Aetiology of acute pancreatitis.
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"6654",leadTitle:null,fullTitle:"Weight Loss",title:"Weight Loss",subtitle:null,reviewType:"peer-reviewed",abstract:"Epidemiological studies show that weight loss has many health benefits, so different strategies have been explored to lose weight, with health and esthetic reasons being the base of those strategies. Weight loss may be the result of pathologies, so both intentional and unintentional weight loss are different situations, each being a relevant focus of study. Along with that distinction, gender and ethnic topics are also relevant aspects, and different chapters of this book are related to male vs. female topics as well as to cultural differences related to weight loss. Childhood obesity from a parenting style perspective is also developed in this book. Finally, it must be noted that activity is essential to improve body composition and also to keep an ideal weight.",isbn:"978-1-78923-691-0",printIsbn:"978-1-78923-690-3",pdfIsbn:"978-1-83881-622-3",doi:"10.5772/intechopen.71828",price:119,priceEur:129,priceUsd:155,slug:"weight-loss",numberOfPages:170,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"a7b1748cdbd8e86c1cac93238b57242e",bookSignature:"Ignacio Jáuregui Lobera",publishedDate:"October 31st 2018",coverURL:"https://cdn.intechopen.com/books/images_new/6654.jpg",numberOfDownloads:8221,numberOfWosCitations:2,numberOfCrossrefCitations:6,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:10,numberOfDimensionsCitationsByBook:0,hasAltmetrics:1,numberOfTotalCitations:18,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 27th 2017",dateEndSecondStepPublish:"November 17th 2017",dateEndThirdStepPublish:"January 16th 2018",dateEndFourthStepPublish:"April 6th 2018",dateEndFifthStepPublish:"June 5th 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"323887",title:"Prof.",name:"Ignacio",middleName:null,surname:"Jáuregui-Lobera",slug:"ignacio-jauregui-lobera",fullName:"Ignacio Jáuregui-Lobera",profilePictureURL:"https://mts.intechopen.com/storage/users/323887/images/system/323887.png",biography:null,institutionString:"Pablo de Olavide University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"7",totalChapterViews:"0",totalEditedBooks:"4",institution:{name:"Pablo de Olavide University",institutionURL:null,country:{name:"Spain"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1132",title:"Health Care",slug:"medicine-public-health-health-care"}],chapters:[{id:"60386",title:"Unintentional Weight Loss",doi:"10.5772/intechopen.74860",slug:"unintentional-weight-loss",totalDownloads:902,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"Unintentional weight loss (UWL) is a common symptom, particularly among older patients. In one site, patients with UWL have increased morbidity and mortality; in the other site, the prognosis of the patients is related to primary cause of the UWL. The differential diagnosis of the underlying diseases leading to UWL is broad and includes both malignant and nonmalignant gastrointestinal (GI) diseases, as well as endocrine, infectious, cardiopulmonary, and psychiatric disorders and side effects of medications. Patients with UWL should be investigated. The diagnostic approach to patients with UWL includes comprehensive medical history, physical examination, laboratory testing, imaging, and endoscopy. The imaging and endoscopy should be targeted according to the symptom, physical examination findings, and laboratory results. The treatment of UWL should be targeted to the primary disease causing weight loss. Non-pharmacologic nutrition intervention is the important treatment, and some pharmacologic treatment could be helpful in part of the patients.",signatures:"Naim Abu Freha",downloadPdfUrl:"/chapter/pdf-download/60386",previewPdfUrl:"/chapter/pdf-preview/60386",authors:[{id:"232387",title:"Dr.",name:"Naim",surname:"Abu Freha",slug:"naim-abu-freha",fullName:"Naim Abu Freha"}],corrections:null},{id:"60844",title:"Self-Control in Weight Loss Process",doi:"10.5772/intechopen.76127",slug:"self-control-in-weight-loss-process",totalDownloads:961,totalCrossrefCites:2,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Classical motivation theories assumed that the probability of success in goal striving process (including weight loss) depended on two factors: likelihood of success and attractiveness of the result. However, research referring to obesity