\r\n\tThere will be a chapter on secondary causes of sexual dysfunction disorders related to diabetes, cardiovascular disease, and obesity. A chapter on remedial measures to enhance sexual activity and maintain human relationships will be discussed. As there is a growing number of cancer survivors a chapter on cancer-related sexual dysfunction will be welcomed for including it.
",isbn:null,printIsbn:null,pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"b988fda30a4e2364ee9d47e417bd0ba9",bookSignature:"Dr. Dhastagir Sultan Sheriff",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11889.jpg",keywords:"Sex, Sexual Response Cycle, Erection, Premature Ejaculation, Libido, Orgasm, Painful Intercourse, Psychological, Female, Lack of Desire, Erectile Disorders, Pain Disorders",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 8th 2022",dateEndSecondStepPublish:"May 6th 2022",dateEndThirdStepPublish:"July 5th 2022",dateEndFourthStepPublish:"September 23rd 2022",dateEndFifthStepPublish:"November 22nd 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"3 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dhastagir Sultan Sheriff is a life member of the European Society for Human Reproduction and Early Human Development, Association of Physiologists and Pharmacologists of India, member of the National Academy of Medical Sciences, New Delhi, and resource person for UNESCO for Medical and Bioethics. 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The natural extension and broader application of EFT couple’s treatment can prove especially valuable and effective when working in a family system [1, 2]. The foundational principles of Emotionally Focused Couple’s Therapy is based on attachment and bonding theories that aim to help individuals gain a greater awareness of their emotions, to provide them with strategies to effectively cope, regulate, and transform their emotions[3]. It is a short term, evidence-based approach that allows the therapist to set goals, target key processes, and chart a destination for couples to identify and remove those emotional blocks which derail the promotion of healthy functioning, while providing alternative approaches that serve to increase levels of attentiveness, empathy and feelings attachment and belonging with one another.
\nAccording to Johnson, [4] EFFT is similar to emotionally focused therapy for couples, except that with families, the goal is “to modify family relationships in the direction of increased accessibility and responsiveness, thus helping the family create a secure base for children to grow and leave from.” Working within a larger family system can be especially daunting as therapists attempt to navigate the vast landscape of family dynamics encompassing multiple, complex interpersonal processes between members, especially the powerful bonds that exist between parent and child, which when weak and broken—are often the root of familiar distress and dysfunction. The core of the human experience of a family lies within its ability to create supportive bonds that sustain it during turbulent and stressful times in its life cycle. The application of EFT to family treatment offers a practical, useful and expedient model from which to effectively bolster stronger and more empathic bonds between parents and their children.
\nThis chapter provides an overview of EFFT process, its theoretical underpinnings and the strategies EFT family therapists employ to promote healthy family functioning. Through a presentation of a case study, beginning therapists are provided a unique lens from which to view the interactions of both family and therapist as they attempt to create new family interactions, marked by increased parental accessibility and responsiveness to children, which ultimately leads to their enhanced sense of attachment, communication, belongingness and security.
\nEmotionally Focused Family Therapy (EFFT) is an integration of humanistic [5] and systemic therapeutic approaches [6]. The focus of treatment is on the ongoing construction of a family’s present experience and how patterns of interaction are organized and expressed between family members. Another significant aspect of EFFT is its detailed attention to emotions. Identifying emotions is viewed by the therapist as essential in how family members view themselves and others, or an event. Emotions are hard wired in our brain and are meant to inform us about our environment. They also, contain physical impulses, which are designed by nature to be an immediate and adaptive call to action. In EFFT, emotions are categorized as primary and secondary. Primary emotions have been identified by researchers as universal emotions, such as joy, anger, fear, sadness, surprise, and shame. These emotions are frequently outside of people’s awareness. Secondary emotions are defined as reactions, and they help people cope with their primary emotions. The word “emotion” comes from the Latin word,
EFFT is grounded in attachment theory and based on the work of psychologist John Bowlby [7]. Bowlby maintains that human beings are biologically and fundamentally driven to pursue relationships that create security and belonging. He contends that the most critical attachment relationship is an infant’s sense of protection created by the primary caregiver (typically the mother) through a series of reciprocal interactions which promote bonding and love. As Karen [8] in
In EFFT, one’s sense of a secure attachment is linked to positive mental health. Children who are securely attached are best able to turn to their attachment figures for comfort and support [12]. Mikulincer and Shaver [13] capture the distinction between these predictable patterns of attachment behavior as shown in their research when they describe the issues of secure vs. insecure scripts. The secure script is: “If I encounter an obstacle and/or become distressed, I can approach a significant other for help; he or she is likely to be available and supportive; I will experience relief and comfort as a result of proximity to this person; I can then return to other activities [13].” However, when the attachment system remains in an activated state, there are two different insecure coping responses. The avoidant (dismissive) approach “includes rapid self-protective responses to danger without examining one’s emotions, consulting other people or seeking to receive help from them [13].” The implicit script is, “If I am in distress, I will carry on with other activities.” In contrast, the anxious approach is described as always being on guard for threat, and having difficulty receiving comfort. The implicit script is, “If I am in distress, I will reach for you and reach for you and reach for you, endlessly and to no avail.”
\nAttachment anxiety and avoidance are natural responses to the lack of confidence in the parents’ emotional availability. Drawing from attachment theory, the EFFT therapist conceptualizes distress in terms of attachment dilemmas in which ineffective responses to attachment needs fuel miscommunication, creating parenting dysfunctions and exacerbating symptoms associated with individual psychopathology [14]. The therapist must obtain a clear understanding of symptoms that generate distress in the family and furthermore, evaluate the parent(s) availability and their children’s confidence in their availability. These observations will provide the therapist with information about the attachment quality in the parent–child relationship. Insecure attachment is evident when the parent’s capacity for empathy is blocked, giving precedence to feelings of anxiety and anger, thus viewing the child as difficult, antagonistic or uncooperative. In such instance, parents tend to blame the adolescent or child as solely the identified patient and remain oblivious to the underlying emotions, of fear, or sadness that are at play [15]. The EFFT therapist connects the child/adolescent’s symptoms to their perception that the caregiver is unavailable and detached. This perception increases a child’s anxiety, anger and defensiveness that contributes to the presenting problem [9, 16]. The goal of the EFFT therapist is to work through a series of interventions that reframe the family problem as one arising out of an attachment crisis, and subsequently works to normalize family difficulties without blaming anyone [17]. Key to the EFFT process is understanding and integrating these core theoretical principals.
\nThe process of EFFT is categorized into three stages and nine treatment steps. In the initial four treatment steps, the therapist carefully focuses on assessing the interactive styles of the family and judiciously works to deescalate any conflicts as they emerge. In the middle phases of treatment (steps five, six, and seven), the therapist and family, work in concert to find new ways to establish more secure familial relationships. In the final two steps of treatment, the therapist highlights and validates new patterns of positive interaction. As importantly, the therapist reinforces family members confidence to handle future conflicts and issues now that they are armed with greater empathy and understanding for one another. The stages and steps of EFFT are outlined and discussed below.
\n\n
Step 1: Forming an alliance and family assessment.
Step 2: Identifying negative interactional patterns that maintain insecure attachment.
Step 3: Accessing underlying emotions informing interactional positions/relational blocks.
Step 4: Reframing the problem in light of relational blocks and negative interaction patterns.
The primary focus in stage one is for the therapist to identify and track behaviors and secondary emotions that fuel attachment insecurities. The therapist guides the family away from focusing on the content of their presenting conflicts, to developing a more attentive awareness about what underlies their expressed difficulties. The therapist accomplishes this task by tracking familial behaviors driven by intense emotion. As therapists understand, in times of distress, family members commonly deal with their feelings and interpersonal behaviors in unproductive ways. Some may withdraw, argue, submit, explain, or engage in other behaviors designed to minimize and distract from their emotional pain. In this stage, the therapist pays close attention to the interactive behaviors of the family and reframes maladaptive or secondary emotional responses in efforts to bring into awareness their negative cycle of interactions. A negative cycle is defined as a predictable interactional pattern that gets repeated and organizes the family around insecurity, rather than vulnerability. Negative cycles are fatiguing and destructive for family functioning. Tracking the cycle interrupts the behavior and reveals for the first time to the family their true underlying emotions and how their current behaviors serve as protective mechanisms to avoid discomfort and pain. Accessing primary emotions such as fear, hurt, and sadness creates empathy among family members, facilitates responsiveness, and helps the family deescalate [18]. During this phase of treatment, the therapist often returns to utilizing tracking interventions to reemphasize to the family the importance of understanding and dealing with the underlying issues of their discontent in order to enhance family stability and healthy functioning.
\n\n
Step 5: Accessing and deepening a child’s disowned aspects of self and attachment needs.
Step 6: Fostering acceptance of child’s new experience and attachment related needs.
Step 7: Restructuring family interactions focusing on sharing attachment needs and supportive caregiving responses.
In stage two, the focus is on deepening and expanding primary emotions and unmet attachment needs, in order to reshape attachment bonds between family members that are more secure and connected. The change event in stage two involves the therapist accessing the needs embedded in the newly expanded primary emotions that drive the negative family cycle; and helping family members learn to identify and request that previously unexpressed core attachment needs be addressed. The therapist intentionally structures interventions known as enactments that function to restructure attachment bonds between family members [14]. Typically, these requests are for direct care, contact, or comfort and the shift is premised on the parent(s) ability to respond to their children’s vulnerability. It is very common in this stage to observe parents having the desire to respond in a more emotionally connected way to their child, but their empathy may be restricted. In such instances, the EFFT therapist will work with the parents to develop their capacity and ability to respond in a way that shifts family relationships toward more secure bonds, replacing negative and harmful cycles of interactions.
