.
\n\t\t\t\t
According to the Bayesian theorem, the post-test probability of coronary artery disease is dependent on the prevalence of the disease in the population being tested. Impact of screening tests is highest in patients with intermediate pre-test probability. Proceeding to coronary angiography without functional tests may be justifiable in patients with high pre-test probability of coronary artery disease. In patients with multiple coronary risk factors and typical angina, coronary angiography without functional tests may be more appropriate as the results of functional tests are less likely to obviate the need for angiography in these patients. Cost-effectiveness analyses by Patterson et al suggested that proceeding straight to coronary angiography in patients with high pre-test probability of disease (>80%) may be more cost-effective (Patterson et al., 1995). One would expect that the use of functional tests would be higher in patients with low to intermediate pre-test probability of coronary disease. However, the results of the present study showed that this is not the case; the use of functional tests in these patients was low (Figures 1 and 2). The use of functional tests was particularly low for hospital inpatients. Inpatients were less likely to have undergone functional tests prior to angiography compared with day-only patients across all three groups of pre-test probability of coronary disease. For intermediate risk patients, 83.5% of day-only patients compared with only 42.1% of inpatients had undergone functional tests prior to angiography. For low risk patients, 79.7% of day-only patients compared with only 36.3% of inpatients had undergone functional tests. This cannot be explained by any differences in risk factor profiles or pre-test probability of disease.
\n\t\t\t\t
There could be a number of possible explanations for these findings. Hospital inpatients may be more likely to be perceived as unstable, which may have made the treating physicians reluctant to subject them to functional testing. Some of our regional referring hospitals do not have stress testing facilities and direct referral to our institution for coronary angiography might have been an easier solution. The delay in obtaining stress echocardiography or stress perfusion nuclear imaging contrasted with the overriding pressure to discharge patients from hospital may make such functional testing less attractive to treating physicians.
\n\t\t\t\t
Functional tests are neither 100% sensitive nor 100% specific. In our study, a high proportion of patients with negative functional tests with adequate stress still proceeded to angiography. This may have resulted from the suspicion of a false negative functional test, frustration on the part of the physicians about the lack of a definitive diagnosis and the desire to answer the question "once and for all". However, despite the lack of 100% sensitivity, patients with normal stress echocardiograms or stress nuclear perfusion imaging had very low cardiac event rates on follow up, in the range of <0.5%/year (Metz et al., 2007). Functional tests may also be falsely positive. However, patient and test characteristics associated with false positive functional tests are well described. Exercise ECG is well known to be non-specific in young or middle aged women. The basal inferior wall changes on stress echocardiogram and diaphragmatic and breast attenuation artefacts on stress nuclear perfusion imaging are well-described sources of false positive findings. The recent advent of CT coronary angiography may help in ruling out coronary artery disease and its use in equivocal or un-interpretable functional tests is considered appropriate.
\n\t\t\t\t
The increased use of coronary angiography, regardless of whether it is indicated or not, may have more than just an economic impact. In addition to the increased risks of procedural complications, increased diagnostic testing has been shown to result in an increased therapeutic intervention rate downstream (Verrilli Welch, 1996; Wennberg et al., 1996). While the concern of increased downstream therapeutic intervention is minimal in patients with angiographically normal coronary arteries, the risks of procedural complications and the increased overall costs of investigations cannot justify indiscriminate use of angiography in patients with low to intermediate pre-test probability of disease.
\n\t\t\t\t
There are considerable variations in the use of coronary angiography (Pilote et al., 1995), which was closely related to the availability of cardiac catheterization facilities (Every et al., 1993). With the use of angiography closely related to its availability, there have been concerns over the appropriateness of coronary angiography (Bernstein et al., 1999; Chassin et al., 1987b). A significant proportion of coronary angiography was found to be "inappropriate" (Gray et al., 1990), with "inappropriate" use of coronary angiography higher in high-use sites (Chassin et al., 1987a). In the study by Chassin et al (Chassin et al., 1987b), patients without angina or with atypical angina and who had not undergone exercise testing constituted the most common subgroup of inappropriate angiography. In a random audit of 320 patients referred for coronary angiography (Gray et al., 1990), only 53% of the patients had undergone functional tests prior to angiography. In a consecutive series of 3631 patients referred for coronary angiography, 5% were performed for inappropriate indications and another 33% for uncertain indications (Hemingway et al., 2001). Similarly, asymptomatic patients and patients with atypical angina or mild angina who had not undergone exercise testing comprised the majority of the inappropriate and uncertain indications. Furthermore, the appropriateness ratings for angiography predicted both the angiographic findings of coronary disease, subsequent rates of revascularisation and mortality rates after a mean follow-up time of 2.5 years (Hemingway et al., 2001).
\n\t\t\t\t
There has been considerable interest in examining the difference in treatment (Borowsky et al., 1995), procedural use (Nash et al., 1997), and patient outcome between cardiologists and non-cardiologists in patients with coronary artery diseases. It has been reported that cardiologists were more likely than non-cardiologists to recommend "clinically necessary" coronary angiography (Borowsky et al., 1995). Some reports suggested that cardiologists were more likely to prescribe medical therapies of proven efficacy in the care of patients with myocardial infarction (Ayanian et al., 1994), while others suggested that myocardial infarct patients in the care of cardiologists had a lower risk-adjusted mortality rate (Nash et al., 1997). The results of our study suggested that cardiologists were more likely to have referred patients with suspected coronary artery disease for functional tests prior to angiography and procedural cardiologists were as likely as their non-procedural counterparts to utilise functional tests prior to referral for angiography.
\n\t\t\t\t
Our study is only a single centre experience and may not reflect experience of other centres. We selected only patients with angiographically normal coronary arteries as these patients represent a lower clinical risk subgroup where functional tests should have been more widely used and clinically relevant. As a result of the selection, we did not include patients who had undergone functional tests but were not referred for angiography. Furthermore, our aim was to document the use of functional tests and not to judge whether referral of low to intermediate risk patients without functional tests was "appropriate" or not.
\n\t\t\t\t
In conclusion, use of functional tests prior to coronary angiography was only modest and was particularly low for hospital inpatients in our large consecutive series of patients with angiographically normal coronary arteries. A significant proportion of patients proceeded to coronary angiography despite negative functional tests. Referrer characteristics and hospital inpatient status, rather than pre-test probability of coronary artery disease, appeared to have greater impact on utilization of functional tests.
\n\t\t\t
\n\t\t
\n\t\t
\n\t\t\t
3. Adherence to guidelines on coronary angiography
\n\t\t\t
The American College of Cardiology and The American Heart Association initially published their guidelines on the use of invasive coronary angiography in 1987. An update was issued in 1999 (Scanlon et al., 1999). The guidelines examined the indications for coronary angiography in a wide range of commonly encountered clinical situations. These included patients with known or suspected coronary artery disease with minimal or stable symptoms, patients with unstable coronary symptoms, patients after myocardial infarction, patients after revascularisation, patients with heart failure or with haemodynamic instability, patients undergoing non cardiac surgery and patients with valvular or congenital heart disease. These guidelines incorporate the latest available evidence and provide guidance to clinicians to the best evidence based practice. Despite the wide dissemination of these guidelines, there is little information on how they are incorporated into daily clinical practice and how closely they are adhered to. It would be interesting to find out how compliant clinicians are with these guidelines and how compliance is translated into the clinical results. Furthermore, it will be helpful to identify areas where compliance is low so that further efforts may be spent on these problem areas to improve compliance.
\n\t\t\t
\n\t\t\t\t
3.1. The study - methods
\n\t\t\t\t
A total of 802 consecutive patients referred to our cardiac catheterisation laboratory for coronary angiography were prospectively enrolled and evaluated over a 5-month period in 2002. Clinical history including coronary risk factors, presenting symptoms, electrocardiograms and laboratory test results were recorded prospectively. Chest pain as a presenting symptom was assessed and classified as typical angina, atypical angina or non-anginal chest pain. Five coronary risk factors were considered: diabetes mellitus, cigarette smoking, hypertension, hypercholesterolemia and family history of coronary artery disease. Electrocardiographic changes were considered ischaemic if there was horizontal ST segment depression or elevation of ≥ 1 mm or if there was symmetrical T wave inversion of ≥ 3 mm in ≥ 2 contiguous leads.
\n\t\t\t\t
The physicians who referred these patients were classified as cardiologists or general physicians according to their primary field of specialisation. Cardiologists were further sub-classified into non-invasive or invasive cardiologists according to whether they performed coronary angiography. The type and results of functional tests, if performed, were recorded and information on left ventricular function, if available, was also collected. Functional tests were considered positive it there was evidence of inducible ischaemia on testing (ST segment deviation of ≥ 1mm on exercise electrocardiography, inducible new segmental wall dysfunction on stress echocardiography or reversible perfusion defects on nuclear perfusion imaging). They were considered negative if there was no evidence of inducible ischaemia on testing and if the level of the stress was considered adequate for exercise stress (peak heart rate ≥ 85% age predicted maximum). Functional tests were considered inconclusive if there was equivocal evidence of inducible ischaemia or if there was no inducible ischaemia at inadequate levels of stress for exercise stress.
\n\t\t\t\t
Patients with no irregularities detected in any of the epicardial coronary artery on angiography were considered to have normal coronary arteries on angiography. Patients with less than 50% diameter stenosis in any of the epicardial coronary arteries or its major branches were considered to have minor coronary artery disease. Angiograms on patients who had previously undergone coronary artery bypass surgery and were found to have all bypass grafts patent (<50% diameter stenosis) and no ungrafted but stenotic native vessels on angiography were not considered to have significant flow limiting stenosis. Complications of coronary angiography, if any, were also recorded.
\n\t\t\t\t
Compliance with guidelines on coronary angiography was assessed for these 802 patients by 2 independent assessors, blinded to the results of angiography, according to the American College of Cardiology/American Heart Association guidelines on coronary angiography (Scanlon et al., 1999). Referrals were considered compliant with guidelines if they fulfilled either the Class I or Class II indications. Referrals were considered non-compliant (outside guidelines) if they fulfilled Class III indications or none of the Class I or II indications. Disagreements between the 2 assessors were reconciled with arbitration by an independent third assessor. Intra-observer agreement was assessed with the same assessor evaluating compliance on the same 802 patients, 12 months after the initial assessment. Both assessments were done with the assessor blinded to the results of the initial assessment and coronary angiography.
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
3.2. Results
\n\t\t\t\t
\n\t\t\t\t\t
3.2.1. Patients characteristics
\n\t\t\t\t\t
We evaluated a total of 802 patients (Table 3). The indications for coronary angiography were; assessment of chest pain with known or suspected coronary artery disease in 491 patients (61.1%), non ST segment elevation myocardial infarction in 127 patients (15.8%), ST segment elevation myocardial infarction in 72 patients (9%), congestive heart failure or dyspnoea in 70 patients (8.7%), valvular heart disease in 20 patients (2.5%), prior to non cardiac surgery in 11 patients (1.5%), arrhythmias in 5 patients and miscellaneous in 6 patients (0.8%). Two hundred and thirty six patients (29.4%) had had coronary angiography previously.
\n\t\t\t\t\t
One hundred and nineteen patients (14.8%) were referred by general physicians (internists), 341 (42.5%) by non-invasive cardiologists and 342 (42.6%) by invasive cardiologists. Cardiac Troponin T levels were measured in 354 patients and a significantly higher proportion of patients referred by general physicians had raised cardiac Troponin T levels compared to those referred by cardiologists (56 of the 69 patients versus 141 of 285 patients, p<0.001)
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
3.2.2. Investigations prior to angiography
\n\t\t\t\t\t
All patients had 12-lead electrocardiography before coronary angiography as part of the initial diagnostic work-up. Twelve-lead electrocardiography was normal in 261 patients (32.5%), showed non-specific changes in 174 patients (21.7%), was un-interpretable in 30 patients (3.7%) and showed ischemic changes in 337 patients (42%).
\n\t\t\t\t\t
Left ventricular function was assessed as part of the diagnostic work up before coronary angiography with echocardiography in 232 (28.9%) patients and with radionuclide ventriculography in another 123 patients (15.3%). Left ventricular function was assessed in a further 37 patients (3.6%) from previous contrast ventriculography. Left ventricular function was not assessed prior to coronary angiography in 410 patients (51.1%). Inpatients were significantly less likely to have their left ventricular function evaluated prior to coronary angiography compared with day-only patients (36.9% vs 62.9%, p<0.001). Of the 392 patients who had left ventricular function assessment, 149 (38%) had an ejection fraction of < 50% and 243 patients had normal function (ejection fraction 50%).
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Age
\n\t\t\t\t\t\t\t\t
62 ± 11 years
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Male / Female (n)
\n\t\t\t\t\t\t\t\t
522 / 280
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Average number of coronary risk factors
\n\t\t\t\t\t\t\t\t
2.7 ± 1.3
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Medications, n (%)
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Aspirin
\n\t\t\t\t\t\t\t\t
642 (80%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Beta blockers
\n\t\t\t\t\t\t\t\t
542 (67.6%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Calcium antagonists
\n\t\t\t\t\t\t\t\t
177 (22.1%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Nitrates
\n\t\t\t\t\t\t\t\t
289 (36%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Angiotensin converting enzyme inhibitors
\n\t\t\t\t\t\t\t\t
375 (46.8%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Statins
\n\t\t\t\t\t\t\t\t
547 (68.2%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Clopidogrel
\n\t\t\t\t\t\t\t\t
111 (13.8%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Unfractionated heparin or enoxaparin
\n\t\t\t\t\t\t\t\t
220 (27.5%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Angiotension receptor blockers
\n\t\t\t\t\t\t\t\t
103 (12.8%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Inpatient / day only procedure (n)
\n\t\t\t\t\t\t\t\t
433 / 369
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Previous coronary artery bypass surgery, n(%)
\n\t\t\t\t\t\t\t\t
89 (11.1%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Previous percutaneous coronary intervention, n(%)
\n\t\t\t\t\t\t\t\t
88 (11%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
History of myocardial infarction, n(%)
\n\t\t\t\t\t\t\t\t
141 (17.6%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Acute coronary syndrome during index hospital admission (for inpatients), n(%)
\n\t\t\t\t\t\t\t\t
199 (24.8%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Renal impairment, n(%)
\n\t\t\t\t\t\t\t\t
71 (8.9%)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 3.
The baseline clinical characteristics of the 802 patients. (Reproduced with permission from: Leung DY, Hallani H, Lo ST, Hopkins AP, Juergens CP. How compliant are we with guidelines for coronary angiography in clinical practice? Internal Medicine Journal 2007, Oct;37(10):699-704. John Wiley and Sons)
\n\t\t\t\t\t
Serum cardiac Troponin T levels were measured in 347 of the 433 inpatients (80.1%) and were elevated to ≥ 0.03 ng/ml in one or more blood samples in 194 patients (44.8%). Cardiac Troponin T levels were measured in only 7 of the 369 day-only patients and were elevated in 3 patients (0.8%).
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
3.2.3. Functional test results
\n\t\t\t\t\t
Functional tests were performed in 262 of the 369 (71%) day-only patients and in only 75 of the 433 inpatients (17.3%, p<0.001). Even after the 197 patients with raised cardiac Troponin T levels were excluded from analysis, inpatients were still significantly less likely to have had functional tests prior to coronary angiography compared with day-only patients (28.5% vs 71.6%, p<0.001). Patients with history of percutaneous coronary intervention, coronary artery bypass surgery or documented myocardial infarction were significantly less likely to have functional tests prior to coronary angiography (79/224, 35.3%) than patients with no such history (258/578, 44.6%, p=0.016). Only 288 of the 491 patients (58.6%) referred for assessment of chest pain not associated with either non-ST elevation or ST elevation myocardial infarction had functional tests prior to angiography. One hundred and nine patients (13.6%) underwent exercise electrocardiography, 41 patients (5.1%) underwent exercise echocardiography, 57 (7.1%) underwent exercise nuclear perfusion scan and 130 patients (16.2%) underwent vasodilator stress nuclear perfusion scan. Table 4 shows the results of functional tests in these 337 patients.
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t\tPositive functional test (n)\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Negative functional test (n)
\n\t\t\t\t\t\t\t\t
Total (n)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Adequate stress level (For exercise stress, n)*
\n\t\t\t\t\t\t\t\t
81 (74)
\n\t\t\t\t\t\t\t\t
23 (20)
\n\t\t\t\t\t\t\t\t
104 (94)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Inadequate stress level* (For exercise stress, n)
\n\t\t\t\t\t\t\t\t
65 (58)
\n\t\t\t\t\t\t\t\t
38 (33)
\n\t\t\t\t\t\t\t\t
103 (91)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Vasodilator stress (n)
\n\t\t\t\t\t\t\t\t
108 (83)
\n\t\t\t\t\t\t\t\t
22 (20)
\n\t\t\t\t\t\t\t\t
130 (103)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Total (n)
\n\t\t\t\t\t\t\t\t
254 (215)
\n\t\t\t\t\t\t\t\t
83 (73)
\n\t\t\t\t\t\t\t\t
337 (288)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 4.
Results for functional tests in the 337 patients (The numbers in parentheses are the number of patients with assessment of chest pain as indications for coronary angiography in each category). (Reproduced with permission from: Leung DY, Hallani H, Lo ST, Hopkins AP, Juergens CP. How compliant are we with guidelines for coronary angiography in clinical practice? Internal Medicine Journal 2007, Oct;37(10):699-704. John Wiley and Sons)
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
3.2.4. Coronary angiography results
\n\t\t\t\t\t
The coronary arteries were angiographically normal in 152 patients (19%) and showed only minor disease in another 111 patients (13.8%). One hundred and sixty six patients (20.7%) had single vessel disease, 145 (18.1%) had double vessel disease and 228 (28.4%) had triple vessel disease. Of the 89 patients who had previous coronary artery bypass surgery, 40 patients (45%) had no significant graft disease. The overall rate of angiography showing either normal or minor diseases was 37.7%. The overall complication rate of coronary angiography was low. There were 51 cases of access site haematoma (6.4%), one case for each of pseudo-aneurysm, arterio-venous fistula, neurologic deficit, significant arrhythmia and contrast allergy. No deaths as a result of the angiography were recorded.
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
3.2.5. Compliance with guidelines
\n\t\t\t\t\t
Referrals for coronary angiography were considered outside the guidelines for coronary angiography in 34.3% and 36.2% as evaluated by the 2 independent assessors. The concordance rate between the 2 independent assessors was 88.2% (kappa 0.74, p<0.001). The concordance rate between the 2 independent evaluations by the same assessor was 97.5% (kappa 0.945, p<0.001).
\n\t\t\t\t\t
Coronary angiography showed normal coronary arteries or only minor coronary disease in a significantly higher proportion of patients when the referrals were outside published guidelines compared with referrals within the guidelines (181 of the 264 referrals, 68.4% versus 121 of the 538 referrals, 22.6%, p<0.001).
\n\t\t\t\t\t
There were no significant differences in complications of coronary angiography between the group where referrals were within guidelines (6.7%) and the group where referrals were outside guidelines (7.2%, p = 0.79).
\n\t\t\t\t\t
\n\t\t\t\t\t\tTable 5 shows the compliance rate for each of the indications of coronary angiography. The compliance rates were high with indications of non-ST elevation and ST elevation myocardial infarction, valvular heart disease and arrhythmias. However, the compliance rates were lower with indications of assessment of dyspnoea or heart failure and prior to non-cardiac surgery and were particularly low with assessment of chest pain (n = 491, mean age 61.3 ± 11 years, 300 men). Two hundred and ninety five of these 491 patients (60%) were day-only patients. Only 288 of these 491 (58.7%) had functional tests and only 254 (51.7%) had assessment of left ventricular function prior to coronary angiography.
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Indication
\n\t\t\t\t\t\t\t\t
Non-compliant with guidelines n(%)
\n\t\t\t\t\t\t\t\t
Compliant with guidelines n(%)
\n\t\t\t\t\t\t\t\t
Total (n)
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Assessment of Chest pain
\n\t\t\t\t\t\t\t\t
230 (46.8%)
\n\t\t\t\t\t\t\t\t
261 (53.2%)
\n\t\t\t\t\t\t\t\t
491
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Non-ST elevation myocardial infarction
\n\t\t\t\t\t\t\t\t
1 (0.8%)
\n\t\t\t\t\t\t\t\t
126 (99.2%)
\n\t\t\t\t\t\t\t\t
127
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
ST elevation myocardial infarction
\n\t\t\t\t\t\t\t\t
3 (4.2%)
\n\t\t\t\t\t\t\t\t
69 (95.8%)
\n\t\t\t\t\t\t\t\t
72
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Dyspnea/heart failure
\n\t\t\t\t\t\t\t\t
18 (25.7%)
\n\t\t\t\t\t\t\t\t
52 (74.3%)
\n\t\t\t\t\t\t\t\t
70
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Valvular disease
\n\t\t\t\t\t\t\t\t
4 (20%)
\n\t\t\t\t\t\t\t\t
16 (80%)
\n\t\t\t\t\t\t\t\t
20
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Prior to non cardiac surgery
\n\t\t\t\t\t\t\t\t
3 (27.3%)
\n\t\t\t\t\t\t\t\t
8 (72.7%)
\n\t\t\t\t\t\t\t\t
11
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Arrhythmia
\n\t\t\t\t\t\t\t\t
1 (20%)
\n\t\t\t\t\t\t\t\t
4 (80%)
\n\t\t\t\t\t\t\t\t
5
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Others
\n\t\t\t\t\t\t\t\t
4 (66.7%)
\n\t\t\t\t\t\t\t\t
2 (33.3%)
\n\t\t\t\t\t\t\t\t
6
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Total
\n\t\t\t\t\t\t\t\t
264 (32.9%)
\n\t\t\t\t\t\t\t\t
538 (67.1%)
\n\t\t\t\t\t\t\t\t
802
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 5.