showed that motivational factors are not sufficient in effective weight loss. In other words, obese people value anticipated weight loss but still do not succeed in this process. It is implied by the fact that effectiveness and persistence of this process depend also on volitional factor. This factor refers to self-control mechanisms, which mediate between intention to reach the goal and its enactment. The current empirical data suggest that implementation intentions and mental simulations are especially beneficial techniques of self-control enhancement. This chapter will unveil main theories and research concerning self-control mechanisms and influence of various mental simulations and implementation intentions in weight loss process and weight-related behaviors. Moreover, our empirical data concerning individual differences in self-control of weight loss process are presented.",signatures:"Magdalena Marszał-Wiśniewska and Ewa Jarczewska-Gerc",downloadPdfUrl:"/chapter/pdf-download/60844",previewPdfUrl:"/chapter/pdf-preview/60844",authors:[{id:"232693",title:"Prof.",name:"Magdalena",surname:"Marszal-Wisniewska",slug:"magdalena-marszal-wisniewska",fullName:"Magdalena Marszal-Wisniewska"},{id:"233655",title:"Dr.",name:"Ewa",surname:"Jarczewska-Gerc",slug:"ewa-jarczewska-gerc",fullName:"Ewa Jarczewska-Gerc"}],corrections:null},{id:"59602",title:"The Eating Attitudes and Mental Health in Japanese Female University Students",doi:"10.5772/intechopen.74627",slug:"the-eating-attitudes-and-mental-health-in-japanese-female-university-students",totalDownloads:855,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"First, the relationship between eating attitudes and anxiety in Japanese female university students was examined. The results of the analysis show that especially trait anxiety significantly relates with eating disorder tendency. Following this, the interrelationship of eating attitudes, body-checking behavior cognition, and depression was examined. The results show that the obsessive thoughts body image score increases as the eating disorder tendency score also increases, indicating that inappropriate eating attitudes have a strong impact on obsessive thoughts. Finally, the relationship between eating attitudes, trust, and isolation was examined. The results of the analysis show that inappropriate eating behavior significantly correlates with distrust and isolation.",signatures:"Daiki Kato, Mio Yoshie and Mari Ishihara",downloadPdfUrl:"/chapter/pdf-download/59602",previewPdfUrl:"/chapter/pdf-preview/59602",authors:[{id:"198255",title:"Ph.D.",name:"Daiki",surname:"Kato",slug:"daiki-kato",fullName:"Daiki Kato"},{id:"232327",title:"Ms.",name:"Mio",surname:"Yoshie",slug:"mio-yoshie",fullName:"Mio Yoshie"},{id:"232329",title:"Ms.",name:"Mari",surname:"Ishihara",slug:"mari-ishihara",fullName:"Mari Ishihara"}],corrections:null},{id:"62174",title:"Impact of Body Image Perception on Weight Status: A Refuelling of Non-communicable Disease in Urban South African Zulu Women: Not Just Calipers, Tapes and Scales",doi:"10.5772/intechopen.74644",slug:"impact-of-body-image-perception-on-weight-status-a-refuelling-of-non-communicable-disease-in-urban-s",totalDownloads:896,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The purpose of this study was to determine Zulu women’s perceptions of their body image relative to weight status attending a noncommunicable diseases (NCDs) clinic in South Africa. A cross-sectional exploratory study design was used and included 328 (91%) Zulu women who were sampled systematically. The women were subjected to anthropometric measurements and engaged the Stunkard’s body image figures to determine perception. The study showed that 61% of the sample was in the 40–59 age strata. The mean body mass index (BMI) was 37 kg/m2 (±9.41 kg/m2) with over 90% being overweight or obese. A discrepancy between Zulu women’s perceived body image and actual (BMI) existed in all weight status categories with overweight and obesity demonstrating the widest variations (p < 0.000). Women perceived themselves to be thinner than their actual BMI. More than 99% associated an underweight body image to one with disease. Diabetes mellitus (72%) was the most frequent NCD encountered. Only 23% with this condition correctly perceived their body image. It was shown that the negative impact of preferring a larger body image in Zulu women with preexisting NCD’s could be refueling their existing