\n\n
Step 8: Exploring new solutions to past problems from more secure positions.
Step 9: Consolidating new positions and strengthening positive patterns.
Finally, in stage three of EFFT, positive cycles of bonding are consolidated and integrated into the life of the family. At the end of this stage, the family is best able to integrate new ways of engaging in discussions and investing in greater security [18]. Discussions are characterized by more openness, responsiveness, and engagement among family members. It is imperative for the family to learn how to repair failed attempts to connect outside of sessions. Before termination, the therapist affirms that the family is now able to handle its issues and conflicts by examining and resolving them in new and more effective ways. The therapist also focuses on amplifying the family’s vision to include more mindfulness of positive affect, vulnerable reaching, and connection.
\nThere are two primary sets of interventions utilized by EFFT clinicians to help families navigate through the various stages of the treatment process. These core interventions are designed to direct families toward developing relational bonds that enhance their security, communication and strength. The first set are interventions for accessing, expanding and reprocessing of emotional experience. The second set are interventions for restructuring the family interactions.
\nThe EFFT techniques used within these categories are described below, followed by an example of a therapist’s response to highlight and reinforce a more concrete understanding of the techniques deployed. For a more detailed explanation the reader is referred to the EFT manual [3].
\nReflect (name, order, or distill) emotional processing as it occurs. Slows down the process, directs and focuses attention inward, helps the therapist attune to the client experience, thus conveying understanding and helps in creating alliance. Empathic reflections need to be specific and vivid in order to move the client into a deeper awareness of their emotional experiencing.
\nTherapist: “I think I hear you say that you become so anxious about his future that you find yourself wanting to control, wanting to know what he has in mind because not knowing or not having ‘a say’ is so overwhelming. Is that it? And then you become very critical with your son. Is that right?”
\nConveys that the client is entitled to their experience. Such statements function to affirm, and legitimize, the client’s experience as understandable, given the attachment relationship context. Validating statements start with, “it makes sense that you would feel this way, given (state specific context)”.
\nTherapist
Through the use of questions, evocative language, and metaphors the therapist opens up the client’s experience and encourages them to take another step toward it
\nTherapist: “What’s happening right now as you hear him say that?” “What’s it like for you when she follows you around the house, pushing for your attention?”
\nThis intervention intensifies, clarifies, and deepens an emotion through persistent focus, reflection or enactments. Thus, allowing the client to identify and accept their emotional experience. The therapist’s pacing, tone and timing are significant. The acronym RISSSC, implying emotional risk [3], represents how this intervention is done: with repetition, images, speaking simply, softly, slowly, and using client’s words. The soft tone heightens vulnerability and sooths the dysregulated brain, so the client can process clearly.
\nTherapist: “This sounds really important, can we stay here for a bit, I think I hear you say that deep down you really go to a bad place, a place where you get the message that you are nothing but a failure in their eyes. A real disappointment for a son, and that makes you feel so sad, so hurt inside.”
\nTherapist offers an interpretation of client’s experience, or a hunch seen through the attachment lens. This facilitates a more intense experiencing from which new meanings may arise and an expanded awareness. It is important to convey tentativeness when offering a conjecture and to check if what is communicated matches the client’s experience.
\nTherapist: “As I listen to you, I hear you saying that you are angry about her lack of concern for you, but I see the tears in your eyes and I wonder if you are also saying that you are hurt by her lack of concern. Does that seem to fit?”
\nThe following interventions are used in EFFT to address the restructuring task:
\nReflections that track family members behaviors slow down and clarify the interactional process.
\nTherapist: “So, when Alex gets frustrated and walks away ignoring what you say, you get angry too and follow him. You need him to listen to you. And, when your mom follows you around wanting your attention it makes you shut down even more.”
\nReframing interactions in the context of the negative cycle, and attachment needs. An attachment reframe functions to access a positive meaning or intention for a seemingly negative response. It shifts the view of the member to a positive portrayal.
\nTherapist: “You don’t experience that the louder she gets, the more desperately she is trying to find you. It sounds as if she is upset with you, but she is doing everything she can to get close to you.”
\nThe therapist requests direct sharing of a clearly distilled message from one family member to another. Enactments, the most powerful intervention in EFFT, their function is to heighten emotional experience and reshape new interactions among family members which lead to positive cycles of accessibility and responsiveness.
\nTherapist: “Can you tell her, ‘I go away because I don’t want things to get worse between the two of us.’ Can you tell her this?”
\nTo help illustrate EFFT treatment in action, a case study of a family recently seen by the author is provided below:
\nThe family is composed of James and Penny (names and identifying information have been altered), a professional couple in their early 50s, married for 28 years. They have two children; Ellie (23) and Alex (19). The couple has been on and off in couple therapy for a year. The presenting problem described by the parents focused on their son Alex, who had told them at the end of his third semester in college that he wanted to drop out because “this kind of education” was not for him, and he did not see how it would help him get a job. Both parents were very upset and after much discussion, hesitantly agreed to allow him to take a “gap year.” It was their understanding that after the year break, Alex was to resume his studies. During that time Alex worked as a waiter, earning spending money while living at home. His work hours provided him with the flexibility to develop an online business that in the long run became a source of income. Alex enjoyed being independent and learning about the world through travel, reading and much You Tube video viewing. A year later, his goal was to be an entrepreneur and not re-enroll in university. Both parents were extremely upset with Alex and had tried to talk “some sense” into him, but to no avail. It was at this point that Penny- the mom requested a family session.
\nDuring the first two sessions the therapist met once with the entire family in order to assess they viewed the problem; and once individually with Alex, in order to develop an alliance and get to know him better. Alex, was a slender young man with short blond hair, and green eyes. He appeared younger than his years and was soft spoken as he stated that he was eager to start the process. Alex perceived his mother as critical, with strong opinions about a college education and persistent about him returning to school. This made him angry and he said that he frequently avoided conversations with her because they always ended up on the topic of his future. Mom viewed her son as unreasonable, and disrespectful because he ignored her questions and refused to engage with her. She experienced him as spoiled, entitled and selfish; this made her feel frustrated. James agreed with his wife and said that the tension between Alex and his mother stressed him, but he did not know what to do to resolve the issue.
\nRight from the start the EFFT therapist aims to understand the ways family members react to each other and tracks their interaction pattern. As family members discuss how they each perceive their concerns, reactive emotional responses are expressed or suppressed, thus allowing the therapist to witness the negative interaction pattern firsthand. The therapist tracks and reflects the behaviors that elicit the negative response and begins to identify the family pattern that is associated with the problem [3, 4]. It was obvious that this family was caught in a reactive pattern of defensiveness, which escalated with increasing anger and frustration. The family’s escalation included mom trying to advise Alex and Alex avoiding the conversation. The more mom insisted in engaging him the more Alex ignored her and she would get so upset that she would turn to her husband for help. James, not knowing what to do would try to calm her by promising he would talk to Alex. However, his approach was not successful either. The more they tried to talk to him or present him with consequences for his actions, the more Alex pulled away. The more he pulled away, the less valued they felt. It appeared to be a hopeless situation.
\nWhat follows is an actual dialog from the initial sessions with the family. This excerpt highlights the goal of stage one treatment to track the cycle between Alex and his mom and attempt to deescalate the tensions between family members.
\nALEX: Well, yes… she is unbelievable. She asks me questions, a lot of questions about what I am going to do with my life and I do answer her but a few days later she is asking me the same questions!
\nTHERAPIST: all these questions coming your way, regarding your future and you answer them, and then she asks again. Is that right?
\nALEX: Yes, it’s so frustrating because it’s like, does she not remember? What’s going on?
\nTHERAPIST: I can understand your frustration- because, you wonder ‘isn’t what I say important enough to remember’ Is that right?
\nALEX: yes, that’s exactly right.
\nTHERAPIST: When your mom asks the same question, what happens inside you? What do you say to yourself?
\nALEX: I hear myself saying, what is the point? I get frustrated.
\nTHERAPIST: Are you feeling frustrated right now?
\nALEX: Yes!
\nTHERAPIST: Would you be willing to stay curious with me for a moment about this part that feels frustrated? Do you notice it somewhere in your body? (
ALEX: I feel tightening in my chest and my shoulders.
\nTHERAPIST: you hear your mom asking another question about your plans, you get frustrated, which you notice as a tightening in your chest and shoulders, is that right?
\nALEX: yes.
\nTHERAPIST: And then what does this frustrated part want to do or say to mom?
\nALEX: It wants to avoid her.
\nTHERAPIST: How do you do that?
\nALEX: By ignoring her and eventually leaving the room.
\nTHERAPIST: What would happen if you did not ignore her and did not leave; if you stayed and talked with her?
\nALEX: Nothing good would come out of that. I will only disappoint her again. There is no point.
\nTHERAPIST: So, if talking makes it worse and you worry that you will disappoint her, then it makes sense that you do not want to engage. It sounds like when these fights happen there is nothing more to do but leave. Is that right?
\nALEX: That seems to be the best option, right then and there.
\nTHERAPIST: It makes sense to me that you leave the conversation to avoid making things worse between the two of you and, not disappoint your mom. Do you think your mom knows this? Can you tell her that you leave in order to not escalate things between the two of you?
\nALEX: (turning to mom) I do not get into it with you and I walk away because I do not want us to fight and I do not want to disappoint you.
\nMOM: I had no idea.
\nTHERAPIST: Yes (nodding). This is something new you are learning about Alex.
\nThe therapist also works with mom to identify her behaviors, thoughts and feelings as they relate to the negative cycle.
\nTHERAPIST: And when he walks away what happens to you?
\nMOM: I get fired up and I follow him, and I ask again. I insist that he listens to me and not ignore me.
\nTHERAPIST: Would you be willing to stay curious with me for a moment about this part that gets all fired up? Do you notice it somewhere in your body?