The compliance rates for coronary angiography to the American College of Cardiology/American Heart Association guidelines according to the indications for angiography. (Reproduced with permission from: Leung DY, Hallani H, Lo ST, Hopkins AP, Juergens CP. How compliant are we with guidelines for coronary angiography in clinical practice? Internal Medicine Journal 2007, Oct;37(10):699-704. John Wiley and Sons)
\n\t\t\t\t\t
Concentrating on referrals from cardiologists (n=683), referrals from non-invasive cardiologists were significantly more likely to be outside published guidelines compared with referrals from invasive cardiologists (141 of the 341 referrals, 41.3% versus 103 of the 342 referrals, 30.1%, p = 0.002). Multivariate logistic regression analysis identified younger age (OR 1.04 for every year younger, 95% CI 1.029 – 1.048, p<0.001), female gender (OR 2.67, 95% CI 2.24 – 3.19, p<0.001), day-only procedure (OR 2.27, 95% CI 1.91 – 2.69, p<0.001) and non-invasive cardiologist referrer (OR 1.41, 95% CI 1.19 – 1.67, p = 0.046) to be independent predictors of non-compliance with published guidelines.
\n\t\t\t\t\t
When patients with raised cardiac Troponin T (n = 197) were excluded from the multivariate analysis, day-only procedure was no longer a significant independent predictor of non-compliance. Younger age (OR 1.04 for every year younger, 95% CI 1.03 – 1.05, p<0.001), female gender (OR 2.24, 95% CI 1.87 – 2.69, p<0.001) and non-invasive cardiologist referrer (OR 1.47, 95% CI 1.29 – 1.67, p = 0.004) remained independent predictors of non-compliance with guidelines.
\n\t\t\t\t
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
3.3. Discussion
\n\t\t\t\t
In our large consecutive series of patients referred for coronary angiography, we found that more than a third of the referrals were outside the American College of Cardiology/American Heart Association guidelines for coronary angiography. The inter-observer and intra-observer agreement in assessing compliance were high. The rate of coronary angiography showing either normal coronary arteries or only minor diseases was significantly higher when the referrals were outside guidelines. The compliance rate was particularly low with indications of assessment of chest pain. Younger age, female gender, day-only procedure and non-invasive cardiologist referrals were independent predictors of non-compliance with the guidelines.
\n\t\t\t\t
Practice guidelines have proliferated in clinical medicine in the past 2 decades in all major fields. The compilation and publication of these practice guidelines represent efforts by professional bodies to incorporate an ever-expanding evidence based medicine into best clinical practice. A systemic review suggested significant improvement of care after introduction of clinical guidelines although the size of the improvement varied considerably (Grimshaw Russell, 1993). The dissemination and implementation of these guidelines have emerged as major challenges. Furthermore, awareness of these guidelines does not necessarily equate to compliance. Therefore, the full potential for these guidelines to improve health care delivery and clinical outcomes has yet to be completely realized.
\n\t\t\t\t
A number of studies have found significant gaps between clinical practice and guidelines in a number of areas (Brand et al., 1995; Leape et al., 2003; Vikman et al., 2003). In a study of antithrombotic therapy in atrial fibrillation, a report found that only 47% of the eligible patients received warfarin according to published guidelines and 4 patients had a stroke during a 12-month follow-up period (Nair et al., 2005). These 4 patients were not on warfarin despite recommendations by the guidelines. In a random audit of Medicare data in 5 US states showed that 30% of percutaneous coronary angioplasties was rated as Class III indications according to the 1988 American College of Cardiology/American Heart Association guidelines whereas 24% were class III by use of the 1993 guidelines (Leape et al., 2003). Similar gaps were found between clinical practice and the European Society of Cardiology guidelines for the management of non-ST elevation myocardial infarction (Vikman et al., 2003) and only about 50% of patients post myocardial infarction received beta blockers as recommended by the guidelines (Brand et al., 1995).
\n\t\t\t\t
Adherence to guidelines has been suggested to lead to an improved clinical outcome. A clear relationship was found between extent of guideline implementation and one-year mortality in patients with acute myocardial infarction (Schiele et al., 2005). Compliance remained an independent predictor of survival even after adjustment for clinical risk. Similarly, compliance with the guidelines significantly improved prognosis in acute coronary syndrome regardless of risk score (Gulati et al., 2004) and resulted in an improved outcome in high risk patients with non ST elevation myocardial infarction (Vikman et al., 2004). In evaluating the impact of compliance with guidelines for coronary angiography, patient outcome such as survival may not be appropriate. Nevertheless, we were able to demonstrate that the rate of coronary angiography showing either normal coronary arteries or only minor diseases was significantly lower when the referrals were within the guidelines. Rates of normal coronary angiography may be a reasonable surrogate for measuring the impact of compliance as a high negative rate has significant implications due to inappropriate costs, superfluous resource utilisation and unnecessary risks for the patient.
\n\t\t\t\t
Little is known about the barriers to compliance with guidelines by physicians. Potential barriers may include awareness, familiarity, disagreement with the guidelines, resistance to change, and absence of disincentives or penalties for not adhering to recommendations on the part of the physicians (Cabana et al., 1999). In addition to physician factors, our study also identified clinical parameters and scenarios that were predictive of non-compliance with the guidelines. Younger age and female gender were found to be predictors. One may postulate that physicians may be more aggressive in recommending coronary angiography outside guidelines in younger patients as they do not want to “miss” significant coronary disease in such patients. The compulsion for a “definitive” diagnosis and fear of litigation in an increasing medico-legal environment may also have contributed. Day-only procedure as a predictor of non-compliance may be explained by the fact that patients with acute coronary syndrome with raised cardiac Troponin T levels almost always underwent angiography as inpatients. This is supported by the fact that day-only procedure was not an independent predictor when patients with elevated Troponin levels were excluded from the multivariate analysis. In our study, non-invasive cardiologists were more likely to refer outside the guidelines for coronary angiography. This may be because non-invasive cardiologists are potentially less familiar with the guidelines. Furthermore, in the present study, clinical scenarios of assessment of chest pain in patients with suspected or known coronary artery disease appeared to be areas where the non-compliance rate was particularly high. These may be areas in which physicians have the most difficulties adhering to the recommendations of the guidelines.
\n\t\t\t\t
Only a small proportion of patients, especially for inpatients, had functional tests prior to coronary angiography. Functional tests, which play an important role in the risk stratification of patients with suspected or confirmed coronary artery disease as depicted in the published guidelines, were performed in a relatively small proportion of the patients in our study. Our previous study on a different patient population also found a low rate of utilisation of functional tests. Referrer characteristics and inpatient status, rather than pre-test probability of coronary disease, appeared to have the greatest impact on utilisation of functional tests (Leung et al., 2005). Non-utilisation of functional tests prior to coronary angiography was a common reason for “inappropriate” referral for coronary angiography, as established by previous studies (Chassin et al., 1987b; Gray et al., 1990).
\n\t\t\t\t
Our study represents the experiences of a single tertiary referral hospital, and hence may not be representative of other centres around the world. However, we feel that our study population was representative as our institution is the only cardiac catheterisation laboratory in a public hospital tertiary referral centre serving a population of about 800,000. The aim of the present study was to evaluate compliance with the American College of Cardiology and American Heart Association guidelines for coronary angiography and not to judge whether the referrals were appropriate. Referral outside guidelines may be entirely appropriate depending on the patient’s specific clinical situation. These guidelines for coronary angiography were published in 1999. As the evidence base has been evolving and improving, these guidelines may not reflect contemporary practice. Although the rate of angiography showing either normal coronary arteries or minor disease was significantly higher when the referrals were outside published guidelines, which can have significant cost-effective implications, our results do not allow us to perform cost-effectiveness analysis.
\n\t\t\t
\n\t\t
\n\t\t
\n\t\t\t
4. Conclusions
\n\t\t\t
Coronary angiography is one of the most commonly performed cardiac procedures. It continues to play an important role in the management of cardiac patients and is indispensible in patients considered for coronary revascularisation. It is an invasive procedure not without significant risks and, together with its inherent costs, should not be carried out or repeated without sufficient justification. Functional tests, including stress ECG, stress echo, nuclear perfusion imaging and magnetic resonance imaging are all accepted functional tests that provide important diagnostic and prognostic information and should form part of the body of investigations in patients suspected to be suffering from coronary artery disease. More recently, CT coronary angiography is being used as a “ruling out” test and is considered an appropriate indication in certain subsets of patients with chest pain. Improvement in the use of these functional tests may lead to better risk stratification so that low risk patients may be spared the risks and costs of invasive coronary angiography and higher risk patients can have their angiography expedited. We identified that the use of functional tests, especially in low to intermediate risk patients, was suboptimal and have identified certain problematic areas where their use was very low. The ACC and AHA have published guidelines on coronary angiography. Although the guidelines were published in 1999, it is still a useful document applicable to clinical practice today. There is ample evidence to suggest, in multiple areas of cardiology, that adherence to guidelines was associated with improved patient outcomes. In our study, we found that the adherence to the guidelines on coronary angiography was only modest in certain indications and non-adherence led to a higher rate of normal coronary angiography. Attention should be paid to these problem areas to identify the underlying reasons for non-compliance so that efforts can be made by both individual physicians and professional bodies to improve the rate of compliance so that the full potential of these guidelines can be realised.
\n\t\t
\n\t
Acknowledgments
\n\t\t\t
We would like to thank all co-authors of the 2 manuscripts for their help in the studies.
\n\t\t
\n',keywords:null,chapterPDFUrl:"https://cdn.intechopen.com/pdfs/18292.pdf",chapterXML:"https://mts.intechopen.com/source/xml/18292.xml",downloadPdfUrl:"/chapter/pdf-download/18292",previewPdfUrl:"/chapter/pdf-preview/18292",totalDownloads:1333,totalViews:102,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,dateSubmitted:"November 3rd 2010",dateReviewed:"April 27th 2011",datePrePublished:null,datePublished:"September 15th 2011",dateFinished:null,readingETA:"0",abstract:null,reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/18292",risUrl:"/chapter/ris/18292",book:{slug:"coronary-angiography-advances-in-noninvasive-imaging-approach-for-evaluation-of-coronary-artery-disease"},signatures:"James T Leung and Dominic Y Leung",authors:[{id:"34706",title:"Prof.",name:"Dominic",middleName:null,surname:"Leung",fullName:"Dominic Leung",slug:"dominic-leung",email:"d.leung@unsw.edu.au",position:null,institution:null},{id:"47587",title:"Mr.",name:"James",middleName:null,surname:"Leung",fullName:"James Leung",slug:"james-leung",email:"jimmie_l1988@yahoo.com.au",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction ",level:"1"},{id:"sec_2",title:"2. Utilisation of functional tests prior to coronary angiography",level:"1"},{id:"sec_2_2",title:"2.1. The study - methods",level:"2"},{id:"sec_3_2",title:"2.2. Results",level:"2"},{id:"sec_3_3",title:"Table 1.",level:"3"},{id:"sec_4_3",title:"Table 2.",level:"3"},{id:"sec_6_2",title:"2.3. Discussion",level:"2"},{id:"sec_8",title:"3. Adherence to guidelines on coronary angiography",level:"1"},{id:"sec_8_2",title:"3.1. The study - methods",level:"2"},{id:"sec_9_2",title:"3.2. Results",level:"2"},{id:"sec_9_3",title:"3.2.1. Patients characteristics",level:"3"},{id:"sec_10_3",title:"Table 3.",level:"3"},{id:"sec_11_3",title:"Table 4.",level:"3"},{id:"sec_12_3",title:"3.2.4. Coronary angiography results",level:"3"},{id:"sec_13_3",title:"Table 5.",level:"3"},{id:"sec_15_2",title:"3.3. Discussion",level:"2"},{id:"sec_17",title:"4. Conclusions ",level:"1"},{id:"sec_18",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",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\tAyanian\n\t\t\t\t\t\t\tJ. Z.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHauptman\n\t\t\t\t\t\t\tP. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGuadagnoli\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAntman\n\t\t\t\t\t\t\tE. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPashos\n\t\t\t\t\t\t\tC. L. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMc Neil\n\t\t\t\t\t\t\tB. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1994Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. New England Journal of Medicine, 331, 17, 1136\n\t\t\t\t\t1142\n\t\t\t\t\n\t\t\t'},{id:"B2",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\tBernstein\n\t\t\t\t\t\t\tS. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrorsson\n\t\t\t\t\t\t\tB.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAberg\n\t\t\t\t\t\t\tT.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEmanuelsson\n\t\t\t\t\t\t\tH.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrook\n\t\t\t\t\t\t\tR. H. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWerko\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1999Appropriateness of referral of coronary angiography patients in Sweden. SECOR/SBU Project Group. Heart, 81, 5, 470\n\t\t\t\t\t477\n\t\t\t\t\n\t\t\t'},{id:"B3",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\tBorowsky\n\t\t\t\t\t\t\tS. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKravitz\n\t\t\t\t\t\t\tR. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLaouri\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLeake\n\t\t\t\t\t\t\tB.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPartridge\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKaushik\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHaywood\n\t\t\t\t\t\t\tL. J. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrook\n\t\t\t\t\t\t\tR. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1995Effect of physician specialty on use of necessary coronary angiography. Journal of the American College of Cardiology, 26, 6, 1484\n\t\t\t\t\t1491\n\t\t\t\t\n\t\t\t'},{id:"B4",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\tBrand\n\t\t\t\t\t\t\tD. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNewcomer\n\t\t\t\t\t\t\tL. N.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFreiburger\n\t\t\t\t\t\t\tA. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHao\n\t\t\t\t\t\t\tT.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1995Cardiologists’ Practices Compared With Practice Guidelines: Use of Beta-Blockade After Acute Myocardial Infarction. Journal of the American College of Cardiology, 26, 6, 1432\n\t\t\t\t\t1436\n\t\t\t\t\n\t\t\t'},{id:"B5",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\tCabana\n\t\t\t\t\t\t\tM. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRand\n\t\t\t\t\t\t\tC. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPowe\n\t\t\t\t\t\t\tN. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWu\n\t\t\t\t\t\t\tA. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWilson\n\t\t\t\t\t\t\tM. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAbboud\n\t\t\t\t\t\t\tP. A. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRubin\n\t\t\t\t\t\t\tH. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1999Why don’t physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association, 282, 15, 1458\n\t\t\t\t\t1465\n\t\t\t\t\n\t\t\t'},{id:"B6",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\tChassin\n\t\t\t\t\t\t\tM. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKosecoff\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPark\n\t\t\t\t\t\t\tR. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWinslow\n\t\t\t\t\t\t\tC. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKahn\n\t\t\t\t\t\t\tK. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMerrick\n\t\t\t\t\t\t\tN. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKeesey\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFink\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSolomon\n\t\t\t\t\t\t\tD. H. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrook\n\t\t\t\t\t\t\tR. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1987aDoes inappropriate use explain geographic variations in the use of health care services? A study of three procedures. Journal of the American Medical Association, 258, 18, 2533\n\t\t\t\t\t2537\n\t\t\t\t\n\t\t\t'},{id:"B7",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\tChassin\n\t\t\t\t\t\t\tM. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKosecoff\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSolomon\n\t\t\t\t\t\t\tD. H. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrook\n\t\t\t\t\t\t\tR. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1987bHow coronary angiography is used. Clinical determinants of appropriateness. Journal of the American Medical Association, 258, 18, 2543\n\t\t\t\t\t2547\n\t\t\t\t\n\t\t\t'},{id:"B8",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\tDiamond\n\t\t\t\t\t\t\tG. A. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tForrester\n\t\t\t\t\t\t\tJ. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1979Analysis of probability as an aid in the cllinical diagnosis of coronary artery disease. New England Journal of Medicine, 300, 1350\n\t\t\t\t\t1358\n\t\t\t\t\n\t\t\t'},{id:"B9",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\tEvery\n\t\t\t\t\t\t\tN. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLarson\n\t\t\t\t\t\t\tE. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLitwin\n\t\t\t\t\t\t\tP. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMaynard\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFihn\n\t\t\t\t\t\t\tS. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEisenberg\n\t\t\t\t\t\t\tM. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHallstrom\n\t\t\t\t\t\t\tA. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMartin\n\t\t\t\t\t\t\tJ. S. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWeaver\n\t\t\t\t\t\t\tW. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1993The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. Myocardial Infarction Triage and Intervention Project Investigators. New England Journal of Medicine, 329, 8, 546\n\t\t\t\t\t551\n\t\t\t\t\n\t\t\t'},{id:"B10",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\tGray\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHampton\n\t\t\t\t\t\t\tJ. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBernstein\n\t\t\t\t\t\t\tS. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKosecoff\n\t\t\t\t\t\t\tJ. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrook\n\t\t\t\t\t\t\tR. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1990Audit of coronary angiography and bypass surgery. Lancet, 335, 8701, 1317\n\t\t\t\t\t1320\n\t\t\t\t\n\t\t\t'},{id:"B11",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\tGrimshaw\n\t\t\t\t\t\t\tJ. M. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRussell\n\t\t\t\t\t\t\tI. T.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1993Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet, 342, 8883, 1317\n\t\t\t\t\t1322\n\t\t\t\t\n\t\t\t'},{id:"B12",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\tGulati\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPatel\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJaffe\n\t\t\t\t\t\t\tA. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJoseph\n\t\t\t\t\t\t\tA. J. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCalvin Jr\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2004Impact of contemporary guideline compliance on risk stratification models for acute coronary syndromes in The Registry of Acute Coronary Syndromes. The American Journal of Cardiology, 94, 7, 873\n\t\t\t\t\t878\n\t\t\t\t\n\t\t\t'},{id:"B13",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\tHemingway\n\t\t\t\t\t\t\tH.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCrook\n\t\t\t\t\t\t\tA. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBanerjee\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDawson\n\t\t\t\t\t\t\tJ. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFeder\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMagee\n\t\t\t\t\t\t\tP. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWood\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPhilpott\n\t\t\t\t\t\t\tS. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTimmis\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2001Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings, mortality, and revascularisation rate? The ACRE study. Heart, 85, 6, 672\n\t\t\t\t\t679\n\t\t\t\t\n\t\t\t'},{id:"B14",body:'\n\t\t\t\tHendel, R. C.;Patel, M. R.;Kramer, C. M.;Poon, M.;Carr, J. C.;Gerstad, N. A.;Gillam, L. D.;Hodgson, J. M.;Kim, R. J.;Lesser, J. R.;Martin, E. T.;Messer, J. V.;Redberg, R. F.;Rubin, G. D.;Rumsfeld, J. S.;Taylor, A. J.;Weigold, W.;Woodard, P. K.;Brindis, R. G.;Douglas, P. S.;Peterson, E. D.;Wolk, M. J. &Allen, J. M. (2006). ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging: A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. Journal of the American College of Cardiology, 48, 7, pp. 1475-1497\n\t\t\t'},{id:"B15",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\tLeape\n\t\t\t\t\t\t\tL. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWeissman\n\t\t\t\t\t\t\tJ. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSchneider\n\t\t\t\t\t\t\tE. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPiana\n\t\t\t\t\t\t\tR. N.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGatsonis\n\t\t\t\t\t\t\tC. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEpstein\n\t\t\t\t\t\t\tA. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003Adherence to practice guidelines: the role of specialty society guidelines. American Heart Journal, 145, 1, 19\n\t\t\t\t\t26\n\t\t\t\t\n\t\t\t'},{id:"B16",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\tLeung\n\t\t\t\t\t\t\tD. Y.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLo\n\t\t\t\t\t\t\tS. T.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLiew\n\t\t\t\t\t\t\tC. T.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWong\n\t\t\t\t\t\t\tA. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHopkins\n\t\t\t\t\t\t\tA. P. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJuergens\n\t\t\t\t\t\t\tC. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2005Use of functional tests before angiography in patients with normal coronary arteries. International Journal of Cardiology, 104, 3, 326\n\t\t\t\t\t331\n\t\t\t\t\n\t\t\t'},{id:"B17",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\tMarwick\n\t\t\t\t\t\t\tT. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMehta\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tArheart\n\t\t\t\t\t\t\tK. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLauer\n\t\t\t\t\t\t\tM. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1997Use of exercise echocardiography for prognostic evaluation of patients with known or suspected coronary artery disease. Journal of the American College of Cardiology, 30, 1, 83\n\t\t\t\t\t90\n\t\t\t\t\n\t\t\t'},{id:"B18",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\tMarwick\n\t\t\t\t\t\t\tT. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tShaw\n\t\t\t\t\t\t\tL. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLauer\n\t\t\t\t\t\t\tM. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKesler\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHachamovitch\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHeller\n\t\t\t\t\t\t\tG. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTravin\n\t\t\t\t\t\t\tM. I.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBorges-Neto\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBerman\n\t\t\t\t\t\t\tD. S. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMiller\n\t\t\t\t\t\t\tD. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1999The noninvasive prediction of cardiac mortality in men and women with known or suspected coronary artery disease. Economics of Noninvasive Diagnosis (END) Study Group. American Journal of Medicine, 106, 2, 172\n\t\t\t\t\t178\n\t\t\t\t\n\t\t\t'},{id:"B19",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\tMetz\n\t\t\t\t\t\t\tL. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBeattie\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHom\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRedberg\n\t\t\t\t\t\t\tR. F.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGrady\n\t\t\t\t\t\t\tD. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFleischmann\n\t\t\t\t\t\t\tK. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2007The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis. Journal of the American College of Cardiology, 49, 2, 227\n\t\t\t\t\t237\n\t\t\t\t\n\t\t\t'},{id:"B20",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\tNair\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHazell\n\t\t\t\t\t\t\tW.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSutton\n\t\t\t\t\t\t\tT. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPillai\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2005Antithrombotic therapy in atrial fibrillation: an assessment of compliance with guidelines. New Zealand Medical Journal, 118, 1208, U1258\n\t\t\t\t\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\tNash\n\t\t\t\t\t\t\tI. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNash\n\t\t\t\t\t\t\tD. B. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFuster\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1997Do cardiologists do it better? Journal of the American College of Cardiology, 29, 3, 475\n\t\t\t\t\t478\n\t\t\t\t\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\tPatterson\n\t\t\t\t\t\t\tR. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEisner\n\t\t\t\t\t\t\tR. L. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHorowitz\n\t\t\t\t\t\t\tS. F.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1995Comparison of cost-effectiveness and utility of exercise ECG, single photon emission computed tomography, positron emission tomography, and coronary angiography for diagnosis of coronary artery disease. Circulation, 91, 1, 54\n\t\t\t\t\t65\n\t\t\t\t\n\t\t\t'},{id:"B23",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\tPilote\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\tCaliff\n\t\t\t\t\t\t\tR. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSapp\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMiller\n\t\t\t\t\t\t\tD. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMark\n\t\t\t\t\t\t\tD. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWeaver\n\t\t\t\t\t\t\tW. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGore\n\t\t\t\t\t\t\tJ. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tArmstrong\n\t\t\t\t\t\t\tP. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tOhman\n\t\t\t\t\t\t\tE. M. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTopol\n\t\t\t\t\t\t\tE. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1995Regional variation across the United States in the management of acute myocardial infarction. GUSTO-1 Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. New England Journal of Medicine, 31, 9, 565\n\t\t\t\t\t722\n\t\t\t\t\n\t\t\t'},{id:"B24",body:'\n\t\t\t\tScanlon, P. J.;Faxon, D. P.;Audet, A. M.;Carabello, B.;Dehmer, G. J.;Eagle, K. A.;Legako, R. D.;Leon, D. F.;Murray, J. A.;Nissen, S. E.;Pepine, C. J.;Watson, R. M.;Ritchie, J. L.;Gibbons, R. J.;Cheitlin, M. D.;Gardner, T. J.;Garson, A., Jr.;Russell, R. O., Jr.;Ryan, T. J. &Smith, S. C., Jr. (1999). ACC/AHA guidelines for coronary angiography. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions. Journal of the American College of Cardiology, 33, 6, pp. 1756-18241756\n\t\t\t\t\t1824\n\t\t\t\t\n\t\t\t'},{id:"B25",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\tSchiele\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMeneveau\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSeronde\n\t\t\t\t\t\t\tM. F.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCaulfield\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFouche\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLassabe\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBaborier\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLegalery\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBassand\n\t\t\t\t\t\t\tJ. P.\n\t\t\t\t\t\t\n\t\t\t\t\ton behalf of the Reseau de Cardiologie de Franche Comte, g. (2005Compliance with guidelines and 1-year mortality in patients with acute myocardial infarction: a prospective study. European Heart Journal, 26, 873\n\t\t\t\t\t880\n\t\t\t\t\n\t\t\t'},{id:"B26",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\tShaw\n\t\t\t\t\t\t\tL. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHachamovitch\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBerman\n\t\t\t\t\t\t\tD. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMarwick\n\t\t\t\t\t\t\tT. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLauer\n\t\t\t\t\t\t\tM. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHeller\n\t\t\t\t\t\t\tG. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tIskandrian\n\t\t\t\t\t\t\tA. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKesler\n\t\t\t\t\t\t\tK. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTravin\n\t\t\t\t\t\t\tM. I.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLewin\n\t\t\t\t\t\t\tH. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHendel\n\t\t\t\t\t\t\tR. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBorges-Neto\n\t\t\t\t\t\t\tS. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMiller\n\t\t\t\t\t\t\tD. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1999aThe economic consequences of available diagnostic and prognostic strategies for the evaluation of stable angina patients: an observational assessment of the value of precatheterization ischemia. Economics of Noninvasive Diagnosis (END) Multicenter Study Group. Journal of the American College of Cardiology, 33, 3, 661\n\t\t\t\t\t669\n\t\t\t\t\n\t\t\t'},{id:"B27",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\tShaw\n\t\t\t\t\t\t\tL. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHeller\n\t\t\t\t\t\t\tG. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTravin\n\t\t\t\t\t\t\tM. I.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLauer\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMarwick\n\t\t\t\t\t\t\tT.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHachamovitch\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBerman\n\t\t\t\t\t\t\tD. S. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMiller\n\t\t\t\t\t\t\tD. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1999bCost analysis of diagnostic testing for coronary artery disease in women with stable chest pain. Economics of Noninvasive Diagnosis (END) Study Group. Journal of Nuclear Cardiology., 6, 6, 559\n\t\t\t\t\t569\n\t\t\t\t\n\t\t\t'},{id:"B28",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\tVerrilli\n\t\t\t\t\t\t\tD. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWelch\n\t\t\t\t\t\t\tH. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1996The impact of diagnostic testing on therapeutic interventions. Journal of the American Medical Association, 275, 15, 1189\n\t\t\t\t\t1191\n\t\t\t\t\n\t\t\t'},{id:"B29",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\tVikman\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAiraksinen\n\t\t\t\t\t\t\tK. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPeuhkurinen\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTierala\n\t\t\t\t\t\t\tI.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMajamaa-Voltti\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNiemela\n\t\t\t\t\t\t\tM. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNiemela\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003Gap between guidelines and management of patients with acute coronary syndrome without persistent ST elevation. Finnish prospective follow-up survey. Scandinavian Cardiovascular Journal, 37, 4, 187\n\t\t\t\t\t192\n\t\t\t\t\n\t\t\t'},{id:"B30",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\tVikman\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAiraksinen\n\t\t\t\t\t\t\tK. E. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTierala\n\t\t\t\t\t\t\tI.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPeuhkurinen\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMajamaa-Voltti\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNiemela\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTuunanen\n\t\t\t\t\t\t\tH.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNieminen\n\t\t\t\t\t\t\tM. S. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNiemela\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2004Improved adherence to practice guidelines yields better outcome in high-risk patients with acute coronary syndrome without ST elevation: findings from nationwide FINACS studies. Journal of Internal Medicine, 256, 4, 316\n\t\t\t\t\t323\n\t\t\t\t\n\t\t\t'},{id:"B31",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\tWennberg\n\t\t\t\t\t\t\tD. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKellett\n\t\t\t\t\t\t\tM. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDickens\n\t\t\t\t\t\t\tJ. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMalenka\n\t\t\t\t\t\t\tD. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKeilson\n\t\t\t\t\t\t\tL. M. .\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKeller\n\t\t\t\t\t\t\tR. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t1996The association between local diagnostic testing intensity and invasive cardiac procedures. Journal of the American Medical Association, 275, 15, 1161\n\t\t\t\t\t1164\n\t\t\t\t\n\t\t\t'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"James T Leung",address:null,affiliation:'
Sydney Medical School, University of Sydney, Australia
'},{corresp:null,contributorFullName:"Dominic Y Leung",address:null,affiliation:'
Liverpool Hospital, University of New South Wales, Australia
'}],corrections:null},book:{id:"1346",title:"Coronary Angiography",subtitle:"Advances in Noninvasive Imaging Approach for Evaluation of Coronary Artery Disease",fullTitle:"Coronary Angiography - Advances in Noninvasive Imaging Approach for Evaluation of Coronary Artery Disease",slug:"coronary-angiography-advances-in-noninvasive-imaging-approach-for-evaluation-of-coronary-artery-disease",publishedDate:"September 15th 2011",bookSignature:"Branislav Baskot",coverURL:"https://cdn.intechopen.com/books/images_new/1346.jpg",licenceType:"CC BY-NC-SA 3.0",editedByType:"Edited by",editors:[{id:"33401",title:"Prof.",name:"Baskot",middleName:null,surname:"Branislav",slug:"baskot-branislav",fullName:"Baskot Branislav"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},chapters:[{id:"18292",title:"Utilization of Functional Tests Prior to and Adherence to Guidelines on Coronary Angiography",slug:"utilization-of-functional-tests-prior-to-and-adherence-to-guidelines-on-coronary-angiography",totalDownloads:1333,totalCrossrefCites:0,signatures:"James T Leung and Dominic Y Leung",authors:[{id:"34706",title:"Prof.",name:"Dominic",middleName:null,surname:"Leung",fullName:"Dominic Leung",slug:"dominic-leung"},{id:"47587",title:"Mr.",name:"James",middleName:null,surname:"Leung",fullName:"James Leung",slug:"james-leung"}]},{id:"18293",title:"Transthoracic Echocardiography in the Assessment of Coronary Arteries",slug:"transthoracic-echocardiography-in-the-assessment-of-coronary-arteries",totalDownloads:3749,totalCrossrefCites:3,signatures:"Alla Boshchenko, Alexander Vrublevsky and Rostislav Karpov",authors:[{id:"44841",title:"Dr.",name:"Alla",middleName:"A.",surname:"Boshchenko",fullName:"Alla Boshchenko",slug:"alla-boshchenko"},{id:"49790",title:"Dr.",name:"Alexander",middleName:null,surname:"Vrublevsky",fullName:"Alexander Vrublevsky",slug:"alexander-vrublevsky"},{id:"49791",title:"Dr.",name:"Rostislav",middleName:null,surname:"Karpov",fullName:"Rostislav Karpov",slug:"rostislav-karpov"}]},{id:"18294",title:"Contrast Echocardiography in Coronary Artery Disease",slug:"contrast-echocardiography-in-coronary-artery-disease",totalDownloads:1818,totalCrossrefCites:0,signatures:"Mai Tone Lønnebakken and Eva Gerdts",authors:[{id:"34832",title:"Dr.",name:"Mai Tone",middleName:null,surname:"Lønnebakken",fullName:"Mai Tone Lønnebakken",slug:"mai-tone-lonnebakken"},{id:"51262",title:"Prof.",name:"Eva",middleName:null,surname:"Gerdts",fullName:"Eva Gerdts",slug:"eva-gerdts"}]},{id:"18295",title:"Non-Invasive Imaging in Approaching Ischemic Coronary Artery Disease",slug:"non-invasive-imaging-in-approaching-ischemic-coronary-artery-disease",totalDownloads:1624,totalCrossrefCites:0,signatures:"Lucia Agoston-Coldea, Teodora Mocan and Silvia Lupu",authors:[{id:"52537",title:"Dr.",name:"Lucia",middleName:null,surname:"Agoston-Coldea",fullName:"Lucia Agoston-Coldea",slug:"lucia-agoston-coldea"}]},{id:"18296",title:"Non-Invasive Coronary Angiography",slug:"non-invasive-coronary-angiography",totalDownloads:2223,totalCrossrefCites:0,signatures:"Mohanaluxmi Sriharan, Paula McParland, Stephen Harden and Edward Nicol",authors:[{id:"47852",title:"Prof.",name:"Ed",middleName:null,surname:"Nicol",fullName:"Ed Nicol",slug:"ed-nicol"},{id:"47853",title:"Dr",name:"Mohanaluxmi",middleName:null,surname:"Sriharan",fullName:"Mohanaluxmi Sriharan",slug:"mohanaluxmi-sriharan"},{id:"47854",title:"Prof.",name:"Paula",middleName:null,surname:"McParland",fullName:"Paula McParland",slug:"paula-mcparland"},{id:"47855",title:"Prof.",name:"Stephen",middleName:null,surname:"Harden",fullName:"Stephen Harden",slug:"stephen-harden"}]},{id:"18297",title:"Coronary CT Angiography as an Alternative to Invasive Coronary Angiography",slug:"coronary-ct-angiography-as-an-alternative-to-invasive-coronary-angiography",totalDownloads:2840,totalCrossrefCites:1,signatures:"Seshu C. Rao and Randall C. Thompson",authors:[{id:"42146",title:"Prof.",name:"Randall",middleName:null,surname:"Thompson",fullName:"Randall Thompson",slug:"randall-thompson"},{id:"42147",title:"Dr.",name:"Seshu",middleName:"C",surname:"Rao",fullName:"Seshu Rao",slug:"seshu-rao"}]},{id:"18298",title:"New Noninvasive Modalities in Coronary Angiography: Cardiac Computed Tomography Angiography",slug:"new-noninvasive-modalities-in-coronary-angiography-cardiac-computed-tomography-angiography",totalDownloads:1512,totalCrossrefCites:0,signatures:"Ryotaro Wake and Minoru Yoshiyama",authors:[{id:"34443",title:"Dr.",name:"Ryotaro",middleName:null,surname:"Wake",fullName:"Ryotaro Wake",slug:"ryotaro-wake"}]},{id:"18299",title:"Simultaneous Assessment Beyond Coronary Stenosis by Multislice Computed Tomography",slug:"simultaneous-assessment-beyond-coronary-stenosis-by-multislice-computed-tomography",totalDownloads:1141,totalCrossrefCites:0,signatures:"Shoichi Ehara and Kenei Shimada",authors:[{id:"30580",title:"Dr.",name:"Kenei",middleName:null,surname:"Shimada",fullName:"Kenei Shimada",slug:"kenei-shimada"},{id:"31119",title:"Dr.",name:"Shoichi",middleName:null,surname:"Ehara",fullName:"Shoichi Ehara",slug:"shoichi-ehara"}]},{id:"18300",title:"Assessment of Coronary Artery Bypass Graft (CABG) Patency and Graft Disease Using Multidetector Computed Tomography (MDCT)",slug:"assessment-of-coronary-artery-bypass-graft-cabg-patency-and-graft-disease-using-multidetector-comput",totalDownloads:4253,totalCrossrefCites:1,signatures:"Bong Gun Song, Hyun Suk Yang, Joon Hyung Doh, Hong Jang, Gu Hyun Kang, Yong Hwan Park, Woo Jung Chun, Ju Hyeon Oh, Sung Min Ko and Hweung Kon Hwang",authors:[{id:"32974",title:"Prof.",name:"Bong Gun",middleName:null,surname:"Song",fullName:"Bong Gun Song",slug:"bong-gun-song"},{id:"63973",title:"Prof.",name:"Hong",middleName:null,surname:"Jang",fullName:"Hong Jang",slug:"hong-jang"},{id:"63974",title:"Prof.",name:"Joon Hyung",middleName:null,surname:"Doh",fullName:"Joon Hyung Doh",slug:"joon-hyung-doh"},{id:"65323",title:"Prof.",name:"Hyun Suk",middleName:null,surname:"Yang",fullName:"Hyun Suk Yang",slug:"hyun-suk-yang"},{id:"65327",title:"Prof.",name:"Sung Min",middleName:null,surname:"Ko",fullName:"Sung Min Ko",slug:"sung-min-ko"},{id:"78012",title:"Prof.",name:"Woo Jung",middleName:null,surname:"Chun",fullName:"Woo Jung Chun",slug:"woo-jung-chun"},{id:"78013",title:"Prof.",name:"Ju Hyeon",middleName:null,surname:"Oh",fullName:"Ju Hyeon Oh",slug:"ju-hyeon-oh"},{id:"78022",title:"Prof.",name:"Hweung Kon",middleName:null,surname:"Hwang",fullName:"Hweung Kon Hwang",slug:"hweung-kon-hwang"},{id:"78963",title:"Prof.",name:"Yong Hwan",middleName:null,surname:"Park",fullName:"Yong Hwan Park",slug:"yong-hwan-park"},{id:"78965",title:"Prof.",name:"Gu Hyun",middleName:null,surname:"Kang",fullName:"Gu Hyun Kang",slug:"gu-hyun-kang"}]},{id:"18301",title:"Detection Myocardial Bridging Using Non-Invasive Technique",slug:"detection-myocardial-bridging-using-non-invasive-technique",totalDownloads:2393,totalCrossrefCites:0,signatures:"Junbo Ge and Jianying Ma",authors:[{id:"32260",title:"Dr.",name:"Junbo",middleName:null,surname:"Ge",fullName:"Junbo Ge",slug:"junbo-ge"}]},{id:"18302",title:"When Cardiac Computed Tomography Becomes the Gold Standard Technique to Evaluate Coronary Artery Disease Patients",slug:"when-cardiac-computed-tomography-becomes-the-gold-standard-technique-to-evaluate-coronary-artery-dis",totalDownloads:1240,totalCrossrefCites:0,signatures:"Mohamed Bamoshmoosh",authors:[{id:"35710",title:"Prof.",name:"Mohamed",middleName:null,surname:"Bamoshmoosh",fullName:"Mohamed Bamoshmoosh",slug:"mohamed-bamoshmoosh"}]},{id:"18303",title:"Physiologic Risk Assessment in Stable Ischemic Heart Disease – Functional Evaluation Versus Coronary Anatomy",slug:"physiologic-risk-assessment-in-stable-ischemic-heart-disease-functional-evaluation-versus-coronary-a",totalDownloads:1370,totalCrossrefCites:0,signatures:"Alessia Gimelli and Paolo Marzullo",authors:[{id:"33377",title:"Dr.",name:"Alessia",middleName:null,surname:"Gimelli",fullName:"Alessia Gimelli",slug:"alessia-gimelli"},{id:"48747",title:"Dr.",name:"Paolo",middleName:null,surname:"Marzullo",fullName:"Paolo Marzullo",slug:"paolo-marzullo"}]},{id:"18304",title:"Clinical Significance of Tetrofosm in Extracardiac Uptake During Myocardial Perfusion Imaging",slug:"clinical-significance-of-tetrofosm-in-extracardiac-uptake-during-myocardial-perfusion-imaging",totalDownloads:6463,totalCrossrefCites:2,signatures:"Panagiotis Georgoulias, Varvara Valotassiou, Ioannis Tsougos, George Angelidis and Nikolaos Demakopoulos",authors:[{id:"32702",title:"Dr.",name:"Varvara",middleName:null,surname:"Valotassiou",fullName:"Varvara Valotassiou",slug:"varvara-valotassiou"},{id:"60382",title:"Prof.",name:"Panagiotis",middleName:null,surname:"Georgoulias",fullName:"Panagiotis Georgoulias",slug:"panagiotis-georgoulias"},{id:"60390",title:"Dr.",name:"Ioannis",middleName:null,surname:"Tsougos",fullName:"Ioannis Tsougos",slug:"ioannis-tsougos"},{id:"60391",title:"Dr.",name:"George",middleName:null,surname:"Angelidis",fullName:"George Angelidis",slug:"george-angelidis"},{id:"60392",title:"Dr.",name:"Nikolaos",middleName:null,surname:"Demakopoulos",fullName:"Nikolaos Demakopoulos",slug:"nikolaos-demakopoulos"}]},{id:"18305",title:"Myocardial Perfusion Imaging in Diagnosis of Culprit Lesion in Patients Undergoing Elective Percutaneous Coronary Intervention",slug:"myocardial-perfusion-imaging-in-diagnosis-of-culprit-lesion-in-patients-undergoing-elective-percutan",totalDownloads:3258,totalCrossrefCites:0,signatures:"Branislav Baskot, Slobodan Obradovic, Saso Rafajlovski, Branko Gligic, Robert Jung, Vladimir Ivanovic, Miroslav Bikicki and Miodrag Pavlovic",authors:[{id:"33401",title:"Prof.",name:"Baskot",middleName:null,surname:"Branislav",fullName:"Baskot Branislav",slug:"baskot-branislav"}]},{id:"18306",title:"New Noninvasive Modalities in Coronary Angiography - Diagnostic Values of New Biomarkers for Cardiovascular Disease",slug:"new-noninvasive-modalities-in-coronary-angiography-diagnostic-values-of-new-biomarkers-for-cardiovas",totalDownloads:1489,totalCrossrefCites:0,signatures:"Yilmaz. N, Yegin A and Aykal G.",authors:[{id:"30763",title:"Dr.",name:"Necat",middleName:null,surname:"Yilmaz",fullName:"Necat Yilmaz",slug:"necat-yilmaz"},{id:"35566",title:"Dr.",name:"Aysenur",middleName:null,surname:"Yegin",fullName:"Aysenur Yegin",slug:"aysenur-yegin"},{id:"39439",title:"Dr.",name:"Guzin",middleName:null,surname:"Aykal",fullName:"Guzin Aykal",slug:"guzin-aykal"}]},{id:"18307",title:"The Role of Inflammatory Biomarkers in the Assessment of Coronary Artery Disease",slug:"the-role-of-inflammatory-biomarkers-in-the-assessment-of-coronary-artery-disease",totalDownloads:1332,totalCrossrefCites:0,signatures:"Patrícia Napoleão, Mafalda Selas, Cláudia Freixo, Catarina Ramos, Valeska Andreozzi, Antónia Turkman, Miguel Mota Carmo, Ana Maria Viegas-Crespo, Rui Cruz Ferreira and Teresa Pinheiro",authors:[{id:"30463",title:"Ms",name:"Patricia",middleName:null,surname:"Napoleao",fullName:"Patricia Napoleao",slug:"patricia-napoleao"},{id:"49201",title:"Prof.",name:"Mafalda",middleName:null,surname:"Selas",fullName:"Mafalda Selas",slug:"mafalda-selas"},{id:"49202",title:"Prof.",name:"Catarina",middleName:null,surname:"Ramos",fullName:"Catarina Ramos",slug:"catarina-ramos"},{id:"49203",title:"Prof.",name:"Antónia",middleName:null,surname:"Turkman",fullName:"Antónia Turkman",slug:"antonia-turkman"},{id:"49204",title:"Prof.",name:"Valeska",middleName:null,surname:"Andreozzi",fullName:"Valeska Andreozzi",slug:"valeska-andreozzi"},{id:"49205",title:"Prof.",name:"Miguel",middleName:null,surname:"Mota Carmo",fullName:"Miguel Mota Carmo",slug:"miguel-mota-carmo"},{id:"49206",title:"Prof.",name:"Ana Maria",middleName:null,surname:"Viegas-Crespo",fullName:"Ana Maria Viegas-Crespo",slug:"ana-maria-viegas-crespo"},{id:"49207",title:"Prof.",name:"Rui",middleName:null,surname:"Cruz Ferreira",fullName:"Rui Cruz Ferreira",slug:"rui-cruz-ferreira"},{id:"49208",title:"Prof.",name:"Teresa",middleName:null,surname:"Pinheiro",fullName:"Teresa Pinheiro",slug:"teresa-pinheiro"}]},{id:"18308",title:"Platelet, Fatty Acids, Membrane Viscosity, Depression and Ischemic Heart Disease - Biological-Molecular Path, with Medical-Anthropology Insights",slug:"platelet-fatty-acids-membrane-viscosity-depression-and-ischemic-heart-disease-biological-molecular-p",totalDownloads:1346,totalCrossrefCites:1,signatures:"Massimo Cocchi, Lucio Tonello and Fabio Gabrielli",authors:[{id:"31438",title:"Prof.",name:"Massimo",middleName:null,surname:"Cocchi",fullName:"Massimo Cocchi",slug:"massimo-cocchi"},{id:"31444",title:"Ph.D.",name:"Lucio",middleName:null,surname:"Tonello",fullName:"Lucio Tonello",slug:"lucio-tonello"}]},{id:"18309",title:"Acceleration of New Biomarkers Development and Discovery in Synergistic Diagnostics of Coronary Artery Disease",slug:"acceleration-of-new-biomarkers-development-and-discovery-in-synergistic-diagnostics-of-coronary-arte",totalDownloads:2190,totalCrossrefCites:0,signatures:"Ewa Stępien",authors:[{id:"33052",title:"Prof.",name:"Ewa",middleName:"Lucja",surname:"Stepien",fullName:"Ewa Stepien",slug:"ewa-stepien"}]},{id:"18310",title:"Biomarkers and Coronary Atherosclerotic Burden and Activity as Assessed by Coronary Angiography and Intra-Coronary Imaging Modalities",slug:"biomarkers-and-coronary-atherosclerotic-burden-and-activity-as-assessed-by-coronary-angiography-and-",totalDownloads:1367,totalCrossrefCites:0,signatures:"Valentina Loria, Nicola Cosentino, Rocco A Montone and Giampaolo Niccoli",authors:[{id:"34054",title:"Dr.",name:"Giampaolo",middleName:null,surname:"Niccoli",fullName:"Giampaolo Niccoli",slug:"giampaolo-niccoli"}]}]},relatedBooks:[{type:"book",id:"1347",title:"Coronary Angiography",subtitle:"The Need for Improvement in Medical and Interventional