comorbidities.",signatures:"Rynal Devanathan and Viveka Devanathan",downloadPdfUrl:"/chapter/pdf-download/62174",previewPdfUrl:"/chapter/pdf-preview/62174",authors:[{id:"232122",title:"Prof.",name:"Rynal",surname:"Devanathan",slug:"rynal-devanathan",fullName:"Rynal Devanathan"},{id:"398798",title:"Dr.",name:"Viveka",surname:"Devanathan",slug:"viveka-devanathan",fullName:"Viveka Devanathan"}],corrections:null},{id:"62108",title:"Male Obesity and Reproductive Health",doi:"10.5772/intechopen.76932",slug:"male-obesity-and-reproductive-health",totalDownloads:1034,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Obesity has reached epidemic proportions globally, and all this evidence suggests that the situation is likely to get worse ahead. A combination of an increasingly sedentary lifestyle and unfavorable diet in the western world has resulted in increasing numbers of overweight and obese children and adults. According to the WHO, approximately 1.6 billion adults were classed as being overweight and 400 million adults were obese in 2005. Also gaining attention is the reported decline in semen quality and male reproductive potential over the past 50 years. Surprisingly, such decreases have not been reported in regions where obesity is less prevalent. Since this decline in fertility has occurred in parallel with increasing rates of obesity, the possibility that obesity is a cause of male infertility and reduced fecundity should be addressed. Effects of obesity on female fertility have been studied extensively. Weight loss in anovulatory women restores fertility and increases the likelihood of ovulation and conception. In contrast to the extensive knowledge of the effects of obesity on female fertility, male factor infertility as a result of obesity has been overlooked, even after the discovery of a threefold increase in the incidence of obesity in patients with male factor infertility, demanding the concern over m ale obesity with respect to infertility.",signatures:"Mir Jaffar, Syed Naseer Ahmad and Mohammed Ashraf Cheruveetil",downloadPdfUrl:"/chapter/pdf-download/62108",previewPdfUrl:"/chapter/pdf-preview/62108",authors:[{id:"232346",title:"Ph.D.",name:"Mir",surname:"Jaffar",slug:"mir-jaffar",fullName:"Mir Jaffar"},{id:"249588",title:"Dr.",name:"Mohammed",surname:"Ashraf Cheruveetil",slug:"mohammed-ashraf-cheruveetil",fullName:"Mohammed Ashraf Cheruveetil"},{id:"253465",title:"Dr.",name:"Syed Naseer",surname:"Ahmad",slug:"syed-naseer-ahmad",fullName:"Syed Naseer Ahmad"}],corrections:null},{id:"59840",title:"Men’s Body Image: The Effects of an Unhealthy Body Image on Psychological, Behavioral, and Cognitive Health",doi:"10.5772/intechopen.75187",slug:"men-s-body-image-the-effects-of-an-unhealthy-body-image-on-psychological-behavioral-and-cognitive-he",totalDownloads:1646,totalCrossrefCites:2,totalDimensionsCites:3,hasAltmetrics:1,abstract:"In the past two decades, growing empirical efforts have illuminated the need to understand body image disturbances and preoccupations associated with the male experience. Scholars, practitioners, and more recently, public policy are increasingly interested in the nature, causes, and consequences of men’s body image apprehensions and weight concerns. This accession is largely due to the fact that men are progressively becoming more visible in popular culture (especially through exceedingly lean and muscular depictions) and concurrently, severe body image-related disorders such as anorexia nervosa among men are on the rise. This chapter aims to provide a review of the consequences associated with men’s unhealthy body image including the psychological (e.g., weight distortions and emotional valence), behavioral (e.g., dieting/fasting, substance use, and cosmetic surgery), and cognitive health outcomes particular to the male experience (e.g., appearance schemas, cognitive performance, and cognitive load/malnutrition on cognitive functioning).",signatures:"Amanda Baker and Céline Blanchard",downloadPdfUrl:"/chapter/pdf-download/59840",previewPdfUrl:"/chapter/pdf-preview/59840",authors:[{id:"240648",title:"Ph.D.",name:"Amanda",surname:"Baker",slug:"amanda-baker",fullName:"Amanda Baker"},{id:"241375",title:"Prof.",name:"Céline",surname:"Blanchard",slug:"celine-blanchard",fullName:"Céline Blanchard"}],corrections:null},{id:"60713",title:"Physical Fitness and Body Shape (Physical