\nMOM: I feel tense all over.
\nTHERAPIST: you see Alex walk away, you get very angry, which you notice as a tension all over your body, is that right?
\nMOM: Yes.
\nTHERAPIST: And then what does this angry part do or say to Alex?
\nALEX: It gets very focused, very energized, and follows him relentlessly to get his attention.
\nTHERAPIST: What would happen if you did not do that?
\nALEX: I would not know what he is up to and I would not be able to help him. I have good advice- I have been where Alex is now, and I can possibly spare him the heartache if he would talk with me. I worry that he will make a mistake, but he does not value my input.
\nTHERAPIST: You want Alex to value your advice. So, you get angry and you insist on engaging in a conversation in the hopes that you can help him see the value in what you say. Is that right?
\nMOM: That’s right.
\nTHERAPIST: What does it feel like when you think that Alex does not value you?
\nMOM: (deep sigh) It feels sad.
\nTHERAPIST: You want him to value you and your input and when he does not that makes you feel sad. Is that right?
\nMOM: (in soft voice) yes.
\nTHERAPIST: Do you think Alex knows that? What would it be like to share a little bit of that with him? That underneath your anger you feel sad because you think that he does not value you? Can you tell him that?
\nIn the above excerpt the therapist looks at the pattern as it unfolds in the room between Alex and his mom. Family de-escalation occurs as Alex and his mom begin to understand their part in the negative interaction pattern and how their attachment-driven behaviors trigger predictable responses in each other. In this case every time mom needed to be assured that Alex was on the right path regarding his future, she asked questions which in turn triggered Alex and made him feel that an argument was imminent and he would disappoint his mother. He then pulled away to avoid the argument, leaving mom to feel sad and not valued and fearful that she was failing as a mother. This triggered mom and she then followed Alex around the house insisting that he engage with her. Alex would get more frustrated and eventually would leave the room thus confirming mom’s fear of not being valued. The therapist helps both uncover these deeper emotions and then invites them to do an enactment. In other words, to turn toward each other and engage in a different conversation. Until now, neither was aware how they protected themselves in their relationship nor had they been able to talk about their underlying feelings. The enactment is successful, and both Alex and mom have a new understanding about each other’s behavior. He expresses that he values her and wants to be able to talk with her without arguing because it does not feel good to either of them. They both share in the new experience of staying engaged. This awareness shifts the focus from blaming each other to owing their contribution in the negative cycle. In turn, this begins to alter their experience; they feel calmer and more open. A level of safety is created that will allow us to go deeper into vulnerabilities in the next stage.
\nWhat follows below is an example of actual dialog used to illustrate the process of restructuring family dynamics:
\nTHERAPIST: A few sessions ago you talked about feeling sad because you see yourself as a disappointment for your parents. Do you remember?
\nALEX: Mhmm.
\nTHERAPIST: I guess, I am curious to know, more about this place that you go to… when you feel that… you are a disappointment. Is it okay for us to go to that place?
\nALEX: Sure. (pause) It’s pretty bad. I try not to think about it. Instead, I just try to focus and work harder.
\nTHERAPIST: It’s so bad that you try to not think about it? Right now as we are thinking about it, talking about, notice what happens in your body.
\nALEX: I feel flushed and I feel tightness in my throat. It’s a bad feeling. That’s why I do not like to think about it.
\nTHERAPIST: Sure, it makes sense. And… who sees you in that place? Who knows about that?
\nALEX: Nobody knows. Nobody sees how much I try to make them proud of me. Instead I am told that everything I do is wrong. My whole approach is wrong, I am all wrong! (eyes closed).
\nTHERAPIST: That’s really painful—it’s hard for you.
\n(Long Pause)
\nALEX: Sometimes it feels that I might be running out of time… you know… my dad had problems with his heart last year. (At this point Alex, with his eyes closed and tears running down his cheeks, can hardly speak. After a long pause he continues). I am afraid that I might not have the chance to prove myself and it will be too late. And that maybe I should give up on my ideas and listen to theirs because it will be faster, but then I get conflicted and I think that, it’s not right to do something that I do not believe in. And I really believe in this. I do not want to disappoint them but I do not want to disappoint myself either.
\nTHERAPIST: Wow! It feels like you are running against time and you have to choose - your parents or yourself. Neither is a good option; and so you go here and you struggle, and you are confused and scared and alone trying to figure things out.
\nAlex is sobbing, and his dad reaches over and hugs him. His mom moves over and she too, sits beside him and hugs him.
\nTHERAPIST: Alex, your parents are right beside you. They want to understand. Can you let them in to that place where you are alone and sad?
\nALEX: I am scared when I think that something suddenly might happen to dad or to you (mom) like last year- and then you would not have the chance to see what I accomplished and be proud of me. Then you will never know that I am capable and that it’s ok to do it my way.
\nTHERAPIST: That is scary, to think that something might happen to either of your parents and trying to prove yourself, trying to get it right and not disappoint while you still have time.
\nDAD: I am so sorry that you are so hurt. I am,
ALEX: I could leave the house, but I really want to work on our relationship, because it is important that I, have both of your “blessings” as I move on. It is important, that I leave “the nest” as you say, knowing that you are proud of me and you love me, even if I failed. It’s like, the baby bird trying to fly out of the nest. The parents have to trust that he can do it- although they may not know for sure. If the baby bird falls, he needs his parents to lovingly encourage him to try again. Sometimes, he flops around for a little bit before the parents rush in to help, and that is ok. The little bird is learning even if he falls, even if he breaks a wing. Keeping the bird in the nest or constantly giving him directions how to fly is constraining—he will not find
DAD: “I had no idea that you felt this way; that you have been trying to fly out of the nest. I didn’t see all this as your attempt in figuring things out. What I thought I saw, was a little bird taking advantage of the safety provided by our nest and unless we pushed, you were not going to fly. I see now how that hurt you and how it made you feel that we didn’t trust you. I love you and want to support you and it’s pretty incredible to hear what has been going on for you.”
\nAt this point Alex is weeping in his father’s arms. Mom joins in the hug and after a small pause, with tears in her eyes says:
\nMOM: “I am so sorry I hurt you. I get scared and I rush in to help you, to save you, to show you and that makes you feel that I don’t believe in you. I want to be there for you. I don’t want you to feel this way.”
\nIn the above excerpt, Alex begins to talk about how scary it is to feel that he disappoints his parents and how he wants to make them proud before he loses either of them. His parents remain open hearted and open minded as he engages with them from a vulnerable place. They see his pain, hurt and fear. Dad not only sees from afar this terrible place that his son struggles in but can stand side by side with him there. His presence is felt, and his apology makes a huge difference to Alex. For the first time, Alex feels seen and feels understood at a much deeper level and therefore, this allows Alex to clearly articulate his attachment needs. Mom and dad worked together to respond to Alex. Often parents cannot empathize because they get caught up in their own secondary responses of fear. Staying present with Alex in his vulnerability allowed both parents to experience how Alex’s problematic behavior was related to the family’s negative cycle of interaction. In a later session, both parents were able to articulate their fear of failure and Alex was able to hear this and understand much of their stress as parents. He then reassured them, “you have been great parents, given me so much. I hope to be able to offer my kids what you have offered me. I love you both and I don’t want you to feel that you have failed as parents.” Additionally, he expressed regret for his past behavior toward his mother. Alex began to ask for contact, and this continued in following sessions which helped to bring them closer together.
\nWhat follows below is an example of actual dialog used to illustrate the process of consolidation:
\nMOM: Things are good. Alex initiated a conversation earlier this week where he confided in me and asked for my advice. He was telling me about an incident that happened at work and how he handled it. And then asked for my opinion–how I would have handled it.
\nALEX: (smiling) “That was nice, and different than times in the past. She did not do anything, other than just listen.
\n(Turning toward his mom) You did not try to fix or problem solve with me the way you used to with all the questions. You listened to me for a long time and then I remember that I asked you for advice. You said that you agreed with how I handled the matter and you would have done the same. It really felt good to talk to you like an adult without running away or avoiding you. I want to say, thank you for that because I feel less tense and more relaxed.
\nTHERAPIST: That’s really great Alex that you felt good to approach your mom and discuss something that was important to you and ask for her input. And it sounds that you both had this conversation in a different way than before. In a way that even feels different in your body.
\nALEX: Yes. Growing up and doing things differently than the way your parents expect is hard and can be kind of scary. Knowing that they are open and that my mom is there without judging me feels great.
\nMOM: I am so glad that we turned a corner. I am always here for you, no matter what and I want to be the mom you want me to be.
\nIn the above excerpt mom discovers during treatment that she could help her son by her attentive presence. She understands that she did not have to solve Alex’s problems or go “undercover” to find out what he was doing and, as a result, this helped her stay more connected with him. The relationship became safer, closer, and more equal. Both were able to confide in and support each other which is the desired outcome for stage three treatment.
\nTreating families in distress is extremely challenging for family therapists. Professionals working with families, especially neophytes, commonly feel uncertain and discouraged as they attempt to navigate the vast landscape of family dynamics encompassing multiple, complex interpersonal processes between members. As a result, family therapists find themselves negotiating or offering solutions to presenting problems, rather than focus on the underlying issues that are at the root cause of the dysfunction. Unfortunately, they soon realize the techniques used are not effective, and before long the family members cycle back where they started from. This makes the therapists feel inefficient and ineffective and therefore may shy away from doing family work.