Therapy",isOpenForSubmission:!1,hash:"0364f245ab942f56734547d6b3acaeac",slug:"coronary-angiography-the-need-for-improvement-in-medical-and-interventional-therapy",bookSignature:"Branislav Baškot",coverURL:"https://cdn.intechopen.com/books/images_new/1347.jpg",editedByType:"Edited by",editors:[{id:"33401",title:"Prof.",name:"Baskot",surname:"Branislav",slug:"baskot-branislav",fullName:"Baskot Branislav"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"},chapters:[{id:"19477",title:"Primary Percutaneous Coronary Intervention for ST–Elevation Myocardial Infarction and Door-to-Balloon Time: A Catheterization Laboratory Perspective",slug:"primary-percutaneous-coronary-intervention-for-st-elevation-myocardial-infarction-and-door-to-ballo1",signatures:"Darryl D. Prime and Robert J. Applegate",authors:[{id:"42076",title:"Dr.",name:"Robert",middleName:null,surname:"Applegate",fullName:"Robert Applegate",slug:"robert-applegate"},{id:"48324",title:"Dr.",name:"Darryl",middleName:null,surname:"Prime",fullName:"Darryl Prime",slug:"darryl-prime"}]},{id:"19478",title:"Risk Stratification and Invasive Strategy in NSTE-ACS",slug:"risk-stratification-and-invasive-strategy-in-nste-acs1",signatures:"Frantisek Kovar, Milos Knazeje and Marian Mokan",authors:[{id:"33966",title:"Dr.",name:"Frantisek",middleName:null,surname:"Kovar",fullName:"Frantisek Kovar",slug:"frantisek-kovar"},{id:"49338",title:"Prof.",name:"Marian",middleName:null,surname:"Mokan",fullName:"Marian Mokan",slug:"marian-mokan"},{id:"49339",title:"Prof.",name:"Milos",middleName:null,surname:"Knazeje",fullName:"Milos Knazeje",slug:"milos-knazeje"}]},{id:"19479",title:"Trans Radial Access for Diagnostic Coronary Angiography and Percutaneous Coronary Interventions: Current Concepts and Future Challenges",slug:"trans-radial-access-for-diagnostic-coronary-angiography-and-percutaneous-coronary-interventions-cur1",signatures:"Deepak Natarajan",authors:[{id:"32141",title:"Dr.",name:"Deepak",middleName:null,surname:"Natarajan",fullName:"Deepak Natarajan",slug:"deepak-natarajan"}]},{id:"19480",title:"An Infected Drug-Eluting Stented Coronary Aneurysm Forming Intracardiac Fistula",slug:"an-infected-drug-eluting-stented-coronary-aneurysm-forming-intracardiac-fistula1",signatures:"Ken Kishida",authors:[{id:"33837",title:"Dr.",name:"Ken",middleName:null,surname:"Kishida",fullName:"Ken Kishida",slug:"ken-kishida"}]},{id:"19481",title:"Acute Coronary Syndromes in Women - Gender Specific Changes in Coronarography",slug:"acute-coronary-syndromes-in-women-gender-specific-changes-in-coronarography",signatures:"Anna Polewczyk, Marianna Janion and Maciej Polewczyk",authors:[{id:"41107",title:"Dr.",name:"Anna",middleName:null,surname:"Polewczyk",fullName:"Anna Polewczyk",slug:"anna-polewczyk"},{id:"50386",title:"Prof.",name:"Marianna",middleName:null,surname:"Janion",fullName:"Marianna Janion",slug:"marianna-janion"},{id:"50387",title:"Mr.",name:"Maciej",middleName:null,surname:"Polewczyk",fullName:"Maciej Polewczyk",slug:"maciej-polewczyk"}]},{id:"19482",title:"Tako-Tsubo Cardiomyopathy: A Recent Clinical Syndrome Mimicking an Acute Coronary Syndrome",slug:"tako-tsubo-cardiomyopathy-a-recent-clinical-syndrome-mimicking-an-acute-coronary-syndrome1",signatures:"Montassier Emmanuel, Segard Julien, Arnaud Martinage, Nicolas Piriou, Philippe Le Conte, Gilles Potel and Jean Pierre Gueffet",authors:[{id:"35663",title:"Dr.",name:"Emmanuel",middleName:null,surname:"Montassier",fullName:"Emmanuel Montassier",slug:"emmanuel-montassier"}]},{id:"19483",title:"Role of Percutaneous Cardiopulmonary Support (PCPS) in Patients with Unstable Hemodynamics During the Peri-Coronary-Intervention Period",slug:"role-of-percutaneous-cardiopulmonary-support-pcps-in-patients-with-unstable-hemodynamics-during-the1",signatures:"Ho-Ki Min and Young Tak Lee",authors:[{id:"41245",title:"Prof.",name:"Young Tak",middleName:null,surname:"Lee",fullName:"Young Tak Lee",slug:"young-tak-lee"},{id:"41262",title:"Prof.",name:"Ho-Ki",middleName:null,surname:"Min",fullName:"Ho-Ki Min",slug:"ho-ki-min"}]},{id:"19484",title:"Coronary Angiography Before and After Renal Transplantation",slug:"coronary-angiography-before-and-after-renal-transplantation1",signatures:"Mihas Kodenchery, Samrat Bhat, Mohamed El-Ghoroury, Hiroshi Yamasaki and Peter A. McCullough",authors:[{id:"31485",title:"Prof.",name:"Peter",middleName:"A",surname:"McCullough",fullName:"Peter McCullough",slug:"peter-mccullough"},{id:"88743",title:"Dr",name:"Mihas",middleName:"M",surname:"Kodenchery",fullName:"Mihas Kodenchery",slug:"mihas-kodenchery"},{id:"89043",title:"Dr.",name:"Samrat",middleName:null,surname:"Bhat",fullName:"Samrat Bhat",slug:"samrat-bhat"},{id:"89044",title:"Dr.",name:"Mohamed",middleName:null,surname:"El-Ghoroury",fullName:"Mohamed El-Ghoroury",slug:"mohamed-el-ghoroury"},{id:"89045",title:"Dr.",name:"Hiroshi",middleName:null,surname:"Yamasaki",fullName:"Hiroshi Yamasaki",slug:"hiroshi-yamasaki"}]},{id:"19485",title:"Coronary Interventions with Mechanical Circulatory Support",slug:"coronary-interventions-with-mechanical-circulatory-support1",signatures:"Markus Ferrari",authors:[{id:"57149",title:"Dr.",name:"Markus",middleName:null,surname:"Ferrari",fullName:"Markus Ferrari",slug:"markus-ferrari"}]},{id:"19486",title:"Coronary Arteriovenous Fistula",slug:"coronary-arteriovenous-fistula1",signatures:"Recep Demirbag",authors:[{id:"48521",title:"Dr.",name:"Recep",middleName:null,surname:"Demirbag",fullName:"Recep Demirbag",slug:"recep-demirbag"}]},{id:"19487",title:"Association Between Fatty Liver and Cardiovascular Disease: Mechanism and Clinical Implications",slug:"association-between-fatty-liver-and-cardiovascular-disease-mechanism-and-clinical-implications",signatures:"Nseir W. and Assy N.",authors:[{id:"42614",title:"Dr.",name:"Nimer",middleName:null,surname:"Assy",fullName:"Nimer Assy",slug:"nimer-assy"}]}]}]},onlineFirst:{chapter:{type:"chapter",id:"74769",title:"Development of Integrated Lean Six Sigma-Baldrige Framework for Manufacturing Waste Minimization: A Case of NAS Foods Plc",doi:"10.5772/intechopen.95279",slug:"development-of-integrated-lean-six-sigma-baldrige-framework-for-manufacturing-waste-minimization-a-c",body:'
1. Introduction
Companies are more competitive in current globalization and every detail is important for the business that wants to improve its competiveness. Since it is not a surprise, the best continuous improvement strategies that could be developed for manufacturing industries provide to improve efficiency and effectiveness of whole systems. Though, automating production and improving process efficiency are two major objectives of the food industry worldwide. Since, implementing advanced continues an improvement strategy in the modern manufacturing provides to improve the performance of the process, reduce waste and ensure on time delivery of the sectors [1]. Because of the continuous improvement is a management philosophy that approaches to tackle the challenge of product and increase process improvement [2]. Thus, from numerous tools firms were invested to implement lean, six-sigma, TQM and JIT strategies in their business process so as to enhance performance and compete at global levels, [3]. Though the lean principle provides to identifying and eliminating non value add (wastes) through continuous improvement tools, flowing the product at the pull of the customer in pursuit of perfection [4]. Since due to comprise on quality development, process focus, continuous improvement and value stream management and worker empowerment future several companies invest in the implementation lean principles [3]. While six sigma is a really effective tool for systematically attacking the highest priority production and support functional problems within an organization [4]. Hence, six sigma is statistical measure of defect rate within a system and the practice requires the knowledge of basic and advanced statistical tools so as to reduce defects and variations within a work process in firm. But the main limitations are six sigma not effective for every problem reduction in the firms [5]. Baldrige national quality award (MBNQA) for helping excellence ever, improving value to marketplace success, improvement of overall organizational effectiveness and capabilities, organizational and personal learning. Though from the above observe that a single improvement tools lacks to coherence to tackle the whole problems of the manufacturing firms. Single tools have good potential to tackle specific problems. Even though, an integrated continuous improvement strategies and methods have great power to improve the performance and the competitiveness of the firms [6]. As long as fewer studies were investigate to implements the integration of lean with six sigma, lean with TQM strategies in the firm so as to improve the performance and global Competitiveness [4]. Therefore integrating three or more continuous improvement strategies provides to enhance, quality of products, optimum product cost, timely delivery of products,the flexibility of their internal business process, reduction of wastes and customer satisfactions [3]. Thus, this study aims to develop an integrated frame work from lean, six sigma and the Malcolm Baldrige Criteria so as to improve the production performance, reduce waste and improve competitiveness of NAS Foods Plc.
2. Problem statements
Nowadays food industry makes a significant contribution to national economy in many developing countries. Here in Ethiopia the economy depend on agricultural and which accounts 43.2% of gross domestic product (GDP) [7]. Also there is less contribution in an improvement of biscuit industry analyzed and waste minimization. There is different waste that are identified in six sigma (DMAIC) on NAS food Plc. Currently the company only uses 30% of its capacity and produce 3000 carton per day via 349 workers but it can produce 10,000 cartons with 1000 workers. As a result the value of waste ratio is 36.7%, this show non lean and can be categorized as a traditional company [8]. The defect of the company also calculated and defect per million are 67,308. This shows that the biscuit production of has a production capability with a failure of 67,308 every 1000,000 productions or equivalent to 6.73% loss and this indicates the production process still has a high failure rate. The other problem here is there are limited studies were conducted so far to implement waste minimization tools like six sigma, lean and MBNQA approach on Ethiopian food processing industries [9].
3. Objective
The main objective of this study is to develop an integrated continuous quality improvement model so as to minimize waste of biscuit manufacturing.
To identify the gaps and strength of previous researches on related to continuous improvement strategies to minimize waste.
To investigate the challenges and potentials of integrating continuous improvement strategies in the context of biscuit manufacturing.
To develop an integrated continuous quality improvement models to reducing waste and enhancing competitiveness of NAS food Plc.
4. Literature review
The purpose of this literature review is to provide a background on challenges of waste, waste controlling mechanism and applicability of waste controlling strategies across a variety of industries. Since this understanding will help determine which waste controlling strategies and principles are appropriate for implementation within the food manufacturing industry, and detail topics discuss in this section are for history of waste minimization in manufacturing industry, lean manufacturing philosophy, six sigma and Malcolm Baldrige National Quality Award (MBNQA) principle, tools and technique in manufacturing industries as whole as well as a detailed summary of the literature concerning improvement and competitiveness problem of Ethiopian food processing industry. Though the principal sources of this information included company reports, published literature in textbooks and journals were incorporated.
4.1 Wastes in the food processing sector
Food loss should mean the decrease in edible food mass throughout the food chain. Food losses take place in production, postharvest and processing stages in the food supply chains. Since a division is to be made whether the loss of resources happens in the early stages of the food supply chains (FSC) or the resource was wasted by the action of the retail sector or consumers. Though in the first case, the problems can call about food losses, while in the latter case about food waste. The food losses can be avoided by a correct action, e.g. by maintaining the cold supply chain or ensuring correct storage conditions for products. Since the food loss also occurs if the product that was originally intended for human consumption is recovered in the form of feed, fertilizer or energy [10, 11]. Besides the waste and food waste is more comprehensive and it includes all resources that are lost in the different sectors of the food supply chain, and will include also those parts that were originally not intended for human consumption.
4.2 Waste minimization strategies and mechanisms
The waste is an important issue that should be treated in such a way that the benefits achieved from that will be in both environmental and social aspects. As in manufacturing industries, waste management is key issues to greater opportunities for waste recovery and diversion of waste from landfill, and services suitable to businesses. Though according to [10] shows that waste management is favoring reuse and recycling before land filling, with the main idea of environmental sustainable society.
4.3 Continuous improvement strategies
Quality is becoming an increasingly important subject in organizations. It is central matter to develop a sustained resource management technique. Therefore, logistics emerges as an activity that allows the achievement of a prodigious efficiency and economic welfares and in long term it is to obtain competitive advantages of the country. However, organizations have improvement choices with time depending up on the way they track to meet their strategic and operational objectives, they can watch to its economic welfares. Science raises continuous improvement as the competence of frequent processes and schemes and is closely integrated with means of waste elimination. The customers focus programs such as total quality management, supply chain management, just-in-time and kaizen also need to be understood how to assess quality of products and systems through use of a variety of quality control tools. It is also important to understand how to interpret findings and how to correct problems. There are countless specific tools and techniques that help the industry process improvement and enhancement. Any organization needs to focus on quality of products, optimum product cost, timely delivery of products and the flexibility of their internal business process to adjust to quick fluctuations. Consequently, continuous and constant improvement tools like Kaizen, Six Sigma, ISO-9000, Lean thinking, TQM, SCM and JIT system are not new to the present situation of industrialization for achieving the above concepts. This method is not only limited to any particular industry but also to large potential benefit. It has a widespread application throughout the whole industries. Many industries have adopted it and others are going to implement for their endurance in the fast competition at each stage in each area.
4.4 The concepts of lean manufacturing
Historically the lean production system is the world famous production system developed and practiced by Toyota Company for a long time [12, 13]. Though the basic ideas behind the lean manufacturing system are waste elimination, cost reduction and employee empowerment. Since this concepts leads to maximize customer value while minimizing all the wastes that come with that significance. Nevertheless, lean processes can make jobs highly repetitive while eliminating critical rest time for employees [14]. Lean is a philosophy that aims to maintain smooth production flow by continuously identifying and eliminating waste resulting in increasing value of activities in the production process [15].
4.5 Waste reduction and waste removal
Through Lean Main goal of lean thinking is to reduce and remove waste. Since lean strategy is a potential tool to minimize and then remove waste so as to achieve sustainable development of manufacturing firms. Even though, the lean strategy reduction is one of the main functions of Lean Manufacturing implementation plan [15]. Since all the form of waste i.e. overproduction, defect, transportation, work in progress inventory, over processing, waiting and motion are reduced with Lean manufacturing implementation (Figure 1).
Figure 1.
The seven wastes that controlled quality.
4.6 Roles of six- sigma on improvement
Numerous companies use Six Sigma practice to achieve competitiveness of their business. Six sigma methodologies are cast-off to improve the excellence of the product and process dramatically. Sigma, σ, is a letter employed from the Greek alphabet to measure the process variability and the sigma level measured to determine the performance of the business processes [15]. The six sigma methodology was introduced by Womack et al. [16] and resulted in the accomplishment of business quality in Motorola. According to the study by Snee [17] states that six sigma concept was constructed by Bill Smith, then an engineer at Motorola who wins the 1988 Baldrige National Quality Award. The deployment of six sigma concept is led by Allied-Signal and General Electric (GE). Six-sigma is described as an improvement programmer for reducing variation. It focuses on continuous and breakthrough improvements. In research the two major improvement methodologies in six- sigma has been considered. These are already existing processes and new processes. The first methodology used to improve an existing process and can be divided into five phases [15]. These are:
Define: which process that needs improvement. Define the most suitable team members to work with the improvement. Define the customers of the process, their needs and requirements, and create a map of the process that should be improved.
Measure: Identify the key factors that have the most influence on the process, and decide upon how to measure them.
Analyze: Analyze the factors that need improvements.
Improve: Design and implement the most effective solution. Cost–benefit analyses should be used to identify the best solution.
Control: Verify if the implementation was successful and ensure that the improvement sustains over time. As well the second methodology is often used when the existing processes do not satisfy the customers or are not able to achieve strategic business objectives, see [18]. This methodology can also be divided into five phases; define measure, analyze, design, verify, according to [15]. In summary, the two different methodologies have obvious similarities [19]. Table 1 indicates the integration of the tools.
Define
Measure
Analyze
Improve
Control
Lean tools
Value Mapping Project Charter
Process Mapping Cause and Effect Matrix
FMEA Bottleneck Analysis
Production Smoothing Kaizen Events
Standard Work 5S Poka-Yoke
Table 1.
Integration of lean tools in the DMAIC framework [3].
4.7 Malcolm Baldrige national quality award
The initiative taken to improve quality management practices and the competitiveness of U.S. firms was signed by President Ronald Reagan on Malcolm Baldrige National Quality Improvement Act in 1987. The Malcolm Baldrige National Quality Award (MBNQA) was created to promote quality awareness, identify the requirements for quality excellence and share information about successful quality strategies and benefits [20]. The Baldrige core values and concepts includes visionary leadership management for innovation, customer-driven, excellence, management by fact, organizational and personal learning, social responsibility, valuing employees and partners, focus on results and creating value, agility systems perspective and focus on the future are the common values [21].
Table 2 indicates the comparison of the different programs and tools. It indicates the difference and similarities the tools have so that they lead to develop the ingrate once. Figure 2 indicates the summery of literature review with the major areas considered during the study.
Program
Six Sigma
Lean thinking
MBNQA
Theory
Reduce variation
Remove waste
Quality awareness
Application and Principles
Define
Measure
Analyze
Improve.
Control
Identify value
Identify value stream.
Flow.
Pull, Perfection.
Visionary Leadership, Customer-Driven, Excellence, Organizational and Personal Learning, Valuing Employees &Partners, Agility, Focus on the Future, and analysis and knowledge transfer and organization performance
Focus
Problem focused
Flow focused
Quality focused
Criticisms
System interaction not considered. Processes improved independently.
Statistical or system analysis not valued
Unfairness, superficiality and publicity the inherent value of the continuously improving award program far outweighs its limitations.
Tools
Flow chart, control chart, graphical chart
5S,VSM
Questioner, ABC
Type of Continuous Quality Improvement (CQI) Initiative
Emphasis processes & outcomes
Greatest for processes plagued by wide variability —logging of pharmaceuticals, standardizing referral processes, etc.
a heavily quantitative approach to CQI
Adapted for targeted changes to specific processes.
Combined with Lean when the focus is on efficiency and quality.
Ideal for practices that want to rigorously quantify improvements in safety, quality, and cost effectiveness
Emphasis on process.
Simplifies overcomplicated processes and considers interdependencies.
Best for known problems with known system change solution.
Integrated throughout the organization.
Ideal for large complex health care organizations and practice networks that want to standardize operations across multiple units
Emphasis on structure and outcomes.
Best for practice-wide problem assessment and goal setting.
A broad, holistic approach to CQI initiated at strategic times.
Ideal for practices that want to establish a new CQI system or overhaul an existing one.
To get enough information about the topic raised so many literatures are reviewed from different sources, among these journal articles, reports, and unpublished master thesis is the main one. During literature survey recent documents concerning waste minimization tool lean, six sigma and Malcolm baldrige quality award are collected from different sources then each document critically examined in order to filter gaps below.
[9, 19, 23, 24, 25, 26, 27, 28, 29] this papers integration lean six sigma with different tools but not integration awards or quality perspective.
[21, 30] these papers see the alignment and reviewed of Lean Six sigma and Baldrige but not integrate all and not much has been found in Ethiopian context.
The organizations are not able to reap out the benefits of Lean Six sigma, Baldrige and other advance tools practices due to lack of awareness.
Integrated Lean, Six sigma and Baldrige approach in Ethiopia Industries is not explored and not much has been found in food industry.
5. Research methodology
This study was conducted based on both secondary and primary data collected from the primary sources and ordinary data. Preliminary literature review and existing company condition was scanned to formulate the problems and objectives of the study. The data collection process considered defines measure and analyses the data sources. The process set improvement model and then control the research process. The research draws the conclusion of the resulting analysis with.
As shown in Figure 3, the research process start at problem formulation and arrives at conclusion and recommendation. The study has been conducted by considering preliminary literature review to develop objectives and problem statement. The study was conducted by considering literature review from different know sources and databases. The literature was reviewed from databases like Scopus indexed, web of science listed journals, PUBMED, MEDIN, research gates and DOJ indexed journals. After analyzing and screening literatures, the study found gaps from literature that helped to know the research focus area. Based on the literature review method of data collection and sources were identified. The data was collected through questionnaires, interviews, and field observation. Data sources were used from primary data which was collected by physical field observation, interviews, questioners and company reports from NAS Foods Plc. Responsible and targeted groups were considered under survey on this study. Interview of top managers were made containing 14 interview questions and answer by 1 management and 2 supervisor of the NAS Foods Plc. during the field visiting.