Shape)",doi:"10.5772/intechopen.76314",slug:"physical-fitness-and-body-shape-physical-shape-",totalDownloads:936,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The purpose of this study was to determine Zulu women’s perceptions of their body image relative to weight status attending a noncommunicable disease (NCD) clinic in South Africa. A cross-sectional exploratory study design was used and included 328 (91%) Zulu women who were sampled systematically. The women were subjected to anthropometric measurements and engaged the Stunkard?s body image figures to determine perception. The study showed that 61% of the sample was in the 40–59 age strata. The mean body mass index (BMI) was 37kg/m2 (±9.41 kg/m2), with over 90% being overweight or obese. A discrepancy between Zulu women?s perceived body image and actual BMI existed in all weight status categories with overweight and obesity demonstrating the widest variations (p < 0.000). Women perceived themselves to be thinner than their actual BMI. More than 99% associated an underweight body image to one with disease. Diabetes mellitus (72%) was the most frequent NCD encountered. Only 23% with this condition correctly perceived their body image. It was shown that the negative impact of preferring a larger body image in Zulu women with preexisting NCDs could be refueling their existing comorbidities.",signatures:"Flor de Maria Cruz Estrada, Miguel Ángel Nieto Castillo, Jorge\nAlberto Sánchez Vega, Patricia Tlatempa Sotelo and Aldo\nHernández Murúa",downloadPdfUrl:"/chapter/pdf-download/60713",previewPdfUrl:"/chapter/pdf-preview/60713",authors:[{id:"231114",title:"Ph.D.",name:"Flor De Maria",surname:"Cruz Estrada",slug:"flor-de-maria-cruz-estrada",fullName:"Flor De Maria Cruz Estrada"},{id:"241299",title:"Dr.",name:"Miguel Angel",surname:"Nieto Castillo",slug:"miguel-angel-nieto-castillo",fullName:"Miguel Angel Nieto Castillo"},{id:"241300",title:"Dr.",name:"Jorge Alberto",surname:"Sanchez Vega",slug:"jorge-alberto-sanchez-vega",fullName:"Jorge Alberto Sanchez Vega"},{id:"241301",title:"Dr.",name:"Jose Aldo",surname:"Hernandez Murúa",slug:"jose-aldo-hernandez-murua",fullName:"Jose Aldo Hernandez Murúa"},{id:"257934",title:"Dr.",name:"Patricia",surname:"Tlatempa Sotelo",slug:"patricia-tlatempa-sotelo",fullName:"Patricia Tlatempa Sotelo"}],corrections:null},{id:"59866",title:"Parenting Influences on Child Obesity-Related Behaviors: A Self-Determination Theory Perspective",doi:"10.5772/intechopen.75118",slug:"parenting-influences-on-child-obesity-related-behaviors-a-self-determination-theory-perspective",totalDownloads:992,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The relationships between parenting behaviors and child obesity-related behaviors have been extensively investigated through the use of different constructs such as parenting styles, domain-specific styles and specific parenting practices, but there is currently a need for a more comprehensive and integrative theoretical framework. This chapter argues about the usefulness of self-determination theory, and in particular of the specific dimensional parenting model related to the theory, as a framework to conceptually organize parenting practices relevant to children’s obesity-related behaviors. The three parenting dimensions of autonomy support, provision of structure and parental positive involvement, identified by self-determination theory as particularly relevant to the process of child’s internalization of socially desired behaviors and values, will be applied as a framework to conceptually organize the parenting practices in the feeding and physical activity domains.",signatures:"Roberta Di Pasquale and Andrea Rivolta",downloadPdfUrl:"/chapter/pdf-download/59866",previewPdfUrl:"/chapter/pdf-preview/59866",authors:[{id:"234591",title:"Ph.D.",name:"Roberta",surname:"Di Pasquale",slug:"roberta-di-pasquale",fullName:"Roberta Di Pasquale"},{id:"241602",title:"Dr.",name:"Andrea",surname:"Rivolta",slug:"andrea-rivolta",fullName:"Andrea Rivolta"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"675",title:"Relevant topics in Eating Disorders",subtitle:null,isOpenForSubmission:!1,hash:"55c8c18e0c81c53cfd79272ab7916099",slug:"relevant-topics-in-eating-disorders",bookSignature:"Ignacio Jauregui-Lobera",coverURL:"https://cdn.intechopen.com/books/images_new/675.jpg",editedByType:"Edited by",editors:[{id:"323887",title:"Prof.",name:"Ignacio",surname:"Jáuregui-Lobera",slug:"ignacio-jauregui-lobera",fullName:"Ignacio