\nHaving access to a practical, organized and effective model for working with families is pivotal if practitioners are to make meaningful differences in the lives of people they serve. EFFT arose from the realization that the change principles used in EFT could be applied to family relationships thus changing the cycles of interaction [3]. EFFT is a powerful and efficient way to assess and create positive change within the family system. At its core, EFFT views family distress as a result of attachment insecurity where family members fail to get their attachment needs met. Such families do not possess the skills necessary in expressing their attachment needs and protect themselves by becoming defensive, beginning a negative cycle of interaction which prevents healthy family functioning and stability. Accessing underlying attachment-related emotions and the needs associated with these emotions opens the family to address needs in new ways [3]. Corrective emotional experiences create safety that change family relationships and most likely impact future generations. Tapping into parents’ unconditional love is powerful; it offers families great hope and holds tremendous promise in revitalizing the field of family therapy.
\nRespiratory compromise due to embolization is one of the leading causes of death among hospitalized patients, a condition known as acute pulmonary embolism (PE). In the United States alone, for every 100,000 individuals, about 70 people will experience pulmonary embolism each calendar year [1].
Simply put, acute pulmonary embolism is a restriction of arterial blood flow in the lung that can be detrimental when misdiagnosed. When the cause of obstruction is blood itself, it is known as venous thromboembolism (VTE). This being the most common cause of pulmonary embolism. It is apropos to mention that blood flow is not the only substance that can cause mechanical lung obstructions. Other substances include, but not limited to fat (traumatic bone fracture, especially of long bones, leads to bone marrow/fat freely circulating systemically), amniotic fluid (as a complication of labor), air (a complication of central venous access), septic embolism (heart valve damage by micro-organism) or even tumor cells metastasizing. The broad array of materials that can lead to this obstructive shock makes it imperative for a clinician to put the clinical picture with the patient’s symptoms to make the diagnosis early. Failure to do so in a timely manner can lead to catastrophic cardiopulmonary compromise and even death.
When PE is caused by venous thromboembolism, greater than 50% of patients will have some clot burden in their lower extremities or a deep vein thrombosis (DVT). The culprit vessels being the femoral and popliteal veins. Some patients may present with symptoms of DVT without PE. Therefore, a thorough investigation is warranted to diagnose, treat and prevent future propagation.
Acute pulmonary embolism is a mechanical obstruction of the blood flow to the lung vasculature and the functional unit involved in respiration, the parenchyma. The parenchyma being starved of oxygen leads to an inflammatory response and cellular death made evident by respiratory compromise and the compensatory respiratory alkalosis on patient presentation. It is imperative to note that both PE and DVT share a spectrum in the realm of VTE. The main difference between these two disease states lies in the location. The main mechanism that leads to PE and DVT, known as the Virchow’s triad, comprises of endothelial injury, venous statis and a hypercoagulable state.
Endothelial injury refers to damage to the vasculature which can lead to an inflammatory response in an attempt to heal with thrombus formation. Most commonly, this occurs in acute trauma, previous history of trauma or prior surgery. Venous stasis, which comprises of a no flow state of blood, can lead to thrombus formation as blood has an affinity to coagulate when not freely flowing. Venous stasis is mostly seen as a complication from immobility (postoperative states) or in patients with major strokes. Lastly, a hypercoagulable state can be a complication of disease states, such as active cancer, medications such as hormonal replacement therapy or oral contraceptives, and finally genetic mutations, most common being factor V Leiden. Other genetic mutations include: protein C and S deficiency, prothrombin gene mutation, antithrombin III deficiency.
Hemodynamically, there are many alterations that occur in the presence of an acute PE that is related to the size of the embolus, the duration of blood flow obstruction as well as the patient’s cardiopulmonary history. Large PEs tend to obstruct the main pulmonary artery along with its branches while smaller PEs are culprits of the smaller peripheral vessels. The obstructive burden coupled with neurohormonal release contribute to hemodynamic compromise and ischemic propagation is presence of neurohormonal release that progress propagate ongoing damage. Common neurohormones present include serotonin, thrombin and histamine [2].
Hypoxic vasoconstriction, a reflex response to acute PE, leads to increase in mean arterial pulmonary pressure. This increase is significantly high in patients with history of pulmonary hypertension. Increased pulmonary artery pressure contributes to increased right ventricular (RV) afterload causing right ventricular enlargement and a leftward bulging of the interventricular septum commonly found on echocardiography. Cardiac arrest is hence from the vascular compromise from increased pressure on the right coronary artery, causing myocardial ischemia.
Acute PE impairs efficient gas exchange. Hypoxemia and increase in the alveolar-arterial oxygen tension gradient are the most common gas exchange abnormalities. Total dead space increases. Ventilation and perfusion become mismatched, with blood flow from obstructed pulmonary arteries redirected to other gas exchange units [2]. The obstruction of blood flow in the pulmonary arteries leads to a redistribution of blood flow causing some alveoli to have low ratios of ventilation to perfusion, whereas others have excessively high ratios of ventilation to perfusion [2].
Assessment of PE in patients can be challenging as symptoms can be nonspecific. The patient could present with an array of different possibilities but a history of dyspnea, progressive or sudden onset in nature is a common complaint. Other complaints include pleuritic chest pain, cough and hemoptysis mostly in patients with pulmonary infarction. Due to the nonspecific symptoms that acute PE could present with, it is imperative to garner the appropriate risk factors that could lead to the suspicion. Another complaint that should increase the index of suspicion is a patient with dyspnea coupled with recent onset lower extremity tenderness or swelling.
Most patients with PE have tachypnea and tachycardia associated with hypoxemia. Similar findings can occur in disorders such as heart failure, pneumonia, or chronic obstructive pulmonary disease [2]. A good clinical examination is apropos to ascertain any other possible disease pathology that may mimic PE.
The diagnosis of PE relies on a high clinical suspicion along with the patient’s history and physical exam. After suspicion, confirmation with appropriate testing leads to the final diagnosis. Diagnostic tests alone are not the reflex course of action with a high index of suspicion due to the fact that there are many disease states that could present similarly. In patients with a high index of suspicion, the Wells criteria, developed by Wells et al., is a simple clinical model to predict the likelihood of PE. Scoring system has a maximum of 12.5 points, based on 7 variables: 3 points each for clinical evidence of DVT and an alternative diagnosis being less likely than PE, 1.5 points each for heart rate > 100 per minute, immobilization/surgery within 4 weeks, and previous deep vein thrombosis/PE, and 1 point each for hemoptysis or cancer [2, 3]. The pretest probability for PE after utilization of the Wells scoring system categorizes PE into low (score < 2), moderate (score between 2 and 6) or high risk (score > 6). This will then guide a clinician on subsequent tests such as a D-dimer assay, a byproduct of ineffective fibrinolysis released into systemic circulation. D-dimer elevation has high sensitivity for acute PE, as high as 98%, albeit poor sensitivity. Instances such as malignancy, advanced age and chronic inflammatory conditions are all reasons for an elevated d-dimer besides PE. Therefore, the benefit of a d-dimer assay lies in its high negative predictive value and its ability to effectively reduce further diagnostic testing in patients with an already low to moderate pretest probability with Wells scoring [4, 5].
Imaging studies in patients with acute PE in recent times have been with computed tomography pulmonary angiography (CT-PA). The benefit of CT-PA is direct thrombi visualization in the pulmonary arteries and effectively ruling out patients without PE [2]. The use of radiocontrast dye should be taken into consideration in patients with a suspicion of PE, but in patients with decompensation coupled with a high index of suspicion, the benefits of imaging clearly outweigh the risk. Furthermore, CT-PA with evidence of thrombus in the pulmonary arteries up to the segmental level provides strong evidence of PE. When negative, it does exclude PE but the presence of PE in the subsegmental regions, sometimes missed by CT-PA, does not alter patient outcome as these patients have at least as good an outcome as patients with a negative lung scan [2, 6].
There are indeed other modalities for investigation of acute PE, though by far a CT-PA has emerged as the more favorable option. Other modalities include a ventilation-perfusion (V/Q) scan, a two-part exam with a ventilation phase and perfusion phase. Diagnosis of PE based on a V/Q scan is made when PE-associated lung areas fail to enhance on the perfusion phase using technetium-labeled albumin macroaggregates. Magnetic resonance imaging (MRI) with gadolinium-enhancement has been shown to have similar efficacy to that of CT-PA.
Anticoagulation has become the mainstay treatment for acute PE though the degree of severity influences the length of treatment. The severity of acute PE depends on parameters such as hemodynamics, right ventricular dysfunction, presence of troponin and/or brain natriuretic peptide (BNP). Risk stratification using the appropriate criteria not only guides the choice of treatment, but also provides outpatient management options. It is also highly important to know if the patient has any contraindications to anticoagulation prior to initiation of treatment. Massive (high-risk) PE is the presence of hemodynamic compromise, right ventricular dysfunction and increased troponin and/or BNP levels. In such patients, the most common cause of death is not the PE, but the complication of acute right ventricular failure. To mitigate this complication, hemodynamic and respiratory support early is crucial. Due to the dependence of preload in right ventricular failure, both fluid expansion and inotropic agents, such as dobutamine, dopamine and/or norepinephrine, are needed to manage shock [2]. In patients with presence of right ventricular dysfunction and increased troponin and/or BNP levels without hemodynamic compromise, are classified as sub-massive (intermediate-risk) PE with consideration of fibrinolytic therapy if very symptomatic. Lastly, low-risk PE classification is in the group of patients with no hemodynamic compromise, right ventricular dysfunction or increased troponin or BNP levels. In such patients, a consideration of outpatient management is acceptable.