Figure 3.
A methodology framework.
Questioners for employees also conducted to collect data from employees by using questioner to find detail of the problems that NAS Foods Plc. currently facing. The other data source was secondary data which was used to meet the research objectives, reviewing the existing research work of 48 journals, government reports, some reference books & paper related to lean thinking, six sigma, Malcolm Baldrige national quality award programs, strategies, role impacts on manufacturing and food processing industries. The key challenges, potentials and strategies to integrating continuous improvement tolls also considered. The Early search results show that a total of 400 article reports and thesis were found from various textbooks, academic and professional journals. Then read and sort for relevance to the continuous improvement and waste minimization strategy and tools and for their integration. The article would be assessed of methodology, method of measurement and finding results. Finally 48 article, reports and thesis selected are important and related to this study. The research methodology used the continuous quality improvement tool integration to reach its conclusion (Refer to Figure 3).
6. Result and discussion
6.1 Quantitative result
6.1.1 Bivariate correlation analysis
Correlation analysis is used to quantify the association between two continuous variables (between an independent and a dependent variable or between two independent variables. Pearson (r) correlation is the most widely used correlation statistic to measure the degree of the relationship between linearly related variables. The correlation value r = −1 indicated that strong negative correlation existence, r = −0.5 negative correlation, r = 0 with no correlation, r = +0.5 with strong correlation and r = +1 is the strong positive correlation (Figure 4).
Figure 4.
Pareto diagrams of seven wastes).
This study showed the respondent result from questioner and it has 4 sections and 25 questions so in order to see the correlations of all indicators it is preferable to make analysis using SPSS. Based on the above principle the study develop the relationships between the waste measurement variance as we see in the next (Table 3) in the SPSS output Pearson correlation r (value of statistical test) should close to +1 and the sig (2-tailed) or p-value is less than 0.05 for strong relation. As we see the table below there is strong relation in each relation.
Bivariate correlation in between waste measurement parameter.
Correlation is significant at 0.01 level with Person (2-tailed) and list wise N = 100.
6.1.2 Analysis of awareness of waste measurement
Waste measures are included seven perspectives in lean typical. In this study it identified each because waste issue is different from process angle and to see further correlation between each viewpoint. Waste minimization is the basic for any organization, in this study waste minimization of NAS food plc. The awareness of each respondent comprised (Table 3).
When it has been seen the relationship of each variable in waste perspective have strong relation with significance level of 0.01 and the causal Pearson Correlation of variable of excessive transport vs. inappropriate process their value is 0. 579 which show moderate positive relationship and the highest Pearson correlation in waste perspective is between unnecessary inventories vs. waiting their value is 0.920 it mean that waiting in NAS food is highest factor in unnecessary inventory analysis. There is also highest Pearson correlation that the value is greater than 0.9 between inappropriate processing vs. over production and inappropriate process vs. Defect.
6.2 Analysis of Malcolm criteria measurement
Malcolm measures are included seven criteria in management perspective. In this study it identified each because Excellence issue is diverse from management angle and to see further correlation between each viewpoint. Quality improvement is the basic for any organization (Table 4).
Bivariate correlation in between Malcolm criteria measurement.
Correlation is significant at 0.01 level with Person (2-tailed) and list wise N = 100.
When we see the above relationship of each variables in management perspective, they have strong relation with significance level of 0.01 and the causal Pearson Correlation of most variable has a strong positive relation and their value is greater than 0.9 whereas the leadership vs. customer and market their value is 0.960 and it has highest value than the others which shows strong positive relationship.
6.3 Analysis of waste minimization tools measurement
Waste minimization tools measures are included six perspectives in this study. It identified each because waste issue is different from process angle and to see further correlation between each viewpoint. Waste minimization is the basic for any organization; the company does not adopt any particular standardized approach to larger improvement projects (Table 5).
Bivariate correlation in between waste minimization tools.
Correlation is significant at 0.05 level with Person (2-tailed) and list wise N = 100.
Correlation is significant at 0.01 level.
When we see the above relationship, each variables in waste minimization tool perspective have strong relation with significance level at 0.01 and 0.05 whereas the causal Pearson Correlation of JIT vs. Six- sigma their value is −0.370 which show negative relationship and the highest Pearson correlation in waste minimization tool perspective is between lean vs. JIT its value is 0.920 which mean that JIT in NAS food is highest factor in Lean analysis.
6.4 Analysis of competitiveness measurement
Competitiveness measurements are included five perspectives that help evaluation and decision making within organizations that occupy in waste issue. It identified the correlation between quality, price, time, customer satisfaction and environmental views (Table 6).
Bivariate correlation in between competitiveness measurement.
Correlation is significant at 0.01 level with Person (2-tailed) and list wise N = 100.
When we see the above relationship of each variables in competitiveness measurement perspective they have strong relation with significance level of 0.01 and the causal Pearson Correlation of most variable has a strong positive relation and their value is greater than 0.9 whereas the time vs. customer satisfaction and environment their value is 0.934 & 0.940 respectively and it has highest value than the others which shows strong positive relationship it mean that time affect the competitiveness of biscuit product in NAS food is highest factor in customer satisfaction and environment analysis.
6.5 Analysis on waste level using the 7 lean wastes
There are certain techniques obtained from previous studies to analyses the seven lean wastes. Among them, the following stages were used.
Defining Stage: The biscuit production process and determination of VA/NVA activities of NAS manufactures varies biscuits’ production lines. The production process of line is run fulltime. According to many studies biscuit production and design revealed that the biscuit production process covers the stages of raw material preparation, mixing, forming or molding, baking by oven, cooling and packing [31, 32]. Each process has a certain design and layout in order to obtain quality, process capability and good capacity in order to meet the needs of consumers.
Measure Stage: it a Waste Identification stage. During the field observation, the biscuit production process in NAS factory, there were several waste of resources identified i.e. non-standard process, fail on the ground,Crimean machine waste area, Rapper wastage, Packaging scrap product drops, error metal detector detection, broken, oval, overweight or small products, imperfect shape, non-standard water content, malfunction process, and engine breakdown. According to [33] Toyota identifies seven types of waste and they include 1. Overproduction, 2.waiting time, 3. Unnecessary transportation, 4. Excessive or erroneous processing, 5. Excessive inventory, 6. Unnecessary movement and 7. Defective product.to identifies the observed. The results of this identification were illustrated by a value stream mapping diagram, to determine the actual condition of the observed objects in several indicators, including value added and non-value added time. The value of Process Cycle Efficiency (PCE) was calculated to determine the value of Lean application level at NAS. Measuring stage is the process of measuring and identification of waste occurring at every stage of production process. The occurrence of each waste was measured and classified using the approach of 7-waste classification and finally calculated by Pareto analysis [34].
Analysis on the mapping process of the whole series of biscuit production is illustrated by some activities that are classified as non-value-added activities and some value-added activities (Tables 7 and 8). Based on the time measure of the VA and NVA activities, the value of Process Cycle Efficiency (PCE) of 49.64% was obtained. The value of PCE is the result of division between Value Added Time and Total Cycle Time.
Activity
Time(minute)
Preparation of flour material
5.0
Preparation of oil material
4.5
Preparation of packaging material
3.05
Weighing of other materials
11
Mixing process
20
Cutting & forming process
6
Baking process
4.5
Cooling process
5
Stacking process
7.8
Cream mixing process
10
Packing process
7.03
Cartoons process
4.8
Total
78.88
Table 7.
The value added process in the biscuit manufacturing for 3 month.
Activity
Time(Minute)
Lay time-dough
50.0
QC product check
30.0
Total
80.0
Table 8.
Non value added process in the biscuit manufacturing for 3 month.
A company can be considered Lean if the ratio of value-to-waste ratio has reached a minimum of 30%; therefore, if the company is not lean and can be categorized as a traditional company [8]. Because of the value of waste ratio is 36.7%.
Analysis Stage: the definition and analysis of this stage is given as Determination of Critical to Quality (CTQ) and CPM value Critical to Quality. CTQ is a standardized or critical measure at every stage of production processes in order to produce quality products that meet the consumers’ expectation in accordance with the capabilities of process technology available. Gazperzs [34] suggests that the characteristics of quality that will satisfy customers should first be identified. Here, the quality characteristics considered as critical should be classified and controlled. Each quality characteristic that has been classified should be determined to see whether it can be controlled through material, machines, work processes, and others control. CTQ standardization helps us to set up a maximum tolerance limit and a minimum tolerance limit. The values of USL and LSL are determining the process variation for each classified quality characteristic. They can also be used as signposts for product and process developments. According to the study by Hasan [35] stated that range of USL and LSL values is determined by the value of ± n sigma, and the Six-sigma approach (DMAIC method) is used as a reference in order to decrease waste or loss (Table 9).
Process stage
Critical to quality (CTQ)
Measurement
LSL
Target
USL
Preparation of raw materials
Process 1
Kg
6
6.5
7.1
Process 2
Kg
10
10.5
11.3
Process 3
Kg
12
12.5
13.2
Mixing
Process 4
Kg
31.5
32
32.7
Process 5
Kg
199.5
200
200.8
Process 6
Kg
89.5
90
90.7
Forming
Process 7
Gr
19.5
20
20.7
Process 8
Gr
17.5
18
18.8
Oven
Process 9
Mm
49.5
50
50.6
Process 10
Mm
44.5
45
45.7
Process 11
%
2.5
3
3.8
Process 12
PH
8.5
9
9.7
Cooling
Process 13
Wt.
39.5
40
40.6
Process 14
Wt.
9.5
10
10.6
Stacking
Process 15
Gr
29.5
30
30.6
Process 16
Mm
34.5
35
35.8
Packing
Process 17
Gr
139.5
140
140.7
Process 18
Gr
29.5
30
30.8
Factors
PPM - Cpk Calculator
Parts per million above USL
150
Parts per million below LSL
−50
Total PPM
100
Zupper
5.12
Zlower
6.25
Z (Sigma)
5.22
Cp
1.74
Cpk
1.71
Table 9.
CTQ of biscuit production process in one line in NAS food plc.
As shown in Figure 5, the research found the values of six sigma calculation and enter the number defect observed is 5.25, enter the size of the sample are 78 and the defects per million (DPMO) of 67,308, and sigma of 3. This shows that the biscuit production of has a production capability with a failure of 67,308 every 1000,000 productions, or equivalent to 6.73% loss, and this indicates the production process still has a high failure rate. Also the research calculate DPOM, percentage of defect, percentage of yield, process sigma by process sigma calculator with inserting the number of defect observed and opportunities then automatically it calculate give result as we see above in the picture.
Improvement Stages: this is the place where determination of FMEA is to be conducted and analyzed. A number of improvement steps were established at each stage of the existing processes from the preparation of raw materials, mixing, forming, baking, cooling, stacking and packing. Then, this stage tabulation was carried out on FMEA analysis. The FMEA method was used to determine the failure of the process and to analyze and improve the production quality [31, 36] (Table 10).
Figure 5.
Control chart for UCL and LCL.
Processes Biscuit making
Steps/ Inputs
Failure mode
Failure Effects
SEV
Causes of failure mode
OCC
Current control
DET
RPN
Material preparation
Material weighing
Wrong ingredient
Inconsistent quality
10
Substandard material supplied by supplier
5
Undetectable
10
500
No electricity power
Damaged dough
8
Main Distributor Panel Trip
6
No monitoring
10
480
Blocking wheat at hopper
Line stop
7
Damaged Filter
6
No monitoring
10
420
Mixing Process
Mixing
Different usage of water between shifts
Unstable dough and waste
6
Differences in methods by operators
10
Controlling only after mixing is finished
6
360
Frequently error censor
Down time and safety issue
6
Unstable socket pad
10
Alarm system of mixer is on
5
300
Forming Process
Forming
Product Tailing
Product jam
10
Uneven surface of blades
10
Checklist of forming
6
600
Product Tailing
Product Jam
10
Loose molder Teflon
10
Visual control
5
500
Oven Process
Baking Process
Irregular thickness of biscuit
Unbalanced thickness of biscuits
10
Uneven weight among rows
10
Check list of intense monitoring
5
500
Product Jam
One side of Wire mesh is loose
10
One side of Wire mesh is loose
10
Visual control
7
700
Cooling process
Cooler
Product is Excess Calm
More rejected products
10
Scrap was taken accidentally
10
Only Visual
5
500
Stacking process
Sandwich
Thin or thick biscuits
packing machine often starts or stops
10
Cream texture is different since the icing weight is different
10
No control/ monitor
10
1000
Mixing cream
Unbalanced Cream
Waste/ thin or thick
10
Inaccurate balance or weighing scale
10
Inappropriate display
8
800
Packing Process
Product packaging
Broken Products
Dead machine, quality potential
10
No sorting tool of sandwich since taken accidentally to packing
10
Visual
10
1000
Poor packaging material
Inconsistent quality
10
Substandard material supplied by supplier
6
No control
10
600
Table 10.
Improvement process 5) control stage: Plan to continue measuring the success of the updated process is usually created and any documentation, process or training material is updated.
6.6 Qualitative result
Analysis on Baldrige model with six sigma methodology they state that “Baldrige provides the framework, Six Sigma the methodology.”
The experience of Motorola with Six Sigma helped the company to won the Baldrige award in 1988. According to Sumberg [37]; Parast [1] the Six Sigma quality laid the foundation for Motorola to be the first company to win the Baldrige award. Such a link between the Six Sigma methodology and the Baldrige model exists in practice.
The MBNQA framework has extended its application beyond businesses. According to the studies, it has specific guides for Education and Health Care organizations [38, 39]. MBNQA seven categories are Leadership, Strategic Planning, Customer and Market Focus, Measurement, Analysis and Knowledge Management; Human Resource Focus; Process Management; and Business Results [3]. Leadership shows how upper management chiefs the organization and organization community. The strategic planning is also the organization establishment of plans to implement strategic directions. Customer and Market Focus is the organization that builds and maintains strong, lasting relationships within customers. Measurement, Analysis and Knowledge Management are also the organizations use of data to support key processes and manage performance while human resource focus is outlining of the importance of human resources. Process Management uses powerful tools like Continuous improvement program, Zero Defect, and Re-engineering. Continuous improvement recognizes that, even when no errors occur, there are opportunities to improve the design of the process or product. All the time, the competitors are seeking to gain an advantage by making their products better. If the companies do not seek to improve, it will get left behind. Company should expect to receive no complaints from customers. This goes beyond the idea of keeping complaints to a minimum. It indicates that the company should adopt a new approach, perhaps checking that each customer is satisfied with his purchase [40]. Finally, business results is an indication of the organization improve in terms of customer satisfaction, finances, human resources, supplier and partner performance, operations, governance and social responsibility and how the organization compares to its competitors.
6.7 Proposed continuous quality improvement model
The integration lean, six sigma and Baldrige model understand separately and define similarity and dissimilarity in each alignment some criteria are considered based on the literature review. These include: focus on work condition in addition to process, easily understandable and having proper metrics; addressing the possible root cause of continuous quality improvement problems; being continuous improvement tool; having clearly defined improvement goal; flexibility to apply from operation to firm level and involving all, including top management to low.
6.8 Feature of the proposed model
6.8.1 Applying six sigma in the lean philosophy
It is true that there is established link between Six Sigma methodology and the lean manufacturing with in the previous studies. The proposed integrative six sigma and lean manufacturing is based on the following basic pillar principles. These principles are:
The Six-Sigma methodology is linked with the lean. It becomes part of the Lean six sigma (LSS) for achieving waste and defect reduction techniques.
The lean self-assessment includes the assessment of each seven waste in the six-sigma (DMAIC).
The proposed model for the integrative lean Six-Sigma is capable of addressing the core values of the lean. Areas such as overproduction, waiting time, unnecessary transportation, excessive or erroneous processing, excessive inventory, unnecessary movement and defect can be addressed by Six Sigma methodology.
6.8.2 Applying Six Sigma in the Baldrige Model
It has been established a link between six sigma methodology and the Baldrige model in similar fashion as six-sigma with leans. The proposed integrative six sigma and Baldrige model given in Figure 6 is based on the following principles.
The Six-Sigma methodology is linked with the Baldrige model. It becomes part of the Baldrige model which is considered as a single unit for achieving performance excellence. This performance analysis requirement is set by the top management. After the establishment of Baldrige model goals, Six Sigma methodologies are used to increase the processes and meet quality purposes.
Six-Sigma projects can be applied to all types of the projects, processes, and products. Based on this application, the selection, administration, and control mechanisms were directed by the top management used in this proposed model.
The proposed model for the integrative six-sigma-Baldrige Quality in Figure 6 is capable of addressing the core values of the Baldrige model. Areas like leadership competencies, strategic development and deployment, and human resource management can be addressed by six-sigma methodology which is a powerful tool.
Figure 6.
Integrated lean-six sigma model.
6.8.3 Applying six sigma in the Baldrige model and lean
We established a link between six sigma methodology and the Baldrige model also six -sigma and lean. The proposed integrative lean Six Sigma and Baldrige model is based on the following principles:
When lean, six sigma integrated with Baldrige model. In fact, it becomes part of Baldrige model for achieving excellence. Such a performance requirement is set by the top management. Afterward aligned with the requirement of the Baldrige model, lean and six sigma methodologies become used for improve the process and meet quality objective.
The Baldrige self-assessment includes both the assessment of each seven categories in the Baldrige model as well as the efficiency and effectiveness of the six sigma projects. Such an approach toward six sigma and lean projects ensures that the company is gaining benefit from implementing the lean- six sigma methodologies.
The proposed models for the integration of lean, six sigma with Baldrige is capable of addressing the core value of the Baldrige model and identify the seven waste of lean. Area such as leadership competencies, strategic development and human resource management can be address by six sigma methodology whereas for the integrative lean Six Sigma identifies such area overproduction, waiting time, unnecessary transportation, excessive or erroneous processing, excessive inventory, unnecessary movement and defect can be addressed by Six Sigma (DMAIC) methodology.
7. Conclusion
The conclusion of this research is that the waste minimization at NAS food Plc. as production process applying the lean process. In such cases, the standard DMAIC cycle may provide structure and ensure that each step is improve thoroughly, thereby helping the success of the project. Lean can contribute to these projects by staking out the direction; that is, indicating where to start, for example through the use of value stream mapping where the process is reviewed in order to find waste. Analysis on the mapping process of the whole series of biscuit production is illustrated by some activities that are classified as non-value-added activities and some value-added activities.
In this paper both qualitative and quantitative analysis are applied and the result of qualitative by using (DMAIC) based on the time measure of the VA and NVA activities, the value of Process Cycle Efficiency (PCE) of 49.64% was obtained. And the research found the value of waste ratio is 36.7%, this show non lean in the company and the values of six sigma calculation and insert the number defect observed is 5.25, the size of the sample are 78 and the result defects per million (DPMO) is 67,308 and sigma of 3. This shows that the biscuit production of has a production capability with a failure of 67,308 every 1000,000 productions, or equivalent to 6.73% loss, and this indicates the production process still has a high failure rate. And improve by using FMEA analysis was carried out each stage of the existing process used to determine the failure of the process and to analyze and improve the production quality and the result of highest RPN on Stacking and packaging process so they should take action for waste minimization and continuous quality improvement. In addition, Organizations try to implement the Baldrige model as a means for achieving excellence. The seven categories within the Baldrige model is integrated and related with the purpose of addressing quality challenges so that companies can be competitive in the dynamic business environment.
In quantitative analysis used SPSS software and the Correlation and regression analysis is used to quantify the association between two continuous variables (between an independent and a dependent variable or between two independent variables). The result of this shown relationship of each variables in waste measurement perspective they have strong relation with significance level of 0.01 and the causal Pearson Correlation of most variable has a strong positive relation and their value is greater than 0.8, likewise The good regression results of equation is selected in each section which is explained R2 value about 0.9 or 90% with statistically significant (P < 0.01) level.
However, In this paper, relying on a review of the national and international literature, 25 key indicators was selected based on the correlation having strong ‘r’ value under four improvement perspectives were identified to assess measurement system of the organization. The Lean Six Sigma & Baldrige application studied here does not point toward one well-defined Lean Six Sigma approach; the company does not adopt any particular standardized approach to larger improvement projects. Instead, the company supports the integration at this level by ensuring that their improvement specialists are widely trained in Lean, Six Sigma and Baldrige model.
8. Recommendation
Further research is required for biscuit manufacturing in terms of waste minimization at each process stage using this DMAIC methodology. This study needs to be continued in terms of FMEA usage along with the development selection model for waste minimization and improving the production process. Instead, the company supports the integration at this level by ensuring that their improvement specialists are widely trained in Lean, Six Sigma and Baldrige model.