Jáuregui-Lobera"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5372",title:"Eating Disorders",subtitle:"A Paradigm of the Biopsychosocial Model of Illness",isOpenForSubmission:!1,hash:"6b686a80d50d3f5823d596057da43e99",slug:"eating-disorders-a-paradigm-of-the-biopsychosocial-model-of-illness",bookSignature:"Ignacio Jauregui-Lobera",coverURL:"https://cdn.intechopen.com/books/images_new/5372.jpg",editedByType:"Edited by",editors:[{id:"323887",title:"Prof.",name:"Ignacio",surname:"Jáuregui-Lobera",slug:"ignacio-jauregui-lobera",fullName:"Ignacio Jáuregui-Lobera"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7983",title:"Psychosomatic Medicine",subtitle:null,isOpenForSubmission:!1,hash:"4eabb8ae6669b096f822a3ebd57ef59d",slug:"psychosomatic-medicine",bookSignature:"Ignacio Jáuregui Lobera",coverURL:"https://cdn.intechopen.com/books/images_new/7983.jpg",editedByType:"Edited by",editors:[{id:"323887",title:"Prof.",name:"Ignacio",surname:"Jáuregui-Lobera",slug:"ignacio-jauregui-lobera",fullName:"Ignacio Jáuregui-Lobera"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1673",title:"Evidence Based Medicine",subtitle:"Closer to Patients or Scientists?",isOpenForSubmission:!1,hash:"d767dfe22c65317eab3fd9ff465cb877",slug:"evidence-based-medicine-closer-to-patients-or-scientists-",bookSignature:"Nikolaos M. 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Acute pancreatitis is an inflammatory condition of the pancreas with a wide spectrum of pathological and clinical manifestations. It ranges from mild and self-limiting condition to severe pancreatitis with multiorgan failure with high mortality [1, 2].
\nIt was one of the most frequent gastrointestinal causes of hospital admissions in the United States with a total of 275,000 admissions in 2009. In the United Kingdom, hospitals serving a population of 300,000–400,000 people admit about 100 cases each year. Patients with severe acute pancreatitis need ICU admission and multidisciplinary team approach for treatment. It increases the health care cost enormously, and those survive will live with pancreatic endocrine and exocrine dysfunction.
\nThis chapter will focus mainly on severe acute pancreatitis.
Acute pancreatitis is an acute inflammatory process of the pancreas. It is an acute condition presenting with abdominal pain and is usually associated with raised pancreatic enzyme levels in the blood or urine as a result of pancreatic inflammation. It is a disorder of the exocrine pancreas and is associated with acinar cell injury with local and systemic inflammatory responses [3].
There is a wide range of classifications for acute pancreatitis. The Revised Atlanta Classification in 2012 classified acute pancreatitis according to the severity of the disease, morphology and temporal relation [1, 3].
\nAcute pancreatitis is classified into three forms based on the severity [3].
\nMild acute pancreatitis, which is characterized by the absence of organ failure and local or systemic complications.
Moderately severe acute pancreatitis, which is characterized by transient organ failure (resolves within 48 hours and without persistent organ failure >48 hours) and/or local or systemic complications.
Severe acute pancreatitis, which is characterized by persistent organ failure that may involve one or multiple organs.
Temporally, two phases of acute pancreatitis are as follows:
\nOnly clinical parameters are important for treatment planning and are determined by the systemic inflammatory response syndrome (SIRS), which can lead to organ failure.
Morphologic criteria based on CT findings combined with clinical parameters determine the care of the patient [4].
Morphologically, there are three types of acute pancreatitis as follows:
\nAcute oedematous (interstitial) pancreatitis
Acute necrotizing pancreatitis
Haemorrhagic
Usually, the necrosis involves both the pancreas and the peripancreatic tissues, less commonly the peripancreatic tissues alone and rarely the pancreatic parenchyma alone [1].
\nThe commonest cause in the western world is gallstones (50%) and alcohol (25%). Rare causes (<5%) include drugs (for example, valproate, steroids, and azathioprine), endoscopic retrograde cholangiopancreatography, hypertriglyceridaemia or lipoprotein lipase deficiency, hypercalcaemia, pancreas divisum and some viral infections (mumps and coxsackie B4). About 10% of patients have idiopathic pancreatitis, where no cause is found [5]. The aetiological factors are enumerated in Table 1.