Anticoagulation has become the cornerstone modality of treatment in patients with acute PE. In patients with a very high index of suspicion or massive PE, anticoagulation should be initiated prior to confirmatory test. The most extensively studied anticoagulant in PE is heparin. Heparin, an anti-thrombin III inhibitor, acts mainly by inactivation of factor Xa in the clotting cascade, preventing the conversion of prothrombin to thrombin. Other options include low molecular weight heparin (LMWH), fondaparinux or the direct factor Xa inhibitors, rivaroxaban and apixaban. Dosing for heparin is usually 80 U/kg bolus followed by an infusion at the rate of 18 U/kg per hour with subsequent doses based on aPTT results [4]. Additionally, it is important to monitor platelet count while heparin is administered due to the risk of heparin-induced thrombocytopenia (HIT). After the initial heparinization phase, continued treatment is with an oral direct thrombin inhibitor, factor Xa inhibitor or warfarin.
The duration of treatment of PE is directly related to the precipitating factors that led to the PE. In other words, whether the PE was provoked or unprovoked. Special considerations in terms of treatment modality and duration are made for certain populations such as pregnant females or patients with active cancer. For all other patient populations with who present with a first time PE, the minimum duration of treatment is 3 months. If the PE is provoked and the factors are withdrawn such as a female stopping hormonal treatment, then a 3-month period of oral anticoagulation is sufficient. In patients with an unprovoked or life-threatening PE, indefinite anticoagulation is ideal due to a higher risk of recurrence. There must be a risk and benefit analysis when indefinite anticoagulation is being pursued, especially in patients with a higher bleeding risk [4].
Systemic thrombolytic therapy is an effective therapy in preventing deaths from PE, however it markedly increases bleeding risks, including intracranial and fatal bleeding [7]. The PEITHO (Pulmonary Embolism Thrombolysis Study), which compared tenecteplase with placebo in 1000 PE patients without hypotension but with right ventricular dysfunction, found no clear net benefit from systemic thrombolytic therapy; the reduction in cardiovascular collapse (odds ratio: 0.30) was offset by the increase in major bleeding (odds ratio: 5.2) [8]. Consequently, systemic thrombolytic therapy is usually reserved for PE patients with hypotension. Catheter-directed thrombolysis (CDT) was initially developed for treatment of arterial, dialysis graft, and deep vein thromboses (leg or arm). When used to treat acute PE, a wire is usually passed through the embolus, followed by placement of a multi-sidehole infusion catheter through which a thrombolytic drug is infused over 12–24 h. The delivery of the drug directly into the thrombus is expected to be as effective as systemic therapy but to cause less bleeding because a much lower dose of the drug is used.
SEATTLE II is a single-arm prospective cohort study in which 150 patients with lobar artery or more central PE (31 with and 119 without hypotension) were treated with ultrasound-assisted CDT using a standardized protocol [9]. Tissue plasminogen activator was infused into each treated lung at a rate of 1 mg/h, to a total dose of 24 mg (over 12 h for bilateral lung infusions), and no additional mechanical maneuvers were used to disrupt or aspirate thrombus. When computed tomography pulmonary angiography was repeated after 48 h, the right ventricular to left ventricular ratio was decreased by 27% and thrombus burden was reduced by 30%. Pulmonary artery pressure also decreased by 27% between the start to the end of CDT. These 3 improvements were each highly statistically significant. There were 17 episodes of major bleeding in 15 patients (10%): one was associated with hypotension; all required transfusion; none was intracranial; and none was fatal.
Acute pulmonary ischemia due to pulmonary embolism results in a cascade of events, from decreasing lung compliance to increasing pulmonary resistance ultimately resulting in RV dysfunction and hemodynamic collapse. Thus, in certain cases more rapid thrombus removal is required, and mechanical techniques are now available.
The FlowTriever System (Figure 1) is a mechanical thrombectomy device indicated for use in the peripheral vasculature and pulmonary arteries (PAs). FlowTriever received U.S. Food and Drug Administration 510(k) clearance for PE in May 2018—the first mechanical thrombectomy device to receive that indication. The FlowTriever System includes Triever aspiration catheters (16-F, 20-F, 24-F) capable of removing large amounts of thrombus via aspiration with a 60 cc syringe. The FlowTriever System also includes FlowTriever catheters with three self-expanding nitinol mesh disks of different sizes designed to aid in extraction, if needed, by engaging and disrupting thrombus. Anticoagulation with heparin is recommended per routine catheterization laboratory practice to prevent thrombosis of the catheter. The aspiration catheter is advanced over a 0.035-inch wire to the level of the right or left PA, just proximal to the occlusive thrombus. Once engaged, the clot is extracted via aspiration through the catheter. The procedure can be repeated several times per side at the discretion of the physician, depending on the amount of clot retrieved and the improvement in distal flow on repeat angiography.
The FlowTriever® system. The Triever aspiration catheter is shown in purple, and the optional FlowTriever® catheter with nitinol disks is shown emerging from the distal end of the Triever catheter.
The FlowTriever System has been evaluated in several clinical studies both prospectively and retrospectively. The first of these was a prospective multi-center study, the FLARE (FlowTriever Pulmonary Embolectomy Clinical Study) trial, which was the largest systematic evaluation of the effectiveness of mechanical thrombectomy for PE at the time [10]. From April 2016 to October 2017, 106 patients were treated with the FlowTriever System at 18 U.S. sites. Two patients (1.9%) received adjunctive thrombolytics. The mean procedural time was 94 min, and the mean intensive care unit stay was 1.5 days. Forty-three patients (41.3%) did not require any intensive care unit stay. At 48 h post-procedure, average RV/LV ratio reduction was 0.38 (25.1%; p < 0.0001). Four patients (3.8%) experienced 6 major adverse events, with 1 patient (1.0%) experiencing major bleeding. One patient (1.0%) died from undiagnosed breast cancer through 30-day follow-up. The trial concluded that percutaneous mechanical thrombectomy with the FlowTriever System appears safe and effective in patients with acute intermediate-risk PE, achieved significant improvement in RV/LV ratio, and resulted in minimal major bleeding.
Large-bore aspiration mechanical thrombectomy with the FlowTriever System was also evaluated in two retrospective single-arm clinical studies. The first of these [11] was a single-center study of 46 patients with both massive (high-risk) and submassive (intermediate-risk) PE. The authors reported a significant reduction in mean PA pressure from 33.9 ± 8.9 mmHg to 27.0 ± 9.0 mmHg (
More recently, the FlowTriever System was studied in a nonrandomized two-arm retrospective analysis versus routine care [13]. This single-center study compared outcomes for 28 patients who underwent mechanical thrombectomy with the FlowTriever System to those for 30 patients who received routine care, which consisted of anticoagulation alone, anticoagulation with CDT, or systemic thrombolysis. In-hospital mortality was significantly lower for patients undergoing mechanical thrombectomy versus routine care (3.6% vs. 23.3%,
Pre procedure planning\t\t
Patient Information
Prior to any pulmonary embolism procedure several patient conditions must be made clear. Several questions that all operators should ask include, what are the current hemodynamics and does that patient require vasopressor support? What is the current respiratory status (Ie O2 supplementation or on mechanical ventilation)? What is the bleeding risk and can the patient be anticoagulated? During our procedure we maintain and actual clotting time (ACT) of >250 secs.
Pre case Imaging
CT is the most rapid and common imaging tool used. Specific items to look for include, location and size of clot, RV/LV Ratio, and pulmonary infarct.
Echocardiography will not only show LV and RV size but RV systolic function.
Additional things to consider:
History or current DVT
IVC Filter in Place
Clot in Transit (is TEE or TTE available urgently)
Recent Surgery/Extended immobile time (travel)
Cancer History
History of PE
Infarct consideration (reperfusion injury/elevated wire perforation risk)
Anesthesia:
Conscious sedation is recommended. General Anesthesia has a risk of worsening hypotension and reducing preload to the RV. If systemic pressure is tenuous, a rapid reduction in RV filling can result in immediate hemodynamic collapse.
Patient Selection
Avoidance of thrombolytics
There are several advantages to the decision making for who would benefit from thrombolytic therapy for pulmonary embolism. The immediate decision is to determine who is at highest risk and thus has the largest to gain. Any patient with right ventricular (RV) dysfunction, we feel should be considered for thrombolytic therapy. Patients with an elevated RV: LV ratio; greater than 0.9, elevated pro-bnp, elevated troponins, and hemodynamics suggestive of reduced cardiac output, should be considered for thrombolytic therapy.
Patients need to be able to lay either supine or prone for a minimum of 30 minutes, thus taking oxygen requirements and body habitus into consideration.
Any patient with a relative contraindication to thrombolytic therapy, or felt to be at elevated risk, immediately should be considered for thrombotic intervention.
Access
US guidance
Access to venous circulation, when using large bore sheaths should always be performed with ultrasound guidance. It is advantageous in the venous system to evaluate for upper or lower extremity deep venous thrombosis, prior to starting the procedure, as well as avoidance of an arterial puncture.
Femoral
The most common access site for pulmonary thrombectomy is the common femoral vein
Jugular
When an alternative access is required another option is the internal jugular vein.
Pulmonary angiogram
Difficulties
Image quality tends to be the dis-advantage. Morbid obesity, patient movement, as well as variations in imaging acquisition (ie dye load, manual vs. power injection), can result in wide range of image quality.
Aspiration thrombectomy catheters
Inari Medical
Twenty-four french aspiration guide catheter that navigates through the right heart and delivers the catheter directly into the pulmonary artery. Aspiration is performed by a manual pull. The large bore catheter maximizes aspiration and collection of thrombus. The 24 F catheter creates an aspiration flow rate of 143 mLs/second.
Sixteen french curve
Due to the natural curvature of the pulmonary artery to the right, the 24 F catheter takes a turn to the right pulmonary artery typically with little difficulty. The catheter when placed in the left pulmonary artery, typically does not engage the left lower lobe. The 16 french curve catheter is placed within the 24F catheter and is preshaped to point down into the left pulmonary artery for selective thrombus aspiration.