Similar research also should be conducted in order to provide added value in the fields of food or agriculture with the application of lean six-sigma and Baldrige model.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"waste, lean, DAMIC, CQI, MBNQA",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/74769.pdf",chapterXML:"https://mts.intechopen.com/source/xml/74769.xml",downloadPdfUrl:"/chapter/pdf-download/74769",previewPdfUrl:"/chapter/pdf-preview/74769",totalDownloads:7,totalViews:0,totalCrossrefCites:0,dateSubmitted:"November 4th 2020",dateReviewed:"November 29th 2020",datePrePublished:"January 11th 2021",datePublished:null,dateFinished:"January 11th 2021",readingETA:"0",abstract:"The aim of this study objective is to develop an integrated constant quality improvement model so as to minimize unwanted biscuit processing industry wastes. The method used was lean- six- sigma elements to define measure and improve unwanted process company wastes. In other word, Baldrige with six-sigma were created to define, measure and improve management perspectives. The tasks were integrated using both quantitative and qualitative analyzing tools implementing mixed strategies. The result was improved by using FMEA analysis was carried out at each stage of the existing process used to determine the failure of the process and to analyses and improve the production quality. The SPSS software was also used. In the finding section, the correlation and regression analysis has shown that there is strong relationship between each variance. There are different wastes that identified in six sigma (DMAIC) on NAS food Plc as a result; the value of waste ratio indicated is 36.7%. This show non-lean of the food industry is practiced. The defect of the company also calculated and defect per million are 67,308. This shows that the biscuit production has a production capability with a failure of 67,308 every 1000,000 productions it high failure rate. The contribution of the paper has indicated that there are limited studies were conducted so far to implement waste minimization tools like six-sigma, lean and MBNQA framework approach integration for food processing industry.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/74769",risUrl:"/chapter/ris/74769",signatures:"Kassu Jilcha Sileyew and Selamawit Gebreyohanis",book:{id:"10548",title:"Lean Manufacturing",subtitle:null,fullTitle:"Lean Manufacturing",slug:null,publishedDate:null,bookSignature:"Prof. Karmen Pažek",coverURL:"https://cdn.intechopen.com/books/images_new/10548.jpg",licenceType:"CC BY 3.0",editedByType:null,editors:[{id:"179642",title:"Prof.",name:"Karmen",middleName:null,surname:"Pažek",slug:"karmen-pazek",fullName:"Karmen Pažek"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Problem statements",level:"1"},{id:"sec_3",title:"3. Objective",level:"1"},{id:"sec_4",title:"4. Literature review",level:"1"},{id:"sec_4_2",title:"4.1 Wastes in the food processing sector",level:"2"},{id:"sec_5_2",title:"4.2 Waste minimization strategies and mechanisms",level:"2"},{id:"sec_6_2",title:"4.3 Continuous improvement strategies",level:"2"},{id:"sec_7_2",title:"4.4 The concepts of lean manufacturing",level:"2"},{id:"sec_8_2",title:"4.5 Waste reduction and waste removal",level:"2"},{id:"sec_9_2",title:"4.6 Roles of six- sigma on improvement",level:"2"},{id:"sec_10_2",title:"4.7 Malcolm Baldrige national quality award",level:"2"},{id:"sec_11_2",title:"4.8 Literature gap",level:"2"},{id:"sec_13",title:"5. Research methodology",level:"1"},{id:"sec_14",title:"6. Result and discussion",level:"1"},{id:"sec_14_2",title:"6.1 Quantitative result",level:"2"},{id:"sec_14_3",title:"Table 3.",level:"3"},{id:"sec_15_3",title:"6.1.2 Analysis of awareness of waste measurement",level:"3"},{id:"sec_17_2",title:"6.2 Analysis of Malcolm criteria measurement",level:"2"},{id:"sec_18_2",title:"6.3 Analysis of waste minimization tools measurement",level:"2"},{id:"sec_19_2",title:"6.4 Analysis of competitiveness measurement",level:"2"},{id:"sec_20_2",title:"6.5 Analysis on waste level using the 7 lean wastes",level:"2"},{id:"sec_21_2",title:"6.6 Qualitative result",level:"2"},{id:"sec_22_2",title:"6.7 Proposed continuous quality improvement model",level:"2"},{id:"sec_23_2",title:"6.8 Feature of the proposed model",level:"2"},{id:"sec_23_3",title:"6.8.1 Applying six sigma in the lean philosophy",level:"3"},{id:"sec_24_3",title:"6.8.2 Applying Six Sigma in the Baldrige Model",level:"3"},{id:"sec_25_3",title:"6.8.3 Applying six sigma in the Baldrige model and lean",level:"3"},{id:"sec_28",title:"7. Conclusion",level:"1"},{id:"sec_29",title:"8. Recommendation",level:"1"},{id:"sec_33",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Mahour M.Parast, E. C. (2006). A Relationship between Six Sigma And Malcom Baldrige Quality Award.'},{id:"B2",body:'Coskun Dalgiç, H. V. (2011). Improvement of Food Safety and Quality by Statistical Process Control (SPC) in Food Processing Systems: A Case Study of Traditional Sucuk (Sausage) Processing. InTech, Available from: http://www.intechopen.com/books.'},{id:"B3",body:'Png, C. L. (2015). A Review of Lean Six Sigma and Malcolm Baldrige. Volume 6.'},{id:"B4",body:'Mousa, A. (2013). Lean, six sigma and lean six sigma Overview. International Journal of Scientific & Engineering Research, volume 4(5).'},{id:"B5",body:'Liang Y, et al. (2014). Engineered pent functional minicellulosome for simultaneous scarification and ethanol fermentation in Saccharomyces cerevisiae. Appl Environ Microbiol 80(21):6677-6684'},{id:"B6",body:'Alie Wube Dametew, D. K. (2017). The Roles of TQM and JIT for Basic Metal Industries Global Competitiveness. Industrial Engineering & Management, 6(2).'},{id:"B7",body:'Workneh, H. (2010). Analysis of Technical Efficiency of the Ethiopian Agro-Processing Industry: The Case of Biscuit and Pasta Processing Firms. AAU School of Economics.'},{id:"B8",body:'Ibrahim Alhuraish, Christian Robledo, Abdessamad Kobi (2017), A comparative exploration of lean manufacturing and six sigma in terms of their critical success factors, Journal of Cleaner Production, Volume 164, 15, Pages 325-337'},{id:"B9",body:'Yasin, a. (2014). Application of lean six sigma for process improvement: the case of Ethiopian paper and pulp s.c. Addis Abab: AAiT.'},{id:"B10",body:'Imam, H. (2010). Recycling in a supply chain context - A case study regarding sorting and collection. Melardeen University of Seweden.'},{id:"B11",body:'Pap, N., Pongrácz, E., & Myllykoski, L. (2014). Waste Minimization and Utilization in the Food Industry. Jatindra Kumar Sahu (ed.).'},{id:"B12",body:'Dave, N. (2002). How to compare six-sigma, lean and the theory of constraints. Volume 6.'},{id:"B13",body:'Eshetu, B. (2017). Integrated Model for Continuous Productivity Improvement in Footwear Industry: (A Case of Anbessa Shoe S.C.). AAiT.'},{id:"B14",body:'Kumar, R., & Kumar, V. (2012). Lean manufacturing: elements and its benefits for manufacturing industry. Trends and Advances in Mechanical Engineering,YMCA University of Science & Technology, Faridabad, Haryana.'},{id:"B15",body:'Thomas Pyzdek (2003),The Six Sigma Handbook, A Complete Guide for Green Belts, Black Belts, and Managers at All Levels, McGraw-Hill Companies, T.H.E.'},{id:"B16",body:'Womack, J.P., Jones, D.T. and Roos, D. (1990), “The machine that changed the world: the story of lean production”, How Japan’s Secret Weapon in the Global Auto Wars Will Revolutionize Western Industry, Rawson Associates, New York, NY'},{id:"B17",body:'Ron Snee (2010), Lean Six Sigma – getting better all the time, International Journal of Lean Six Sigma 1(1):9-29 DOI: 10.1108/20401461011033130'},{id:"B18",body:'Eckes, G. (2001),The Six Sigma Revolution, Wiley, New York, NY'},{id:"B19",body:'Andersson, R., Eriksson, H., and Torstensson, H. (2006) Similarities and differences between TQM, Six Sigma and Lean, The TQM Magazine, 18(3), 282-296.'},{id:"B20",body:'Vokurka, R. Stading, G. & Brazeal, J. (2000). A comparative analysis of national and regional quality programs. Quality Progress, pg 41-49'},{id:"B21",body:'Singh, C.D., Singh, R. and Singh, S. (2013), “Application of lean and JIT principles in supply chain management”, Journal of Regional and Socio-Economic'},{id:"B22",body:'Horne, J. R. (2009). The effect on corporate performance of firms that won the. H. Wayne Huizenga School of Business and Entrepreneurship Nova Southeastern University.'},{id:"B23",body:'Nave, D. (2002). How to Compare Six Sigma, Lean and the Theory of Constraints. USA: American Society for Quality.'},{id:"B24",body:'Ahmed, M. (2013). Lean, six sigma and lean six sigma. International Journal of Scientific & Engineering Research, 6(2), 1137-1153.'},{id:"B25",body:'Hans, S. B. (2013). Applying Lean, Six Sigma, BPM, and SOA to Drive Business Results (Vol. 6). IBM.'},{id:"B26",body:'Young, B. (2001). Waste Minimisation An Environmental Good Practice Guide for Industry. The Environment Agency.'},{id:"B27",body:'Talib, F. R. (2011). Total quality management and service quality: an exploratory study of management practices and barriers in service industries. International Journal of Services and Operations Management, 10(1), 94-118.'},{id:"B28",body:'Jangwoo Lee, K. L. (2015). Supplier Partnership Strategy And Global Competitiveness:A Case Of Samsung Electronics. Eurasian Journal of Business and Management, 3(4), 1-12.'},{id:"B29",body:'Walder, J. (2007). Integrated Lean thinking & ergonomics utilizing material handling assist device solutions for aprodction work place.'},{id:"B30",body:'Sunilkumar N Chaudhari1, A. J. (2015). JIT Implements in manufacturing industry – A Review. International Journal of Engineering Research and General Science, 3(4).'},{id:"B31",body:'Ahmed M, s. a. (2017). PT kraft ultrajaya indonesia. indonesian journal of business and enterpreneur, 77-89.'},{id:"B32",body:'Link, A. N. (2001). Economic Evaluation of the Baldrige National Quality Program. University of North Carolina at Greensboro.'},{id:"B33",body:'Womack, J. a. (2003). The Machine that Changed the World. New York.'},{id:"B34",body:'Addae-Korankye. (2013). Total quality management (tqm): a source of competitive advantage. A comparative study of manufacturing and service firms in ghana. International Journal of Asian Social Science, 3(6), 1293-1305.'},{id:"B35",body:'Milovanoi, M. (2011). Just in time concept as a mean for achieving competitive advantage in the virtual economy. In b. Katalinic (Ed.). 22. DAAAM International, Vienna, Austria, EU.'},{id:"B36",body:'Md. Mazedul Islam, A. M. (2013). Application of Lean Manufacturing to Higher Productivity in the Apparel Industry in Bangladesh. International Journal of Scientific & Engineering Research, volume 10.'},{id:"B37",body:'Praveen, S. (2012). Reduction of working in process inventory & production lead time in bearing industry using value stream mapping. volume 9.'},{id:"B38",body:'Talib, F. (2013). An Overview of Total Quality Management: Understanding the Fundamentals in Service Organization. International Journal of Advanced Quality Management, 1(1), 1-20.'},{id:"B39",body:'Kassuand Kitaw. (2016). A Literature Review On Global Occupational Safety And Health Practice & Accidents Severity. International Journal for Quality Research, PP 279–310.'},{id:"B40",body:'Dr. H. Nagaprasad, 1. B. (2008). Making World Class Product Through Quality Process Management.'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Kassu Jilcha Sileyew",address:"jkassu@gmail.com",affiliation:'
School of Mechanical and Industrial Engineering, Addis Ababa Institute of Technology, Addis Ababa University, Addis Ababa, Ethiopia
School of Mechanical and Industrial Engineering, Addis Ababa Institute of Technology, Addis Ababa University, Addis Ababa, Ethiopia
'}],corrections:null},book:{id:"10548",title:"Lean Manufacturing",subtitle:null,fullTitle:"Lean Manufacturing",slug:null,publishedDate:null,bookSignature:"Prof. Karmen Pažek",coverURL:"https://cdn.intechopen.com/books/images_new/10548.jpg",licenceType:"CC BY 3.0",editedByType:null,editors:[{id:"179642",title:"Prof.",name:"Karmen",middleName:null,surname:"Pažek",slug:"karmen-pazek",fullName:"Karmen Pažek"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},profile:{item:{id:"73993",title:"Dr.",name:"Duicu",middleName:null,surname:"Carmen",email:"duicucarmen@yahoo.com",fullName:"Duicu Carmen",slug:"duicu-carmen",position:null,biography:null,institutionString:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",totalCites:0,totalChapterViews:"0",outsideEditionCount:0,totalAuthoredChapters:"1",totalEditedBooks:"0",personalWebsiteURL:null,twitterURL:null,linkedinURL:null,institution:{name:"University of Medicine and Pharmacy of Târgu Mureş",institutionURL:null,country:{name:"Romania"}}},booksEdited:[],chaptersAuthored:[{title:"The Association of the DNA Repair Genes with Acute Myeloid Leukemia: The Susceptibility and the Outcome After Therapy",slug:"the-association-of-the-dna-repair-genes-with-acute-myeloid-leukemia-the-susceptibility-and-the-outco",abstract:null,signatures:"Claudia Bănescu, Carmen Duicu and Minodora Dobreanu",authors:[{id:"65677",title:"Dr.",name:"Claudia",surname:"Banescu",fullName:"Claudia Banescu",slug:"claudia-banescu",email:"claudia.banescu@gmail.com"},{id:"73992",title:"Prof.",name:"Minodora",surname:"Dobreanu",fullName:"Minodora Dobreanu",slug:"minodora-dobreanu",email:"dobreanum@yahoo.com"},{id:"73993",title:"Dr.",name:"Duicu",surname:"Carmen",fullName:"Duicu Carmen",slug:"duicu-carmen",email:"duicucarmen@yahoo.com"}],book:{title:"Myeloid Leukemia",slug:"myeloid-leukemia-basic-mechanisms-of-leukemogenesis",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"64524",title:"Dr.",name:"Katarzyna",surname:"Piwocka",slug:"katarzyna-piwocka",fullName:"Katarzyna Piwocka",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"64831",title:"Prof.",name:"Maria Teresa",surname:"Vargas",slug:"maria-teresa-vargas",fullName:"Maria Teresa Vargas",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",institutionURL:null,country:{name:"Spain"}}},{id:"71536",title:"Dr.",name:"Maria De Los Angeles",surname:"Portero",slug:"maria-de-los-angeles-portero",fullName:"Maria De Los Angeles Portero",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Hospital Universitario Virgen Macarena",institutionURL:null,country:{name:"Spain"}}},{id:"71537",title:"Dr.",name:"Inmaculada",surname:"Trigo",slug:"inmaculada-trigo",fullName:"Inmaculada Trigo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Hospital Universitario Virgen Macarena",institutionURL:null,country:{name:"Spain"}}},{id:"71538",title:"Dr.",name:"Alicia",surname:"Rodriguez",slug:"alicia-rodriguez",fullName:"Alicia Rodriguez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Hospital Universitario Virgen Macarena",institutionURL:null,country:{name:"Spain"}}},{id:"73363",title:"Dr.",name:"Paulina",surname:"Podszywalow-Bartnicka",slug:"paulina-podszywalow-bartnicka",fullName:"Paulina Podszywalow-Bartnicka",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"73364",title:"MSc",name:"Monika",surname:"Kusio-Kobialka",slug:"monika-kusio-kobialka",fullName:"Monika Kusio-Kobialka",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"121016",title:"Dr.",name:"Alejandra",surname:"Abasolo",slug:"alejandra-abasolo",fullName:"Alejandra Abasolo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Hospital Universitario Virgen Macarena",institutionURL:null,country:{name:"Spain"}}},{id:"121099",title:"Dr.",name:"Antonio",surname:"Garcia-Escudero",slug:"antonio-garcia-escudero",fullName:"Antonio Garcia-Escudero",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Hospital Universitario Virgen Macarena",institutionURL:null,country:{name:"Spain"}}},{id:"121151",title:"Dr.",name:"Kamila",surname:"Wolanin",slug:"kamila-wolanin",fullName:"Kamila Wolanin",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null}]},generic:{page:{slug:"waiver-policy",title:"Waiver Policy",intro:"
We believe financial barriers should not prevent researchers from publishing their findings. With the need to make scientific research more publicly available and support the benefits of Open Access, more and more institutions and funders are dedicating resources to assist faculty members and researchers cover Open Access Publishing Fees (OAPFs). In addition, IntechOpen provides several further options presented below, all of which are available to researchers, and could secure the financing of your Open Access publication.
",metaTitle:"Waiver Policy",metaDescription:"We feel that financial barriers should never prevent researchers from publishing their research. With the need to make scientific research more publically available and support the benefits of Open Access, more institutions and funders have dedicated funds to assist their faculty members and researchers cover the APCs associated with publishing in Open Access. Below we have outlined several options available to secure financing for your Open Access publication.",metaKeywords:null,canonicalURL:"/page/waiver-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"
Paying the OAPF
\\n\\n
At IntechOpen, the majority of OAPFs are paid by an Author’s institution or funding agency - Institutions (73%) vs. Authors (23%).
\\n\\n
The first step in obtaining funds for your Open Access publication begins with your institution or library. IntechOpen’s publishing standards align with most institutional funding programs. Our advice is to petition your institution for help in financing your Open Access publication.
\\n\\n
However, as Open Access becomes a more commonly used publishing option for the dissemination of scientific and scholarly content, in addition to institutions, there are a growing number of funders who allow the use of grants for covering OA publication costs, or have established separate funds for the same purpose.
\\n\\n
Please consult our Open Access Funding page to explore some of these funding opportunities and learn more about how you could finance your IntechOpen publication. Keep in mind that this list is not definitive, and while we are constantly updating and informing our Authors of new funding opportunities, we recommend that you always check with your institution first.
\\n\\n
IntechOpen Waivers in Action
\\n\\n
For Authors who are unable to obtain funding from their institution or research funding bodies and still need help in covering publication costs, IntechOpen offers the possibility of applying for a Waiver.
\\n\\n
Our mission is to support Authors in publishing their research and making an impact within the scientific community. Currently, 14% of Authors receive full waivers and 6% receive partial waivers.
\\n\\n
While providing support and advice to all our international Authors, waiver priority will be given to those Authors who reside in countries that are classified by the World Bank as low-income economies. In this way, we can help ensure that the scientific work being carried out can make an impact within the worldwide scientific community, no matter where an Author might live.
\\n\\n
How to Apply for a Waiver
\\n\\n
The application process is open after your submitted manuscript has been accepted for publication. To apply, please fill out a Waiver Request Form and send it to your Author Service Manager. If you have an official letter from your university or institution showing that funds for your OA publication are unavailable, please attach that as well. The Waiver Request will normally be addressed within one week from the application date. All chapters that receive waivers or partial waivers will be designated as such online.
Feel free to contact us at oapf@intechopen.com if you have any questions about Funding options or our Waiver program. If you have already begun the process and require further assistance, please contact your Author Service Manager, who is there to assist you!
\\n\\n
Note: All data represented above was collected by IntechOpen from 2013 to 2017.
At IntechOpen, the majority of OAPFs are paid by an Author’s institution or funding agency - Institutions (73%) vs. Authors (23%).
\n\n
The first step in obtaining funds for your Open Access publication begins with your institution or library. IntechOpen’s publishing standards align with most institutional funding programs. Our advice is to petition your institution for help in financing your Open Access publication.
\n\n
However, as Open Access becomes a more commonly used publishing option for the dissemination of scientific and scholarly content, in addition to institutions, there are a growing number of funders who allow the use of grants for covering OA publication costs, or have established separate funds for the same purpose.
\n\n
Please consult our Open Access Funding page to explore some of these funding opportunities and learn more about how you could finance your IntechOpen publication. Keep in mind that this list is not definitive, and while we are constantly updating and informing our Authors of new funding opportunities, we recommend that you always check with your institution first.
\n\n
IntechOpen Waivers in Action
\n\n
For Authors who are unable to obtain funding from their institution or research funding bodies and still need help in covering publication costs, IntechOpen offers the possibility of applying for a Waiver.
\n\n
Our mission is to support Authors in publishing their research and making an impact within the scientific community. Currently, 14% of Authors receive full waivers and 6% receive partial waivers.
\n\n
While providing support and advice to all our international Authors, waiver priority will be given to those Authors who reside in countries that are classified by the World Bank as low-income economies. In this way, we can help ensure that the scientific work being carried out can make an impact within the worldwide scientific community, no matter where an Author might live.
\n\n
How to Apply for a Waiver
\n\n
The application process is open after your submitted manuscript has been accepted for publication. To apply, please fill out a Waiver Request Form and send it to your Author Service Manager. If you have an official letter from your university or institution showing that funds for your OA publication are unavailable, please attach that as well. The Waiver Request will normally be addressed within one week from the application date. All chapters that receive waivers or partial waivers will be designated as such online.
Feel free to contact us at oapf@intechopen.com if you have any questions about Funding options or our Waiver program. If you have already begun the process and require further assistance, please contact your Author Service Manager, who is there to assist you!
\n\n
Note: All data represented above was collected by IntechOpen from 2013 to 2017.