Aetiology of Acute Pancreatitis | |
---|---|
Methyl alcohol Smoking Organophosphates Scorpion bite, certain spiders, Gila monster lizard | |
Biliary pancreatitis—Cholelithiasis, Biliary sludge Malignancy—pancreatic, ampullary, cholangiocarcinoma Parasitic infections—ascariasis Periampullary diverticulum Penetrating duodenal ulcer, Duodenal obstruction | |
Abdominal trauma—duct disruption | |
Hyperparathyroidism Hypertriglyceridemia Hypercalcaemia Diabetic ketoacidosis End-stage renal failure Pregnancy Post-renal transplant | |
Necrotising vasculitis—SLE, Thrombotic thrombocytopenia Atheroma Shock | |
Vasculitis—SLE, polyarteritis nodosa | |
Corticosteroids, furosemide, tetracyclines, thiazides, oestrogen, valproic acid, Metronidazole, pentamidine, nitrofurantoin, erythromycin, methyldopa, ranitidine 5-ASA/salicylates, azathioprine/6-MP, didanosine, pentamidine, L-asparaginase | |
Post-ERCP pancreatitis Pancreas divisum in some patients Ischaemia, hereditary pancreatitis is a rare familial condition |
Aetiology of acute pancreatitis.
The exact pathogenesis of acute pancreatitis is unknown, and there is an ongoing research at the molecular level. There are many pathophysiological hypothesis put forward to explain the processes. These hypotheses are based on the aetiology and risk factors. The final result of the pathophysiological process is activation of proteolytic enzymes (intra-acinar activation of trypsinogen) leading to breakdown of the junctional barrier between acinar cells and leakage of pancreatic fluid and enzymes into the interstitial space causing autophagy and autodigestion of acinar cells [2, 3]. Diagram 1 depicts the hypothetical aetiopathogenic process of acute pancreatitis.
Aetiopathogenesis of acute pancreatitis.
Three different phases can be seen during the pathogenesis of acute pancreatitis. The first phase is the acinar cell damage and death. The second phase is local inflammation of the pancreas. The third and final phase is the SIRS. The first two phases take place in the pancreas itself, while in the third phase causes the distant organ damage and extrapancreatic symptoms.
\nPancreatic ductal obstruction and hypersecretion have been mentioned as factors that contribute to the initiation of the inflammatory process. Different pathophysiological mechanisms have been proposed for ethanol-induced pancreatitis. Explanations like ethanol-induced direct toxicity to the acinar cell, sphincter of Oddi dysfunction, hypertriglyceridaemia, free oxygen radical formation, and protein deposition within the pancreatic duct, which favours retrograde flow of enzymatic. These processes lead to activation of inflammation and membrane destruction. Newer hypotheses include ischaemia/reperfusion injury and enzymatic co-localisation. Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis: 1–3% develops pancreatitis, probably due duct disruption and enzyme extravasation. Patients at the risk of developing post-ERCP pancreatitis have sphincter of Oddi dysfunction or a history of recurrent pancreatitis, those who undergo sphincterotomy or balloon dilatation of the sphincter.
\nSystemic inflammatory response syndrome (SIRS) due to acute pancreatitis is because of the acinar cell death which releases activated pancreatic enzymes. This sets up a local inflammatory response which then activates systemic inflammatory response by release of cytokines, tumour necrosis factor, activation of immunocytes and the complement system activation [2–5].
Symptoms of acute pancreatitis are sudden onset of severe, persistent epigastric pain with or without radiation to the back. Radiation to the back is seen in about 50% of patients. It may be relieved by sitting or leaning forwards. Some patients complain of right upper quadrant pain. Pain is usually associated with nausea and vomiting.
Signs vary according to the severity of the disease. It ranges from mild epigastric tenderness to a diffusely tender abdomen.