Bloodloss technology
The FlowSaver blood return system is designed to be used with the FlowTriever aspiration catheter to reduced blood loss by filtering aspirated thrombi and blood for reinfusion back to the patient, thus enabling bloodless thrombectomy for pulmonary embolism procedure. The filtration system includes a 40-micro filter. Filtered blood can be reintroduced using a 60-cc collection syringe.
Penumbra, Inc.
The Indigo aspiration system is indicated for use in the peripheral arterial system and the pulmonary arteries, receiving U.S. Food and Drug Administration 510(k) clearance for PE in December 2019.
The Indigo system lightning 12 aspiration catheter that navigates through the right heart and into the selected pulmonary artery. The 12F system, unlike the manual aspiration of the Inari device, is connected to the Penumbra aspiration pump, resulting in a continuous vacuum system at −28.5 mmHg. If thrombus is not aspirated, the system also has a separator wire that can be advanced through the catheter to disrupt thrombus at the distal tip.
Intraprocedural complications
Perforation
The most common cause of pulmonary artery perforation is due to a wire complication. Wire perforation causes include treating distal clot, poor wire positioning and overlapping vessel (specifically on the left side)
Avoidance and Management
Limit use of guide wires, and always use Amplatz wire to work over
Use multiple shots to confirm location of wire and catheter
Use multiple angles of monitor to confirm locations
If Perforation does occur, increase supplemental oxygen, stop and reverse anticoagulation and consider placing a occlusion balloon proximal to the perforation.
Right heart trauma
If the tricuspid valve crossed safely with angled pigtail catheter or balloon tip catheter, typically not as concerned. If a end hold catheter was used, through a chordae tendinea of the tricuspid valve.
Always advance with caution as advancing through heart monitoring pain, excessive tension advancing catheter, and any arrhythmias happening
Never advance large bore catheters without dilators
Use buddy wires to assist stability in accessing multiple vessels to avoid kick back
Shock/RV failure
There are several methods of determining right ventricular systolic function. A calculated PAPi in the cardiac cath lab can determine who would benefit from RV mechanical support (ie Abiomed Impella RP). If the PAPi is calculated to be less than 1, and you have achieved enough thrombolytic therapy to allow for distal perfusion, mechanical support should be considered. Extracorporeal membrane oxygenation (ECMO) can also be considered for both hemodynamic support and oxygenation.
Closure
Most venous access sites can be closed with manual pressure alone. However, with large bore access we have using the Abbott Medical proglide perclose suture mediated closure. This device has been shown to reduce time to hemostasis, ambulation and discharge compared to manual compression
Post Procedure management
ICU avoidance
The use of thrombolysis for the treatment of PE at some institutions requires ICU level care.
Mechanical thrombectomy is a means of direct therapy which can result in immediate clinical response and will commonly not require intensive care management.
Additionally with the avoidance of tissue plasminogen activator (tPA), ICU admission post procedure is commonly unnecessary.
Venous dopplers
The most common source of PE is DVT. Thus, all patients require bilateral venous duplex for confirmation of residual disease.
Based on these results, it is a clinical decision whether therapy is required for DVT.
Hypercoagulable work up
Patients who benefit from this work up include:
those with/without a family history of VTE
patients age < 45 years
recurrent thrombosis or thrombosis in unusual sites
arterial thrombosis
history of warfarin-induced dermatologic necrosis
These patients will benefit from testing: activated protein C resistance, factor V Leiden, Prothrombin gene mutation, Protein C and S deficiency, Antithrombin deficiency.
DOAC
DOACS such as Factor Xa inhibitors, Apixaban or Rivaroxaban, have become more favorable than Warfarin for anticoagulation due to lower bleeding risk, monitoring for therapeutic INR levels and easier dosing. Apixaban is dosed twice daily while Rivaroxaban is daily dosing. A lower dose is required based on age ≥80, weight ≤60kg and creatinine ≥1.5
Follow up Echo
A follow up echo is used to determine RV dimensions, RV dysfunction and residual pulmonary hypertension.
It is our practice that if there is residual elevation of pulmonary systolic pressure, we refer the patient to a pulmonary hypertension specialist.
Case 1
A 33-year-old woman with no significant past medical history presented to our emergency department after multiple syncopal episodes. An ambulance service was called by family and the patient arrived hypotensive and poorly responsive. She required 6 L of supplemental oxygen and vasopressor support to keep a mean arterial pressure greater than 60 mmHg and oxygen saturation greater than 92%. A bedside anterior-posterior chest X-ray showed a normal cardiac silhouette and clear lung fields. A 12-lead electrocardiogram was consistent with a sinus tachycardia and right bundle branch block. Initial laboratory data was positive for an elevated d-dimer (> 5000 ng/mL), positive troponin (0.4 ng/mL), and pro-brain natriuretic peptide (> 10,000 pg/mL). A stat CT angiogram of the chest demonstrated a massive PE with complete occlusion of the left lower lobe and a RV/LV ratio of 1.5.
The patient was moved emergently to the cardiac catheterization laboratory for immediate therapeutic aspiration thrombectomy. Access was obtained in the right femoral vein using ultrasound guidance. Initial systolic PA pressure was 60 mmHg and the mean PA pressure was 35 mmHg. A pulmonary angiogram confirmed complete occlusion of the left lower lobe (Figure 2). The 24-F Triever aspiration catheter (Triever24) was positioned in the left pulmonary artery. A 20-F Triever Curve catheter, capable of curving up to 260° to aid in navigating in difficult anatomies, (Figure 3) was used coaxially with the Triever24 catheter to angle to the lower lobe where two aspirations were performed. A large amount of thrombus was removed (Figure 4) and repeat pulmonary angiography showed almost complete pulmonary artery opacification and large reduction in thrombus burden (Figure 5). Within minutes there was hemodynamic improvement and oxygen requirements returned to room air alone. Post-thrombectomy pulmonary artery systolic pressure was 33 mmHg. The patient was transferred to the general medical ward and started on oral Factor Xa inhibitor and discharged home the following day.
Case 2
A 75-year-old man with a past medical history of metastatic prostate cancer with known spinal involvement, presented to our emergency room with acute onset of shortness of breath and chest tightness. Initial oxygen saturation was 82% requiring high flow oxygen with a non-rebreather mask. Initial blood pressure was 110/80 mmHg and heart rate of 110 bpm. The pretest probability of PE was high thus the first diagnostic test was a CT pulmonary angiogram, which confirmed a saddle pulmonary embolism and large thrombus burden in the left and right lobes. The RV/LV ratio was 1.4.
Pulmonary angiography was consistent with CT findings (Figure 6). With a known history of spinal metastasis, thrombolytic therapy was contraindicated. The femoral vein access site was dilated to accommodate a 24-F sheath, the Flowtriever System was positioned into the mainstem pulmonary artery and a single aspiration was performed. The catheter was then positioned into the left pulmonary artery performing a single aspiration, followed by the right pulmonary artery, again requiring a single aspiration. Repeat angiography confirmed thrombus resolution and large clot removal (Figure 7). The patient was transferred to the general medical floor on room air. An echocardiogram performed the next day demonstrated normal right ventricular size and function with normal pulmonary pressures. The patient was discharged home the following day.
Case 3
A 44-year-old woman with a recent history of COVID-19 pneumonia presented from home with acute worsening of dyspnea and new pleuritic chest pain. Prior to this admission she required no supplemental oxygen, however, now was on 10 L of oxygen to maintain a saturation > 96%. A CT angiogram of the chest was consistent with a massive right middle lobe pulmonary embolism. The patient was taken to the cardiac catheterization laboratory for emergent intervention. Due to rapid decline in respiratory status and acute hypoxic respiratory failure, the patient was placed on mechanical ventilation. In order to provide rapid therapy, aspiration thrombectomy was performed in the right pulmonary artery. Initial pulmonary angiogram clearly demonstrated large thrombus burden of the right pulmonary artery (Figure 8, left). After a single aspiration was performed, repeat angiogram confirmed almost complete resolution (Figure 8, right), and large thrombus debulking (Figure 9). At the conclusion of the procedure, the patient required <40% fraction of inspired oxygen (Fio2) and positive end-expiratory pressure (PEEP) of 5, maintaining an oxygen saturation > 99%. That evening while in the intensive care unit she was successfully extubated and required 2 L of oxygen by nasal cannula. Seventy-two hours after her initial presentation, she was discharged home on room air.
Pre-treatment pulmonary angiogram showing complete occlusion of the left lower lobe in a patient with massive pulmonary embolism.
Intra-procedure pulmonary angiogram showing the Triever20 curve catheter coaxial within the larger Triever24 catheter in the left lower lobe of the lung in a PE patient.
A large amount of thrombus extracted with the FlowTriever® system from a PE patient.
Post-thrombectomy pulmonary angiogram showing almost complete pulmonary artery opacification and large reduction in thrombus burden.
Pre-thrombectomy pulmonary angiography of the right and left lungs demonstrating a saddle pulmonary embolism with large thrombus burden.
Thrombus extracted using the FlowTriever
Pre- (left) and post-thrombectomy (right) pulmonary angiograms demonstrating large thrombus burden prior to thrombectomy with the FlowTriever
Large amount of thrombus extracted with the FlowTriever
IntechOpen - where academia and industry create content with global impact
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\n\nSara Uhac, COO
\n\nSara Uhac was appointed Managing Director of IntechOpen at the beginning of 2014. She directs and controls the company’s operations. Sara joined IntechOpen in 2010 as Head of Journal Publishing, a new strategically underdeveloped department at that time. After obtaining a Master's degree in Media Management, she completed her Ph.D. at the University of Lugano, Switzerland. She holds a BA in Financial Market Management from the Bocconi University in Milan, Italy, where she started her career in the American publishing house Condé Nast and further collaborated with the UK-based publishing company Time Out. Sara was awarded a professional degree in Publishing from Yale University (2012). She is a member of the professional branch association of "Publishers, Designers and Graphic Artists" at the Croatian Chamber of Commerce.