\n'}]},successStories:{items:[]},authorsAndEditors:{filterParams:{sort:"featured,name"},profiles:[{id:"105746",title:"Dr.",name:"A.W.M.M.",middleName:null,surname:"Koopman-van Gemert",slug:"a.w.m.m.-koopman-van-gemert",fullName:"A.W.M.M. Koopman-van Gemert",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105746/images/5803_n.jpg",biography:"Dr. Anna Wilhelmina Margaretha Maria Koopman-van Gemert MD, PhD, became anaesthesiologist-intensivist from the Radboud University Nijmegen (the Netherlands) in 1987. She worked for a couple of years also as a blood bank director in Nijmegen and introduced in the Netherlands the Cell Saver and blood transfusion alternatives. She performed research in perioperative autotransfusion and obtained the degree of PhD in 1993 publishing Peri-operative autotransfusion by means of a blood cell separator.\nBlood transfusion had her special interest being the president of the Haemovigilance Chamber TRIP and performing several tasks in local and national blood bank and anticoagulant-blood transfusion guidelines committees. Currently, she is working as an associate professor and up till recently was the dean at the Albert Schweitzer Hospital Dordrecht. She performed (inter)national tasks as vice-president of the Concilium Anaesthesia and related committees. \nShe performed research in several fields, with over 100 publications in (inter)national journals and numerous papers on scientific conferences. \nShe received several awards and is a member of Honour of the Dutch Society of Anaesthesia.",institutionString:null,institution:{name:"Albert Schweitzer Hospital",country:{name:"Gabon"}}},{id:"83089",title:"Prof.",name:"Aaron",middleName:null,surname:"Ojule",slug:"aaron-ojule",fullName:"Aaron Ojule",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Port Harcourt",country:{name:"Nigeria"}}},{id:"295748",title:"Mr.",name:"Abayomi",middleName:null,surname:"Modupe",slug:"abayomi-modupe",fullName:"Abayomi Modupe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Landmark University",country:{name:"Nigeria"}}},{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94191/images/96_n.jpg",biography:"Prof. Moustafa got his doctoral degree in earthquake engineering and structural safety from Indian Institute of Science in 2002. He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis",institutionString:null,institution:{name:"Al Azhar University",country:{name:"Egypt"}}},{id:"113313",title:"Dr.",name:"Abdel-Aal",middleName:null,surname:"Mantawy",slug:"abdel-aal-mantawy",fullName:"Abdel-Aal Mantawy",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ain Shams University",country:{name:"Egypt"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5681},{group:"region",caption:"Middle and South America",value:2,count:5161},{group:"region",caption:"Africa",value:3,count:1683},{group:"region",caption:"Asia",value:4,count:10200},{group:"region",caption:"Australia and Oceania",value:5,count:886},{group:"region",caption:"Europe",value:6,count:15610}],offset:12,limit:12,total:1683},chapterEmbeded:{data:{}},editorApplication:{success:null,errors:{}},ofsBooks:{filterParams:{topicId:"8"},books:[{type:"book",id:"10454",title:"Technology in Agriculture",subtitle:null,isOpenForSubmission:!0,hash:"dcfc52d92f694b0848977a3c11c13d00",slug:null,bookSignature:"Dr. Fiaz Ahmad and Prof. Muhammad Sultan",coverURL:"https://cdn.intechopen.com/books/images_new/10454.jpg",editedByType:null,editors:[{id:"338219",title:"Dr.",name:"Fiaz",surname:"Ahmad",slug:"fiaz-ahmad",fullName:"Fiaz Ahmad"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10502",title:"Aflatoxins",subtitle:null,isOpenForSubmission:!0,hash:"34fe61c309f2405130ede7a267cf8bd5",slug:null,bookSignature:"Dr. Lukman Bola Abdulra'uf",coverURL:"https://cdn.intechopen.com/books/images_new/10502.jpg",editedByType:null,editors:[{id:"149347",title:"Dr.",name:"Lukman",surname:"Abdulra'uf",slug:"lukman-abdulra'uf",fullName:"Lukman Abdulra'uf"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10504",title:"Crystallization",subtitle:null,isOpenForSubmission:!0,hash:"3478d05926950f475f4ad2825d340963",slug:null,bookSignature:"Dr. Youssef Ben Smida and Dr. Riadh Marzouki",coverURL:"https://cdn.intechopen.com/books/images_new/10504.jpg",editedByType:null,editors:[{id:"311698",title:"Dr.",name:"Youssef",surname:"Ben Smida",slug:"youssef-ben-smida",fullName:"Youssef Ben Smida"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10552",title:"Montmorillonite",subtitle:null,isOpenForSubmission:!0,hash:"c4a279761f0bb046af95ecd32ab09e51",slug:null,bookSignature:"Prof. Faheem Uddin",coverURL:"https://cdn.intechopen.com/books/images_new/10552.jpg",editedByType:null,editors:[{id:"228107",title:"Prof.",name:"Faheem",surname:"Uddin",slug:"faheem-uddin",fullName:"Faheem Uddin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10572",title:"Advancements in Chromophore and Bio-Chromophore Research",subtitle:null,isOpenForSubmission:!0,hash:"4aca0af0356d8d31fa8621859a68db8f",slug:null,bookSignature:"Dr. Rampal Pandey",coverURL:"https://cdn.intechopen.com/books/images_new/10572.jpg",editedByType:null,editors:[{id:"338234",title:"Dr.",name:"Rampal",surname:"Pandey",slug:"rampal-pandey",fullName:"Rampal Pandey"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10581",title:"Alkaline Chemistry and Applications",subtitle:null,isOpenForSubmission:!0,hash:"4ed90bdab4a7211c13cd432aa079cd20",slug:null,bookSignature:"Dr. Riadh Marzouki",coverURL:"https://cdn.intechopen.com/books/images_new/10581.jpg",editedByType:null,editors:[{id:"300527",title:"Dr.",name:"Riadh",surname:"Marzouki",slug:"riadh-marzouki",fullName:"Riadh Marzouki"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10582",title:"Chemical Vapor Deposition",subtitle:null,isOpenForSubmission:!0,hash:"f9177ff0e61198735fb86a81303259d0",slug:null,bookSignature:"Dr. Sadia Ameen, Dr. M. Shaheer Akhtar and Prof. Hyung-Shik Shin",coverURL:"https://cdn.intechopen.com/books/images_new/10582.jpg",editedByType:null,editors:[{id:"52613",title:"Dr.",name:"Sadia",surname:"Ameen",slug:"sadia-ameen",fullName:"Sadia Ameen"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10696",title:"Calorimetry",subtitle:null,isOpenForSubmission:!0,hash:"bb239599406f0b731bbfd62c1c8dbf3f",slug:null,bookSignature:"",coverURL:"https://cdn.intechopen.com/books/images_new/10696.jpg",editedByType:null,editors:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10697",title:"Raman Spectroscopy",subtitle:null,isOpenForSubmission:!0,hash:"ab2446daed0caa4d243805387a2547ee",slug:null,bookSignature:"",coverURL:"https://cdn.intechopen.com/books/images_new/10697.jpg",editedByType:null,editors:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10700",title:"Titanium Dioxide",subtitle:null,isOpenForSubmission:!0,hash:"c935253773c8ed0220e7b8a6fd90c4c6",slug:null,bookSignature:"",coverURL:"https://cdn.intechopen.com/books/images_new/10700.jpg",editedByType:null,editors:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10702",title:"Polyimide",subtitle:null,isOpenForSubmission:!0,hash:"325bb1a83145389746e590eb13131902",slug:null,bookSignature:"",coverURL:"https://cdn.intechopen.com/books/images_new/10702.jpg",editedByType:null,editors:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],filtersByTopic:[{group:"topic",caption:"Agricultural and Biological Sciences",value:5,count:9},{group:"topic",caption:"Biochemistry, Genetics and Molecular Biology",value:6,count:17},{group:"topic",caption:"Business, Management and Economics",value:7,count:2},{group:"topic",caption:"Chemistry",value:8,count:7},{group:"topic",caption:"Computer and Information Science",value:9,count:10},{group:"topic",caption:"Earth and Planetary Sciences",value:10,count:5},{group:"topic",caption:"Engineering",value:11,count:14},{group:"topic",caption:"Environmental Sciences",value:12,count:2},{group:"topic",caption:"Immunology and Microbiology",value:13,count:5},{group:"topic",caption:"Materials Science",value:14,count:4},{group:"topic",caption:"Mathematics",value:15,count:1},{group:"topic",caption:"Medicine",value:16,count:60},{group:"topic",caption:"Nanotechnology and Nanomaterials",value:17,count:1},{group:"topic",caption:"Neuroscience",value:18,count:1},{group:"topic",caption:"Pharmacology, Toxicology and Pharmaceutical Science",value:19,count:6},{group:"topic",caption:"Physics",value:20,count:2},{group:"topic",caption:"Psychology",value:21,count:3},{group:"topic",caption:"Robotics",value:22,count:1},{group:"topic",caption:"Social Sciences",value:23,count:3},{group:"topic",caption:"Technology",value:24,count:1},{group:"topic",caption:"Veterinary Medicine and Science",value:25,count:2}],offset:12,limit:12,total:11},popularBooks:{featuredBooks:[{type:"book",id:"9208",title:"Welding",subtitle:"Modern Topics",isOpenForSubmission:!1,hash:"7d6be076ccf3a3f8bd2ca52d86d4506b",slug:"welding-modern-topics",bookSignature:"Sadek Crisóstomo Absi Alfaro, Wojciech Borek and Błażej Tomiczek",coverURL:"https://cdn.intechopen.com/books/images_new/9208.jpg",editors:[{id:"65292",title:"Prof.",name:"Sadek Crisostomo Absi",middleName:"C. Absi",surname:"Alfaro",slug:"sadek-crisostomo-absi-alfaro",fullName:"Sadek Crisostomo Absi Alfaro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9139",title:"Topics in Primary Care Medicine",subtitle:null,isOpenForSubmission:!1,hash:"ea774a4d4c1179da92a782e0ae9cde92",slug:"topics-in-primary-care-medicine",bookSignature:"Thomas F. Heston",coverURL:"https://cdn.intechopen.com/books/images_new/9139.jpg",editors:[{id:"217926",title:"Dr.",name:"Thomas F.",middleName:null,surname:"Heston",slug:"thomas-f.-heston",fullName:"Thomas F. Heston"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8697",title:"Virtual Reality and Its Application in Education",subtitle:null,isOpenForSubmission:!1,hash:"ee01b5e387ba0062c6b0d1e9227bda05",slug:"virtual-reality-and-its-application-in-education",bookSignature:"Dragan Cvetković",coverURL:"https://cdn.intechopen.com/books/images_new/8697.jpg",editors:[{id:"101330",title:"Dr.",name:"Dragan",middleName:"Mladen",surname:"Cvetković",slug:"dragan-cvetkovic",fullName:"Dragan Cvetković"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9785",title:"Endometriosis",subtitle:null,isOpenForSubmission:!1,hash:"f457ca61f29cf7e8bc191732c50bb0ce",slug:"endometriosis",bookSignature:"Courtney Marsh",coverURL:"https://cdn.intechopen.com/books/images_new/9785.jpg",editors:[{id:"255491",title:"Dr.",name:"Courtney",middleName:null,surname:"Marsh",slug:"courtney-marsh",fullName:"Courtney Marsh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9343",title:"Trace Metals in the Environment",subtitle:"New Approaches and Recent Advances",isOpenForSubmission:!1,hash:"ae07e345bc2ce1ebbda9f70c5cd12141",slug:"trace-metals-in-the-environment-new-approaches-and-recent-advances",bookSignature:"Mario Alfonso Murillo-Tovar, Hugo Saldarriaga-Noreña and Agnieszka Saeid",coverURL:"https://cdn.intechopen.com/books/images_new/9343.jpg",editors:[{id:"255959",title:"Dr.",name:"Mario Alfonso",middleName:null,surname:"Murillo-Tovar",slug:"mario-alfonso-murillo-tovar",fullName:"Mario Alfonso Murillo-Tovar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7831",title:"Sustainability in Urban Planning and Design",subtitle:null,isOpenForSubmission:!1,hash:"c924420492c8c2c9751e178d025f4066",slug:"sustainability-in-urban-planning-and-design",bookSignature:"Amjad Almusaed, Asaad Almssad and Linh Truong - Hong",coverURL:"https://cdn.intechopen.com/books/images_new/7831.jpg",editors:[{id:"110471",title:"Dr.",name:"Amjad",middleName:"Zaki",surname:"Almusaed",slug:"amjad-almusaed",fullName:"Amjad Almusaed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8468",title:"Sheep Farming",subtitle:"An Approach to Feed, Growth and Sanity",isOpenForSubmission:!1,hash:"838f08594850bc04aa14ec873ed1b96f",slug:"sheep-farming-an-approach-to-feed-growth-and-sanity",bookSignature:"António Monteiro",coverURL:"https://cdn.intechopen.com/books/images_new/8468.jpg",editors:[{id:"190314",title:"Prof.",name:"António",middleName:"Cardoso",surname:"Monteiro",slug:"antonio-monteiro",fullName:"António Monteiro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8816",title:"Financial Crises",subtitle:"A Selection of Readings",isOpenForSubmission:!1,hash:"6f2f49fb903656e4e54280c79fabd10c",slug:"financial-crises-a-selection-of-readings",bookSignature:"Stelios Markoulis",coverURL:"https://cdn.intechopen.com/books/images_new/8816.jpg",editors:[{id:"237863",title:"Dr.",name:"Stelios",middleName:null,surname:"Markoulis",slug:"stelios-markoulis",fullName:"Stelios Markoulis"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9376",title:"Contemporary Developments and Perspectives in International Health Security",subtitle:"Volume 1",isOpenForSubmission:!1,hash:"b9a00b84cd04aae458fb1d6c65795601",slug:"contemporary-developments-and-perspectives-in-international-health-security-volume-1",bookSignature:"Stanislaw P. Stawicki, Michael S. Firstenberg, Sagar C. Galwankar, Ricardo Izurieta and Thomas Papadimos",coverURL:"https://cdn.intechopen.com/books/images_new/9376.jpg",editors:[{id:"181694",title:"Dr.",name:"Stanislaw P.",middleName:null,surname:"Stawicki",slug:"stanislaw-p.-stawicki",fullName:"Stanislaw P. Stawicki"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7769",title:"Medical Isotopes",subtitle:null,isOpenForSubmission:!1,hash:"f8d3c5a6c9a42398e56b4e82264753f7",slug:"medical-isotopes",bookSignature:"Syed Ali Raza Naqvi and Muhammad Babar Imrani",coverURL:"https://cdn.intechopen.com/books/images_new/7769.jpg",editors:[{id:"259190",title:"Dr.",name:"Syed Ali Raza",middleName:null,surname:"Naqvi",slug:"syed-ali-raza-naqvi",fullName:"Syed Ali Raza Naqvi"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9279",title:"Concepts, Applications and Emerging Opportunities in Industrial Engineering",subtitle:null,isOpenForSubmission:!1,hash:"9bfa87f9b627a5468b7c1e30b0eea07a",slug:"concepts-applications-and-emerging-opportunities-in-industrial-engineering",bookSignature:"Gary Moynihan",coverURL:"https://cdn.intechopen.com/books/images_new/9279.jpg",editors:[{id:"16974",title:"Dr.",name:"Gary",middleName:null,surname:"Moynihan",slug:"gary-moynihan",fullName:"Gary Moynihan"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7807",title:"A Closer Look at Organizational Culture in Action",subtitle:null,isOpenForSubmission:!1,hash:"05c608b9271cc2bc711f4b28748b247b",slug:"a-closer-look-at-organizational-culture-in-action",bookSignature:"Süleyman Davut Göker",coverURL:"https://cdn.intechopen.com/books/images_new/7807.jpg",editors:[{id:"190035",title:"Associate Prof.",name:"Süleyman Davut",middleName:null,surname:"Göker",slug:"suleyman-davut-goker",fullName:"Süleyman Davut Göker"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:12,limit:12,total:5126},hotBookTopics:{hotBooks:[],offset:0,limit:12,total:null},publish:{},publishingProposal:{success:null,errors:{}},books:{featuredBooks:[{type:"book",id:"9208",title:"Welding",subtitle:"Modern Topics",isOpenForSubmission:!1,hash:"7d6be076ccf3a3f8bd2ca52d86d4506b",slug:"welding-modern-topics",bookSignature:"Sadek Crisóstomo Absi Alfaro, Wojciech Borek and Błażej Tomiczek",coverURL:"https://cdn.intechopen.com/books/images_new/9208.jpg",editors:[{id:"65292",title:"Prof.",name:"Sadek Crisostomo Absi",middleName:"C. Absi",surname:"Alfaro",slug:"sadek-crisostomo-absi-alfaro",fullName:"Sadek Crisostomo Absi Alfaro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9139",title:"Topics in Primary Care Medicine",subtitle:null,isOpenForSubmission:!1,hash:"ea774a4d4c1179da92a782e0ae9cde92",slug:"topics-in-primary-care-medicine",bookSignature:"Thomas F. Heston",coverURL:"https://cdn.intechopen.com/books/images_new/9139.jpg",editors:[{id:"217926",title:"Dr.",name:"Thomas F.",middleName:null,surname:"Heston",slug:"thomas-f.-heston",fullName:"Thomas F. Heston"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8697",title:"Virtual Reality and Its Application in Education",subtitle:null,isOpenForSubmission:!1,hash:"ee01b5e387ba0062c6b0d1e9227bda05",slug:"virtual-reality-and-its-application-in-education",bookSignature:"Dragan Cvetković",coverURL:"https://cdn.intechopen.com/books/images_new/8697.jpg",editors:[{id:"101330",title:"Dr.",name:"Dragan",middleName:"Mladen",surname:"Cvetković",slug:"dragan-cvetkovic",fullName:"Dragan Cvetković"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9785",title:"Endometriosis",subtitle:null,isOpenForSubmission:!1,hash:"f457ca61f29cf7e8bc191732c50bb0ce",slug:"endometriosis",bookSignature:"Courtney Marsh",coverURL:"https://cdn.intechopen.com/books/images_new/9785.jpg",editors:[{id:"255491",title:"Dr.",name:"Courtney",middleName:null,surname:"Marsh",slug:"courtney-marsh",fullName:"Courtney Marsh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9343",title:"Trace Metals in the Environment",subtitle:"New Approaches and Recent Advances",isOpenForSubmission:!1,hash:"ae07e345bc2ce1ebbda9f70c5cd12141",slug:"trace-metals-in-the-environment-new-approaches-and-recent-advances",bookSignature:"Mario Alfonso Murillo-Tovar, Hugo Saldarriaga-Noreña and Agnieszka Saeid",coverURL:"https://cdn.intechopen.com/books/images_new/9343.jpg",editors:[{id:"255959",title:"Dr.",name:"Mario Alfonso",middleName:null,surname:"Murillo-Tovar",slug:"mario-alfonso-murillo-tovar",fullName:"Mario Alfonso Murillo-Tovar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8468",title:"Sheep Farming",subtitle:"An Approach to Feed, Growth and Sanity",isOpenForSubmission:!1,hash:"838f08594850bc04aa14ec873ed1b96f",slug:"sheep-farming-an-approach-to-feed-growth-and-sanity",bookSignature:"António Monteiro",coverURL:"https://cdn.intechopen.com/books/images_new/8468.jpg",editors:[{id:"190314",title:"Prof.",name:"António",middleName:"Cardoso",surname:"Monteiro",slug:"antonio-monteiro",fullName:"António Monteiro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8816",title:"Financial Crises",subtitle:"A Selection of Readings",isOpenForSubmission:!1,hash:"6f2f49fb903656e4e54280c79fabd10c",slug:"financial-crises-a-selection-of-readings",bookSignature:"Stelios Markoulis",coverURL:"https://cdn.intechopen.com/books/images_new/8816.jpg",editors:[{id:"237863",title:"Dr.",name:"Stelios",middleName:null,surname:"Markoulis",slug:"stelios-markoulis",fullName:"Stelios Markoulis"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7831",title:"Sustainability in Urban Planning and Design",subtitle:null,isOpenForSubmission:!1,hash:"c924420492c8c2c9751e178d025f4066",slug:"sustainability-in-urban-planning-and-design",bookSignature:"Amjad Almusaed, Asaad Almssad and Linh Truong - Hong",coverURL:"https://cdn.intechopen.com/books/images_new/7831.jpg",editors:[{id:"110471",title:"Dr.",name:"Amjad",middleName:"Zaki",surname:"Almusaed",slug:"amjad-almusaed",fullName:"Amjad Almusaed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9376",title:"Contemporary Developments and Perspectives in International Health Security",subtitle:"Volume 1",isOpenForSubmission:!1,hash:"b9a00b84cd04aae458fb1d6c65795601",slug:"contemporary-developments-and-perspectives-in-international-health-security-volume-1",bookSignature:"Stanislaw P. Stawicki, Michael S. Firstenberg, Sagar C. Galwankar, Ricardo Izurieta and Thomas Papadimos",coverURL:"https://cdn.intechopen.com/books/images_new/9376.jpg",editors:[{id:"181694",title:"Dr.",name:"Stanislaw P.",middleName:null,surname:"Stawicki",slug:"stanislaw-p.