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\n\nAdrian Assad De Marco joined the company as a Director in 2017. With his extensive experience in management, acquired while working for regional and global leaders, he took over direction and control of all the company's publishing processes. Adrian holds a degree in Economy and Management from the University of Zagreb, School of Economics, Croatia. A former sportsman, he continually strives to develop his skills through professional courses and specializations such as NLP (Neuro-linguistic programming).
\n\nDr Alex Lazinica
\n\nAlex Lazinica is co-founder and Board member of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his Ph.D. in Robotics at the Vienna University of Technology. There, he worked as a robotics researcher with the university's Intelligent Manufacturing Systems Group, as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and, most importantly, co-founded and built the International Journal of Advanced Robotic Systems, the world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career since it proved to be the pathway to the foundation of IntechOpen with its focus on addressing academic researchers’ needs. Alex personifies many of IntechOpen´s key values, including the commitment to developing mutual trust, openness, and a spirit of entrepreneurialism. Today, his focus is on defining the growth and development strategy for the company.
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More so, the mechanism by which heavy metals cause neurotoxicity, generate free radical which promotes oxidative stress damaging lipids, proteins and DNA molecules and how these free radicals propagate carcinogenesis are discussed. Alongside these mechanisms, the noxious health effects of these heavy metals are discussed.",book:{id:"7111",slug:"poisoning-in-the-modern-world-new-tricks-for-an-old-dog-",title:"Poisoning in the Modern World",fullTitle:"Poisoning in the Modern World - New Tricks for an Old Dog?"},signatures:"Godwill Azeh Engwa, Paschaline Udoka Ferdinand, Friday Nweke Nwalo and Marian N. 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Ahmed",authors:[{id:"175649",title:"Dr.",name:"Tarek A",middleName:null,surname:"Ahmed",slug:"tarek-a-ahmed",fullName:"Tarek A Ahmed"}]},{id:"29240",title:"Oral Absorption, Intestinal Metabolism and Human Oral Bioavailability",slug:"oral-absorption-intestinal-metabolism-and-human-oral-bioavailability-",totalDownloads:27175,totalCrossrefCites:28,totalDimensionsCites:58,abstract:null,book:{id:"672",slug:"topics-on-drug-metabolism",title:"Topics on Drug Metabolism",fullTitle:"Topics on Drug Metabolism"},signatures:"Ayman El-Kattan and Manthena Varma",authors:[{id:"85539",title:"Dr.",name:"Ayman",middleName:null,surname:"El-Kattan",slug:"ayman-el-kattan",fullName:"Ayman El-Kattan"},{id:"88221",title:"Dr.",name:"Manthena",middleName:null,surname:"Varma",slug:"manthena-varma",fullName:"Manthena Varma"}]},{id:"66259",title:"Antioxidant Compounds and Their Antioxidant Mechanism",slug:"antioxidant-compounds-and-their-antioxidant-mechanism",totalDownloads:7587,totalCrossrefCites:58,totalDimensionsCites:152,abstract:"An antioxidant is a substance that at low concentrations delays or prevents oxidation of a substrate. Antioxidant compounds act through several chemical mechanisms: hydrogen atom transfer (HAT), single electron transfer (SET), and the ability to chelate transition metals. The importance of antioxidant mechanisms is to understand the biological meaning of antioxidants, their possible uses, their production by organic synthesis or biotechnological methods, or for the standardization of the determination of antioxidant activity. In general, antioxidant molecules can react either by multiple mechanisms or by a predominant mechanism. The chemical structure of the antioxidant substance allows understanding of the antioxidant reaction mechanism. This chapter reviews the in vitro antioxidant reaction mechanisms of organic compounds polyphenols, carotenoids, and vitamins C against free radicals (FR) and prooxidant compounds under diverse conditions, as well as the most commonly used methods to evaluate the antioxidant activity of these compounds according to the mechanism involved in the reaction with free radicals and the methods of in vitro antioxidant evaluation that are used frequently depending on the reaction mechanism of the antioxidant.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Norma Francenia Santos-Sánchez, Raúl Salas-Coronado, Claudia Villanueva-Cañongo and Beatriz Hernández-Carlos",authors:[{id:"143354",title:"Dr.",name:"Raúl",middleName:null,surname:"Salas-Coronado",slug:"raul-salas-coronado",fullName:"Raúl Salas-Coronado"},{id:"148546",title:"Dr.",name:"Norma Francenia",middleName:null,surname:"Santos-Sánchez",slug:"norma-francenia-santos-sanchez",fullName:"Norma Francenia Santos-Sánchez"},{id:"193718",title:"Dr.",name:"Beatriz",middleName:null,surname:"Hernández-Carlos",slug:"beatriz-hernandez-carlos",fullName:"Beatriz Hernández-Carlos"},{id:"278133",title:"Dr.",name:"Claudia",middleName:null,surname:"Villanueva-Cañongo",slug:"claudia-villanueva-canongo",fullName:"Claudia Villanueva-Cañongo"}]},{id:"66742",title:"Introductory Chapter: Alkaloids - Their Importance in Nature and for Human Life",slug:"introductory-chapter-alkaloids-their-importance-in-nature-and-for-human-life",totalDownloads:4130,totalCrossrefCites:16,totalDimensionsCites:32,abstract:null,book:{id:"6828",slug:"alkaloids-their-importance-in-nature-and-human-life",title:"Alkaloids",fullTitle:"Alkaloids - Their Importance in Nature and Human Life"},signatures:"Joanna Kurek",authors:[{id:"214632",title:"Dr.",name:"Joanna",middleName:null,surname:"Kurek",slug:"joanna-kurek",fullName:"Joanna Kurek"}]}],onlineFirstChaptersFilter:{topicId:"19",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"83076",title:"Treatments for the Infection by SARS-CoV-2",slug:"treatments-for-the-infection-by-sars-cov-2",totalDownloads:3,totalDimensionsCites:0,doi:"10.5772/intechopen.106232",abstract:"In late 2019, pneumonia cases from unknown origin were detected in Wuhan, China. The cause was a new coronavirus. The World Health Organization (WHO) named the virus SARS-CoV-2 and COVID-19 the associated disease. In the first months of 2020, this disease became a pandemic with a high lethality reported. Since then, the search for treatments began. We started by searching among treatments previously approved for human use that were not designed for COVID-19 and were considered to treat this condition. We continued searching on the therapeutics guidelines published by the WHO for the management of infection by SARS-CoV-2. Based on these results, we searched for the literature in PubMed to obtain further evidence on the drugs against SARS-CoV-2. The treatments presented in this chapter are Ivermectin, Hydroxychloroquine, Nitazoxanide, Azithromycin, Molnupiravir, Casirivimab-Imdevimab, Ritonavir-Nirmatrelvir, Ritonavir-Lopinavir, Remdesivir, and Favipiravir. Two years ahead of the start of the COVID-19 pandemic, a plenty of options for treatment have been investigated. Only a few of them have been shown to be efficient and safe. According to the WHO, Ritonavir-Nirmatrelvir outperforms other proposed therapeutics.",book:{id:"11690",title:"COVID-19 Drug Development - Recent Advances, New Perspectives, and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/11690.jpg"},signatures:"Nicolás Padilla-Raygoza, Gilberto Flores-Vargas, María de Jesús Gallardo-Luna, Efraín Navarro-Olivos, Francisco Javier Magos-Vázquez and Daniel Alberto Díaz-Martínez"},{id:"83054",title:"Pulsatory Liposome: A Possible Biotechnological Device",slug:"pulsatory-liposome-a-possible-biotechnological-device",totalDownloads:1,totalDimensionsCites:0,doi:"10.5772/intechopen.106347",abstract:"A unilamellar liposome filled with an osmotic solution is introduced into a hypotonic aqueous environment. Because of the mechanical tension induced by the osmotic flow, the vesicle swells up to a critical size, when suddenly a transbilayer pore appears and the vesicle relaxing stage starts. A part of the intracellular material leaks out through this pore, and the liposome membrane relaxes and finally recovers. The swelling begins again and the liposome experiences a periodical process. For this reason, we have named it a pulsatory liposome. The swelling of the liposome is described by a differential equation. All the processes which contribute to the vesicle relaxing and its coming back to the initial size are described by three differential equations. The pulsatory liposome can be programmed to work a number of cycles, established before. The activity of a pulsatory liposome can be characterized by the following parameters: (a) number of cycles, the length time of each cycle, and liposome activity life; (b) the length time of the swelling stage and the relaxation stage for each cycle; (c) the amount of solute leaked out through the pore in each cycle. The pulsatory liposome may be regarded as a two-stroke engine.",book:{id:"11814",title:"Liposomes - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/11814.jpg"},signatures:"Dumitru Popescu and Alin Gabriel Popescu"},{id:"82962",title:"Pluralism Medical Treatment, Prevention, and Control of COVID-19 Infection and Its Long-Sufferings among the Older Adults in the Northeast of Thailand from 2019 to 2022",slug:"pluralism-medical-treatment-prevention-and-control-of-covid-19-infection-and-its-long-sufferings-amo",totalDownloads:48,totalDimensionsCites:0,doi:"10.5772/intechopen.106339",abstract:"COVID-19 in 2019 has brought both changes and challenges to the world. This global pandemic has an impact on people of all age levels, especially older adults. In Thailand, older persons are at high risk of COVID-19 infection. They are included in the so-called 608 groups. The objective of this review article was to synthesize and present medical pluralism, the development of drugs from herbs, and projects conducted to treat, prevent, and control the infection and long sufferings of COVID-19. The review covers 10 studies, three projects produced at Mahasarakham University, Chaiyaphum Rajabhat University, and Khon Kaen University that were reviewed, synthesized, and analyzed. The results of the synthesis indicate that modern and Thai traditional medicine can help reduce the severity of the infection and long sufferings of COVID-19. The medical pluralism between modern and Thai traditional medicine is needed to remedy COVID-19 cases among the older adults in the Northeast of Thailand.",book:{id:"11690",title:"COVID-19 Drug Development - Recent Advances, New Perspectives, and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/11690.jpg"},signatures:"Pissamai Homchampa, Khemika Napattaradechanon, Parichat Yatniyom, Thawalrat Ratanasiri, Piyaporn Sansila, Thanawan Sirisuk, Thawalwong Ratanasiri and Amornrat Ratanasiri"},{id:"82353",title:"Pharmacovigilance of Biological Drugs",slug:"pharmacovigilance-of-biological-drugs",totalDownloads:5,totalDimensionsCites:0,doi:"10.5772/intechopen.105520",abstract:"The use of biological drugs has significantly increased over the past decades and has allowed for the treatment of many life-threatening and chronic diseases. The patent expiration of biological innovative medicines enables copies of these drugs called biosimilars. The availability of biosimilars enhances competition, with the potential to improve patient access to biological medications and contribute to the financial sustainability of the healthcare systems. Unlike equivalent drugs, biosimilars are not identical but similar to their innovator products because of the differences in the manufacturing process, which is a biological process. However, they are considered comparable to their originators in safety, quality characteristics, biological activity, and efficacy. The regulatory procedures used for generic drugs cannot be applied for biosimilars, so they are subjected to rigorous characterization as well as comparative clinical studies. Since they are highly complex molecules produced from living cells, even small change in the production process can have major implications on their safety and effectiveness profile, causing a potential risk of immune-based adverse reactions. For all these reasons, for biological drugs, a robust long-term pharmacovigilance system is necessary. It is desirable that in the future, there are further guidance and resolution of the ongoing discussions on biosimilar labeling, naming, pharmacovigilance and interchangeability/substitution, to ensure the appropriate use of these drugs in clinical practice.",book:{id:"11679",title:"Pharmacovigilance and Regulations",coverURL:"https://cdn.intechopen.com/books/images_new/11679.jpg"},signatures:"Simona Guerzoni, Flavia Lo Castro, Carlo Baraldi, Giuliana Colella and Luca Pani"},{id:"82868",title:"Recent Strategies for Ocular Drug Delivery: Promises and Challenges",slug:"recent-strategies-for-ocular-drug-delivery-promises-and-challenges",totalDownloads:9,totalDimensionsCites:0,doi:"10.5772/intechopen.106335",abstract:"Ocular diseases include various anterior and posterior segment diseases. Due to the unique anatomy and physiology of the eye, efficient ocular drug delivery is a great challenge to researchers. The emerging nanoscience is playing an important role in the development of novel strategies for ocular disease management. Various active molecules have been designed to associate with nanocarriers to overcome ocular barriers and interact with certain ocular tissues. In this chapter, highlights will be made on barrier to intraocular delivery, general pathways for ocular absorption, and factors affecting intraocular bioavailability. The recent attempts of nanotechnology for treating anterior and posterior ocular diseases will be explored. This will include nanomicelles, nanoparticles, nanosuspensions, vesicular systems, in situ gel, dendrimers, contact lenses, implants, microneedles, and cell-based delivery systems. In addition, gene-based ocular delivery systems will be discussed. In this chapter, we will also provide a comprehensive overview of drug-device combinations used for ocular diseases such as glaucoma, dry eye disease, infections, and inflammations. Furthermore, drug delivery devices for ocular surgeries are discussed. Finally, challenges and future prospective of ocular delivery systems will be explored.",book:{id:"11688",title:"Advances in Drug Delivery Methods",coverURL:"https://cdn.intechopen.com/books/images_new/11688.jpg"},signatures:"Amal H. El-Kamel and Asmaa A. Ashour"},{id:"82727",title:"Mesoporous Silica Based Cancer Theranostic: A Modern Approach in Upcoming Medicine",slug:"mesoporous-silica-based-cancer-theranostic-a-modern-approach-in-upcoming-medicine",totalDownloads:13,totalDimensionsCites:0,doi:"10.5772/intechopen.105447",abstract:"In case cancers are located deep inside the body and are very tough to diagnose, diagnostic tools like MRI/CT scans can be employed to detect these cancers. The major challenge in such cases is the delivery of MRI active agents or visualizing agents to the target site. In this context we will discuss different mesoporous nanoparticles that can be employed to target the tissue at a specific location, its functionalization to reach the target site (Folic acid), different simple dyes as well as specific dyes which offer theranostic functionality. The nanoparticles like mesoporous silica nanoparticles offer the possibility to load therapeutic and diagnostic agents. Its surface allow multiple functionalization and conjugations which offer target specific delivery of these agents. Moreover we will also overview different modern drug delivery inventions for offering theranostic application.",book:{id:"11688",title:"Advances in Drug Delivery Methods",coverURL:"https://cdn.intechopen.com/books/images_new/11688.jpg"},signatures:"Ajinkya Pote, Vikas Ahirrao and Vishal Pande"}],onlineFirstChaptersTotal:57},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:108,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:9,numberOfPublishedChapters:141,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:123,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:22,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:11,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983",scope:"Biochemistry, the study of chemical transformations occurring within living organisms, impacts all areas of life sciences, from molecular crystallography and genetics to ecology, medicine, and population biology. Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"August 2nd, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:33,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"14",title:"Cell and Molecular Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",isOpenForSubmission:!0,editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",slug:"rosa-maria-martinez-espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",biography:"Dr. Rosa María Martínez-Espinosa has been a Spanish Full Professor since 2020 (Biochemistry and Molecular Biology) and is currently Vice-President of International Relations and Cooperation development and leader of the research group 'Applied Biochemistry” (University of Alicante, Spain). Other positions she has held at the university include Vice-Dean of Master Programs, Vice-Dean of the Degree in Biology and Vice-Dean for Mobility and Enterprise and Engagement at the Faculty of Science (University of Alicante). She received her Bachelor in Biology in 1998 (University of Alicante) and her PhD in 2003 (Biochemistry, University of Alicante). She undertook post-doctoral research at the University of East Anglia (Norwich, U.K. 2004-2005; 2007-2008).\nHer multidisciplinary research focuses on investigating archaea and their potential applications in biotechnology. She has an H-index of 21. She has authored one patent and has published more than 70 indexed papers and around 60 book chapters.\nShe has contributed to more than 150 national and international meetings during the last 15 years. Her research interests include archaea metabolism, enzymes purification and characterization, gene regulation, carotenoids and bioplastics production, antioxidant\ncompounds, waste water treatments, and brines bioremediation.\nRosa María’s other roles include editorial board member for several journals related\nto biochemistry, reviewer for more than 60 journals (biochemistry, molecular biology, biotechnology, chemistry and microbiology) and president of several organizing committees in international meetings related to the N-cycle or respiratory processes.",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"15",title:"Chemical Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",isOpenForSubmission:!0,editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",slug:"sukru-beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",biography:"Dr. Şükrü Beydemir obtained a BSc in Chemistry in 1995 from Yüzüncü Yıl University, MSc in Biochemistry in 1998, and PhD in Biochemistry in 2002 from Atatürk University, Turkey. He performed post-doctoral studies at Max-Planck Institute, Germany, and University of Florence, Italy in addition to making several scientific visits abroad. He currently works as a Full Professor of Biochemistry in the Faculty of Pharmacy, Anadolu University, Turkey. Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. Dr. Beydemir is also Rector of Bilecik Şeyh Edebali University, Turkey.",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",slug:"deniz-ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",biography:"Dr. Deniz Ekinci obtained a BSc in Chemistry in 2004, MSc in Biochemistry in 2006, and PhD in Biochemistry in 2009 from Atatürk University, Turkey. He studied at Stetson University, USA, in 2007-2008 and at the Max Planck Institute of Molecular Cell Biology and Genetics, Germany, in 2009-2010. Dr. Ekinci currently works as a Full Professor of Biochemistry in the Faculty of Agriculture and is the Head of the Enzyme and Microbial Biotechnology Division, Ondokuz Mayıs University, Turkey. He is a member of the Turkish Biochemical Society, American Chemical Society, and German Genetics society. Dr. Ekinci published around ninety scientific papers, reviews and book chapters, and presented several conferences to scientists. He has received numerous publication awards from several scientific councils. Dr. Ekinci serves as the Editor in Chief of four international books and is involved in the Editorial Board of several international journals.",institutionString:null,institution:{name:"Ondokuz Mayıs University",institutionURL:null,country:{name:"Turkey"}}},editorThree:null},{id:"17",title:"Metabolism",coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",isOpenForSubmission:!0,editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",slug:"yannis-karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",biography:"Yannis Karamanos, born in Greece in 1953, completed his pre-graduate studies at the Université Pierre et Marie Curie, Paris, then his Masters and Doctoral degree at the Université de Lille (1983). He was associate professor at the University of Limoges (1987) before becoming full professor of biochemistry at the Université d’Artois (1996). He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. His teaching areas are energy metabolism and regulation, integration and organ specialization and metabolic adaptation.",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null},{id:"18",title:"Proteomics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",isOpenForSubmission:!0,editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",slug:"paolo-iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",biography:"Paolo Iadarola graduated with a degree in Chemistry from the University of Pavia (Italy) in July 1972. He then worked as an Assistant Professor at the Faculty of Science of the same University until 1984. In 1985, Prof. Iadarola became Associate Professor at the Department of Biology and Biotechnologies of the University of Pavia and retired in October 2017. Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. 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