-stawicki",fullName:"Stanislaw P. Stawicki"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7769",title:"Medical Isotopes",subtitle:null,isOpenForSubmission:!1,hash:"f8d3c5a6c9a42398e56b4e82264753f7",slug:"medical-isotopes",bookSignature:"Syed Ali Raza Naqvi and Muhammad Babar Imrani",coverURL:"https://cdn.intechopen.com/books/images_new/7769.jpg",editors:[{id:"259190",title:"Dr.",name:"Syed Ali Raza",middleName:null,surname:"Naqvi",slug:"syed-ali-raza-naqvi",fullName:"Syed Ali Raza Naqvi"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],latestBooks:[{type:"book",id:"8468",title:"Sheep Farming",subtitle:"An Approach to Feed, Growth and Sanity",isOpenForSubmission:!1,hash:"838f08594850bc04aa14ec873ed1b96f",slug:"sheep-farming-an-approach-to-feed-growth-and-sanity",bookSignature:"António Monteiro",coverURL:"https://cdn.intechopen.com/books/images_new/8468.jpg",editedByType:"Edited by",editors:[{id:"190314",title:"Prof.",name:"António",middleName:"Cardoso",surname:"Monteiro",slug:"antonio-monteiro",fullName:"António Monteiro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9523",title:"Oral and Maxillofacial Surgery",subtitle:null,isOpenForSubmission:!1,hash:"5eb6ec2db961a6c8965d11180a58d5c1",slug:"oral-and-maxillofacial-surgery",bookSignature:"Gokul Sridharan",coverURL:"https://cdn.intechopen.com/books/images_new/9523.jpg",editedByType:"Edited by",editors:[{id:"82453",title:"Dr.",name:"Gokul",middleName:null,surname:"Sridharan",slug:"gokul-sridharan",fullName:"Gokul Sridharan"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9785",title:"Endometriosis",subtitle:null,isOpenForSubmission:!1,hash:"f457ca61f29cf7e8bc191732c50bb0ce",slug:"endometriosis",bookSignature:"Courtney Marsh",coverURL:"https://cdn.intechopen.com/books/images_new/9785.jpg",editedByType:"Edited by",editors:[{id:"255491",title:"Dr.",name:"Courtney",middleName:null,surname:"Marsh",slug:"courtney-marsh",fullName:"Courtney Marsh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9018",title:"Some RNA Viruses",subtitle:null,isOpenForSubmission:!1,hash:"a5cae846dbe3692495fc4add2f60fd84",slug:"some-rna-viruses",bookSignature:"Yogendra Shah and Eltayb Abuelzein",coverURL:"https://cdn.intechopen.com/books/images_new/9018.jpg",editedByType:"Edited by",editors:[{id:"278914",title:"Ph.D.",name:"Yogendra",middleName:null,surname:"Shah",slug:"yogendra-shah",fullName:"Yogendra Shah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8816",title:"Financial Crises",subtitle:"A Selection of Readings",isOpenForSubmission:!1,hash:"6f2f49fb903656e4e54280c79fabd10c",slug:"financial-crises-a-selection-of-readings",bookSignature:"Stelios Markoulis",coverURL:"https://cdn.intechopen.com/books/images_new/8816.jpg",editedByType:"Edited by",editors:[{id:"237863",title:"Dr.",name:"Stelios",middleName:null,surname:"Markoulis",slug:"stelios-markoulis",fullName:"Stelios Markoulis"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9585",title:"Advances in Complex Valvular Disease",subtitle:null,isOpenForSubmission:!1,hash:"ef64f11e211621ecfe69c46e60e7ca3d",slug:"advances-in-complex-valvular-disease",bookSignature:"Michael S. Firstenberg and Imran Khan",coverURL:"https://cdn.intechopen.com/books/images_new/9585.jpg",editedByType:"Edited by",editors:[{id:"64343",title:null,name:"Michael S.",middleName:"S",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10150",title:"Smart Manufacturing",subtitle:"When Artificial Intelligence Meets the Internet of Things",isOpenForSubmission:!1,hash:"87004a19de13702d042f8ff96d454698",slug:"smart-manufacturing-when-artificial-intelligence-meets-the-internet-of-things",bookSignature:"Tan Yen Kheng",coverURL:"https://cdn.intechopen.com/books/images_new/10150.jpg",editedByType:"Edited by",editors:[{id:"78857",title:"Dr.",name:"Tan Yen",middleName:null,surname:"Kheng",slug:"tan-yen-kheng",fullName:"Tan Yen Kheng"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9386",title:"Direct Numerical Simulations",subtitle:"An Introduction and Applications",isOpenForSubmission:!1,hash:"158a3a0fdba295d21ff23326f5a072d5",slug:"direct-numerical-simulations-an-introduction-and-applications",bookSignature:"Srinivasa Rao",coverURL:"https://cdn.intechopen.com/books/images_new/9386.jpg",editedByType:"Edited by",editors:[{id:"6897",title:"Dr.",name:"Srinivasa",middleName:"P",surname:"Rao",slug:"srinivasa-rao",fullName:"Srinivasa Rao"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9139",title:"Topics in Primary Care Medicine",subtitle:null,isOpenForSubmission:!1,hash:"ea774a4d4c1179da92a782e0ae9cde92",slug:"topics-in-primary-care-medicine",bookSignature:"Thomas F. Heston",coverURL:"https://cdn.intechopen.com/books/images_new/9139.jpg",editedByType:"Edited by",editors:[{id:"217926",title:"Dr.",name:"Thomas F.",middleName:null,surname:"Heston",slug:"thomas-f.-heston",fullName:"Thomas F. Heston"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9208",title:"Welding",subtitle:"Modern Topics",isOpenForSubmission:!1,hash:"7d6be076ccf3a3f8bd2ca52d86d4506b",slug:"welding-modern-topics",bookSignature:"Sadek Crisóstomo Absi Alfaro, Wojciech Borek and Błażej Tomiczek",coverURL:"https://cdn.intechopen.com/books/images_new/9208.jpg",editedByType:"Edited by",editors:[{id:"65292",title:"Prof.",name:"Sadek Crisostomo Absi",middleName:"C. Absi",surname:"Alfaro",slug:"sadek-crisostomo-absi-alfaro",fullName:"Sadek Crisostomo Absi Alfaro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"117",title:"Energy Engineering",slug:"engineering-energy-engineering",parent:{title:"Engineering",slug:"engineering"},numberOfBooks:150,numberOfAuthorsAndEditors:4129,numberOfWosCitations:4954,numberOfCrossrefCitations:3539,numberOfDimensionsCitations:8070,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicSlug:"engineering-energy-engineering",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"8871",title:"Renewable Energy",subtitle:"Resources, Challenges and Applications",isOpenForSubmission:!1,hash:"e00c59554fb355c16623c62064ecc3bb",slug:"renewable-energy-resources-challenges-and-applications",bookSignature:"Mansour Al Qubeissi, Ahmad El-kharouf and Hakan Serhad Soyhan",coverURL:"https://cdn.intechopen.com/books/images_new/8871.jpg",editedByType:"Edited by",editors:[{id:"241686",title:"Dr.",name:"Mansour",middleName:null,surname:"Al Qubeissi",slug:"mansour-al-qubeissi",fullName:"Mansour Al Qubeissi"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8572",title:"Thermodynamics and Energy Engineering",subtitle:null,isOpenForSubmission:!1,hash:"e2e9e95bd0be692c5364418f341102b6",slug:"thermodynamics-and-energy-engineering",bookSignature:"Petrică Vizureanu",coverURL:"https://cdn.intechopen.com/books/images_new/8572.jpg",editedByType:"Edited by",editors:[{id:"12354",title:"Prof.",name:"Petrică",middleName:null,surname:"Vizureanu",slug:"petrica-vizureanu",fullName:"Petrică Vizureanu"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7200",title:"Green Energy and Environment",subtitle:null,isOpenForSubmission:!1,hash:"72ad3cb35d7eb84855d6cb05c6e73897",slug:"green-energy-and-environment",bookSignature:"Eng Hwa Yap and Andrew Huey Ping Tan",coverURL:"https://cdn.intechopen.com/books/images_new/7200.jpg",editedByType:"Edited by",editors:[{id:"185577",title:"Associate Prof.",name:"Eng Hwa",middleName:null,surname:"Yap",slug:"eng-hwa-yap",fullName:"Eng Hwa Yap"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6837",title:"Lithium-ion Batteries",subtitle:"Thin Film for Energy Materials and Devices",isOpenForSubmission:!1,hash:"ea7789260b319b9a4b472257f57bfeb5",slug:"lithium-ion-batteries-thin-film-for-energy-materials-and-devices",bookSignature:"Mitsunobu Sato, Li Lu and Hiroki Nagai",coverURL:"https://cdn.intechopen.com/books/images_new/6837.jpg",editedByType:"Edited by",editors:[{id:"179615",title:"Prof.",name:"Mitsunobu",middleName:null,surname:"Sato",slug:"mitsunobu-sato",fullName:"Mitsunobu Sato"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8394",title:"Low-temperature Technologies",subtitle:null,isOpenForSubmission:!1,hash:"be68d10255b1c1c72aef7caddf946e34",slug:"low-temperature-technologies",bookSignature:"Tatiana Morosuk and Muhammad Sultan",coverURL:"https://cdn.intechopen.com/books/images_new/8394.jpg",editedByType:"Edited by",editors:[{id:"193888",title:"Prof.",name:"Tatiana",middleName:null,surname:"Morosuk",slug:"tatiana-morosuk",fullName:"Tatiana Morosuk"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7659",title:"Organic Rankine Cycles for Waste Heat Recovery",subtitle:"Analysis and Applications",isOpenForSubmission:!1,hash:"98c4b304e87fd0d4e56579783f22a1f7",slug:"organic-rankine-cycles-for-waste-heat-recovery-analysis-and-applications",bookSignature:"Silvia Lasala",coverURL:"https://cdn.intechopen.com/books/images_new/7659.jpg",editedByType:"Edited by",editors:[{id:"190049",title:"Dr.",name:"Silvia",middleName:null,surname:"Lasala",slug:"silvia-lasala",fullName:"Silvia Lasala"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9441",title:"Ocean Thermal Energy Conversion (OTEC)",subtitle:"Past, Present, and Progress",isOpenForSubmission:!1,hash:"b0f6032c45ead7f1cb11bb488bfcd48d",slug:"ocean-thermal-energy-conversion-otec-past-present-and-progress",bookSignature:"Albert S. Kim and Hyeon-Ju Kim",coverURL:"https://cdn.intechopen.com/books/images_new/9441.jpg",editedByType:"Edited by",editors:[{id:"21045",title:"Prof.",name:"Albert S.",middleName:null,surname:"Kim",slug:"albert-s.-kim",fullName:"Albert S. Kim"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8896",title:"Sustainable Mobility",subtitle:null,isOpenForSubmission:!1,hash:"c5b28b438521dcd383df9b6e797ec462",slug:"sustainable-mobility",bookSignature:"Bernardo Llamas, Marcelo F. Ortega Romero and Eugenia Sillero",coverURL:"https://cdn.intechopen.com/books/images_new/8896.jpg",editedByType:"Edited by",editors:[{id:"169368",title:"Dr.",name:"Bernardo",middleName:null,surname:"Llamas",slug:"bernardo-llamas",fullName:"Bernardo Llamas"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8890",title:"Design Optimization of Wind Energy Conversion Systems with Applications",subtitle:null,isOpenForSubmission:!1,hash:"a2ce9419202c074e3aee8dff0d87326c",slug:"design-optimization-of-wind-energy-conversion-systems-with-applications",bookSignature:"Karam Y. Maalawi",coverURL:"https://cdn.intechopen.com/books/images_new/8890.jpg",editedByType:"Edited by",editors:[{id:"18593",title:"Prof.",name:"Karam",middleName:"Youssef",surname:"Maalawi",slug:"karam-maalawi",fullName:"Karam Maalawi"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9425",title:"Advanced Statistical Modeling, Forecasting, and Fault Detection in Renewable Energy Systems",subtitle:null,isOpenForSubmission:!1,hash:"f9dfa41155499eb62f21917c77db5f7c",slug:"advanced-statistical-modeling-forecasting-and-fault-detection-in-renewable-energy-systems",bookSignature:"Fouzi Harrou and Ying Sun",coverURL:"https://cdn.intechopen.com/books/images_new/9425.jpg",editedByType:"Edited by",editors:[{id:"197090",title:"Dr.",name:"Fouzi",middleName:null,surname:"Harrou",slug:"fouzi-harrou",fullName:"Fouzi Harrou"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8124",title:"Advances in Modelling and Control of Wind and Hydrogenerators",subtitle:null,isOpenForSubmission:!1,hash:"8cf2591492537f75db940baa712582e5",slug:"advances-in-modelling-and-control-of-wind-and-hydrogenerators",bookSignature:"Amir Ebrahimi",coverURL:"https://cdn.intechopen.com/books/images_new/8124.jpg",editedByType:"Edited by",editors:[{id:"256252",title:"Dr.",name:"Amir",middleName:null,surname:"Ebrahimi",slug:"amir-ebrahimi",fullName:"Amir Ebrahimi"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10425",title:"Modeling, Simulation and Optimization of Wind Farms and Hybrid Systems",subtitle:null,isOpenForSubmission:!1,hash:"659adb2f2e862e51eab5b274c6673c30",slug:"modeling-simulation-and-optimization-of-wind-farms-and-hybrid-systems",bookSignature:"Karam Y. Maalawi",coverURL:"https://cdn.intechopen.com/books/images_new/10425.jpg",editedByType:"Edited by",editors:[{id:"18593",title:"Prof.",name:"Karam",middleName:"Youssef",surname:"Maalawi",slug:"karam-maalawi",fullName:"Karam Maalawi"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:150,mostCitedChapters:[{id:"40640",doi:"10.5772/51360",title:"Electrostatic Conversion for Vibration Energy Harvesting",slug:"electrostatic-conversion-for-vibration-energy-harvesting",totalDownloads:4303,totalCrossrefCites:78,totalDimensionsCites:124,book:{slug:"small-scale-energy-harvesting",title:"Small-Scale Energy Harvesting",fullTitle:"Small-Scale Energy Harvesting"},signatures:"S. Boisseau, G. Despesse and B. Ahmed Seddik",authors:[{id:"139151",title:"Dr.",name:"Ghislain",middleName:null,surname:"Despesse",slug:"ghislain-despesse",fullName:"Ghislain Despesse"},{id:"164277",title:"Dr.",name:"Sebastien",middleName:null,surname:"Boisseau",slug:"sebastien-boisseau",fullName:"Sebastien Boisseau"},{id:"164439",title:"Mr.",name:"Bouhadjar",middleName:null,surname:"Ahmed Seddik",slug:"bouhadjar-ahmed-seddik",fullName:"Bouhadjar Ahmed Seddik"}]},{id:"20058",doi:"10.5772/17047",title:"Ethanol Production in Brazil: The Industrial Process and Its Impact on Yeast Fermentation",slug:"ethanol-production-in-brazil-the-industrial-process-and-its-impact-on-yeast-fermentation",totalDownloads:22521,totalCrossrefCites:11,totalDimensionsCites:112,book:{slug:"biofuel-production-recent-developments-and-prospects",title:"Biofuel Production",fullTitle:"Biofuel Production - Recent Developments and Prospects"},signatures:"Luiz Carlos Basso, Thiago Olitta Basso and Saul Nitsche Rocha",authors:[{id:"27097",title:"Dr.",name:"Luiz Carlos",middleName:null,surname:"Basso",slug:"luiz-carlos-basso",fullName:"Luiz Carlos Basso"},{id:"27117",title:"Dr.",name:"Thiago Olitta",middleName:null,surname:"Basso",slug:"thiago-olitta-basso",fullName:"Thiago Olitta Basso"},{id:"84059",title:"Prof.",name:"Saul",middleName:"Nitsche",surname:"Rocha",slug:"saul-rocha",fullName:"Saul Rocha"}]},{id:"16242",doi:"10.5772/21398",title:"Wind Turbines Theory - The Betz Equation and Optimal Rotor Tip Speed Ratio",slug:"wind-turbines-theory-the-betz-equation-and-optimal-rotor-tip-speed-ratio",totalDownloads:62278,totalCrossrefCites:47,totalDimensionsCites:94,book:{slug:"fundamental-and-advanced-topics-in-wind-power",title:"Fundamental and Advanced Topics in Wind Power",fullTitle:"Fundamental and Advanced Topics in Wind Power"},signatures:"Magdi Ragheb and Adam M. Ragheb",authors:[{id:"32344",title:"Mr",name:"Adam",middleName:null,surname:"Ragheb",slug:"adam-ragheb",fullName:"Adam Ragheb"},{id:"33227",title:"Prof.",name:"Magdi",middleName:null,surname:"Ragheb",slug:"magdi-ragheb",fullName:"Magdi Ragheb"}]}],mostDownloadedChaptersLast30Days:[{id:"48982",title:"A Comprehensive Modeling and Simulation of Power Quality Disturbances Using MATLAB/SIMULINK",slug:"a-comprehensive-modeling-and-simulation-of-power-quality-disturbances-using-matlab-simulink",totalDownloads:11199,totalCrossrefCites:4,totalDimensionsCites:12,book:{slug:"power-quality-issues-in-distributed-generation",title:"Power Quality Issues in Distributed Generation",fullTitle:"Power Quality Issues in Distributed Generation"},signatures:"Rodney H.G. Tan and Vigna K. Ramachandaramurthy",authors:[{id:"152137",title:"Dr.",name:"Vigna",middleName:null,surname:"Ramachandaramurthy",slug:"vigna-ramachandaramurthy",fullName:"Vigna Ramachandaramurthy"},{id:"175327",title:"Dr.",name:"Rodney",middleName:"H.G.",surname:"Tan",slug:"rodney-tan",fullName:"Rodney Tan"}]},{id:"70874",title:"Social, Economic, and Environmental Impacts of Renewable Energy Resources",slug:"social-economic-and-environmental-impacts-of-renewable-energy-resources",totalDownloads:1610,totalCrossrefCites:4,totalDimensionsCites:6,book:{slug:"wind-solar-hybrid-renewable-energy-system",title:"Wind Solar Hybrid Renewable Energy System",fullTitle:"Wind Solar Hybrid Renewable Energy System"},signatures:"Mahesh Kumar",authors:[{id:"309842",title:"Mr.",name:"Kamlesh",middleName:null,surname:"Kumar",slug:"kamlesh-kumar",fullName:"Kamlesh Kumar"}]},{id:"38933",title:"Wind Turbine Generator Technologies",slug:"wind-turbine-generator-technologies",totalDownloads:11938,totalCrossrefCites:10,totalDimensionsCites:12,book:{slug:"advances-in-wind-power",title:"Advances in Wind Power",fullTitle:"Advances in Wind Power"},signatures:"Wenping Cao, Ying Xie and Zheng Tan",authors:[{id:"154063",title:"Prof.",name:"Ying",middleName:null,surname:"Xie",slug:"ying-xie",fullName:"Ying Xie"},{id:"154064",title:"Mr.",name:"Zheng",middleName:null,surname:"Tan",slug:"zheng-tan",fullName:"Zheng Tan"},{id:"174154",title:"Prof.",name:"Wenping",middleName:null,surname:"Cao",slug:"wenping-cao",fullName:"Wenping Cao"}]},{id:"11458",title:"Natural Gas : Physical Properties and Combustion Features",slug:"natural-gas-physical-properties-and-combustion-features",totalDownloads:30304,totalCrossrefCites:2,totalDimensionsCites:2,book:{slug:"natural-gas",title:"Natural Gas",fullTitle:"Natural Gas"},signatures:"Olivier Le Corre and Khaled Loubar",authors:null},{id:"53557",title:"Energy-Efficient Building Design in the Context of Building Life Cycle",slug:"energy-efficient-building-design-in-the-context-of-building-life-cycle",totalDownloads:3498,totalCrossrefCites:6,totalDimensionsCites:11,book:{slug:"energy-efficient-buildings",title:"Energy Efficient Buildings",fullTitle:"Energy Efficient Buildings"},signatures:"Izzet Yüksek and Tülay Tikansak Karadayi",authors:[{id:"186397",title:"Dr.",name:"İzzet",middleName:null,surname:"Yüksek",slug:"izzet-yuksek",fullName:"İzzet Yüksek"},{id:"186398",title:"Prof.",name:"Tülay",middleName:null,surname:"Tıkansak Karadayı",slug:"tulay-tikansak-karadayi",fullName:"Tülay Tıkansak Karadayı"}]},{id:"56887",title:"Petroleum Source Rocks Characterization and Hydrocarbon Generation",slug:"petroleum-source-rocks-characterization-and-hydrocarbon-generation",totalDownloads:4458,totalCrossrefCites:2,totalDimensionsCites:3,book:{slug:"recent-insights-in-petroleum-science-and-engineering",title:"Recent Insights in Petroleum Science and Engineering",fullTitle:"Recent Insights in Petroleum Science and Engineering"},signatures:"Nabil Mohammed Al-Areeq",authors:[{id:"198686",title:"Dr.",name:"Nabil",middleName:"Mohammed",surname:"Al-Areeq",slug:"nabil-al-areeq",fullName:"Nabil Al-Areeq"}]},{id:"48267",title:"Crystal Structures of CH3NH3PbI3 and Related Perovskite Compounds Used for Solar Cells",slug:"crystal-structures-of-ch3nh3pbi3-and-related-perovskite-compounds-used-for-solar-cells",totalDownloads:6477,totalCrossrefCites:32,totalDimensionsCites:69,book:{slug:"solar-cells-new-approaches-and-reviews",title:"Solar Cells",fullTitle:"Solar Cells - New Approaches and Reviews"},signatures:"Takeo Oku",authors:[{id:"31132",title:"Prof.",name:"Takeo",middleName:null,surname:"Oku",slug:"takeo-oku",fullName:"Takeo Oku"}]},{id:"49438",title:"Perovskite Nanomaterials – Synthesis, Characterization, and Applications",slug:"perovskite-nanomaterials-synthesis-characterization-and-applications",totalDownloads:7401,totalCrossrefCites:12,totalDimensionsCites:25,book:{slug:"perovskite-materials-synthesis-characterisation-properties-and-applications",title:"Perovskite Materials",fullTitle:"Perovskite Materials - Synthesis, Characterisation, Properties, and Applications"},signatures:"Nada F. Atta, Ahmed Galal and Ekram H. El-Ads",authors:[{id:"30072",title:"Prof.",name:"Nada",middleName:null,surname:"F. Atta",slug:"nada-f.-atta",fullName:"Nada F. Atta"},{id:"174033",title:"Prof.",name:"Ahmed",middleName:null,surname:"Galal",slug:"ahmed-galal",fullName:"Ahmed Galal"},{id:"174034",title:"MSc.",name:"Ekram",middleName:null,surname:"El-Ads",slug:"ekram-el-ads",fullName:"Ekram El-Ads"},{id:"176164",title:"MSc.",name:"Ekram",middleName:null,surname:"Ekram H. El-Ads",slug:"ekram-ekram-h.-el-ads",fullName:"Ekram Ekram H. El-Ads"}]},{id:"65239",title:"Thermoelectric Energy Harvesting: Basic Principles and Applications",slug:"thermoelectric-energy-harvesting-basic-principles-and-applications",totalDownloads:3317,totalCrossrefCites:11,totalDimensionsCites:20,book:{slug:"green-energy-advances",title:"Green Energy Advances",fullTitle:"Green Energy Advances"},signatures:"Diana Enescu",authors:[{id:"226207",title:"Ph.D.",name:"Diana",middleName:null,surname:"Enescu",slug:"diana-enescu",fullName:"Diana Enescu"}]},{id:"70583",title:"Recycling of Waste Plastics into Pyrolytic Fuels and Their Use in IC Engines",slug:"recycling-of-waste-plastics-into-pyrolytic-fuels-and-their-use-in-ic-engines",totalDownloads:597,totalCrossrefCites:1,totalDimensionsCites:1,book:{slug:"sustainable-mobility",title:"Sustainable Mobility",fullTitle:"Sustainable Mobility"},signatures:"Sinan Erdogan",authors:[{id:"298608",title:"Dr.",name:"Sinan",middleName:null,surname:"Erdogan",slug:"sinan-erdogan",fullName:"Sinan Erdogan"}]}],onlineFirstChaptersFilter:{topicSlug:"engineering-energy-engineering",limit:3,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[{type:"book",id:"10176",title:"Microgrids and Local Energy Systems",subtitle:null,isOpenForSubmission:!0,hash:"c32b4a5351a88f263074b0d0ca813a9c",slug:null,bookSignature:"Prof. Nick Jenkins",coverURL:"https://cdn.intechopen.com/books/images_new/10176.jpg",editedByType:null,editors:[{id:"55219",title:"Prof.",name:"Nick",middleName:null,surname:"Jenkins",slug:"nick-jenkins",fullName:"Nick Jenkins"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:8,limit:8,total:1},route:{name:"onlineFirst.detail",path:"/online-first/development-of-integrated-lean-six-sigma-baldrige-framework-for-manufacturing-waste-minimization-a-c",hash:"",query:{},params:{chapter:"development-of-integrated-lean-six-sigma-baldrige-framework-for-manufacturing-waste-minimization-a-c"},fullPath:"/online-first/development-of-integrated-lean-six-sigma-baldrige-framework-for-manufacturing-waste-minimization-a-c",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var t;(t=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(t)}()