\nTachypnoea, tachycardia, and hypotension may be present. Fever due to inflammatory response. Acute swinging pyrexia suggests cholangitis. Icterus may be seen in biliary pancreatitis. Cullen sign, i.e. ecchymotic discoloration in the periumbilical area and Grey Turner sign, i.e. ecchymotic discoloration along the flanks due bleeding into the fascial planes, but these signs are not specific for acute pancreatitis. Abdominal distension due to ileus, guarding in the upper abdomen, free fluid may elicit shifting dullness. Pleural effusion is present in 10–20% of patients. Acute confusion due to metabolic derangement and hypoxaemia. Tetany is seen in some patient because hypocalcaemia [6, 7]
\nPerforated peptic ulcer, acute myocardial infarction, and cholecystitis should be rule out in differential diagnoses for acute pancreatitis.
Serum amylase and lipase are both elevated in acute pancreatitis. The rise can be within 4–12 hours. The rise of >3 times the normal upper limit is the threshold for the diagnosis of acute pancreatitis [6, 7].
\nIt is an enzyme that hydrolyses the starch. The principal sources of amylase are the pancreas, salivary glands and fallopian tubes. Amylase has a shorter half life of 10 hours and returns to normal within 3–5 days. Hyperamylasaemia is seen in many other conditions. It may be increased in a number of other conditions like intestinal ischaemia and perforation, parotitis and acute renal failure, it is a less specific marker in acute pancreatitis. Its levels begin to rise 6–12 hours after the onset of acute pancreatitis, and they return to normal in 3–5 days. It has a high sensitivity (>90%) but a low specificity (as low as 70%) for the diagnosis of acute pancreatitis. Normal serum amylase level will not exclude acute pancreatitis if the patients present late to hospital [1, 6, 7].
It a pancreatic enzyme that hydrolyses triglycerides. Its level increases within 4–8 hours of the onset and peaks at 24 hours and then returns to normal after 8–14 days. The rise in levels should be >3 times the upper limit of normal. It has excellent sensitivity in acute alcoholic pancreatitis. It is more specific than serum amylase for the diagnosis of acute pancreatitis. It has a sensitivity and specificity of 80–100% for acute pancreatitis. The principal sources of lipase are pancreas. The other sources are the tongue, liver, and intestine. These enzymes are useful in diagnosis of acute pancreatitis, but daily levels of these enzymes add no advantage in management. The levels are not useful in assessment of the severity of pancreatitis or decreasing levels are not marker of improvement. Simultaneous estimation of amylase and lipase levels does not improve accuracy [1, 6, 7].
In other laboratory investigations which help in etiological diagnosis are liver function test and serum triglycerides. Elevated liver enzymes, especially levels alanine transaminase Alanine Aminotransferase (ALT), level >150 U/L, it has a positive predictive value of 85% for gallstones. It will aid in diagnosis of acute biliary pancreatitis. Liver Function Test (LFT) should be done in all patients acute pancreatitis, patients within 24 hours of admission. C reactive Protein (CRP) levels will help in assessment of the severity of the disease process [5–7].
The most commonly used imaging modalities in acute pancreatitis are transabdominal ultrasound, endoscopic ultrasound, dynamic contrast enhanced CT scan and Magnetic Resonance Cholangiopancreatography (MRCP). Imaging studies are not indicated for diagnosing acute pancreatitis as it does not predict disease severity at the time of presentation to emergency department. Imaging studies are indicated when there is diagnostic dilemma due to non-conclusive biochemical tests or because of the severity clinical condition or unexplained MODS, which warrants to rule out other intra-abdominal pathologies like gastrointestinal tract perforation and peritonitis.
\nIt also helps in rule out other conditions during the differential diagnosis of acute pancreatitis. The role of CT scan and magnetic resonance imaging (MRI) lies in the detection of complications of acute pancreatitis, such as pancreatic necrosis, peripancreatic fluid collections or pseudocysts; the presence of these complications can also be used to predict the severity of the disease [6].
Transabdominal ultrasound is less sensitive and less useful to visualize the inflamed or necrotic pancreas. The distended abdomen because of the gas-filled bowel obscures the pancreatic view. It cannot assess the extent of necrosis.
\nIt helps in detection of gall stones, which are found in about 50% patients with acute pancreatitis or dilatation of biliary tract secondary to obstruction.
\nOnly indication of US scanning abdomen on presentation to emergency department is to rule out cholelithiasis as a cause for pancreatitis. Transabdominal ultrasound in later stages can help diagnosis of infection and therapeutic intervention-like guiding aspiration [6, 7].
It is a combination of ultrasonography and endoscopic simultaneously. It is comparatively less invasive than endoscopic retrograde cholangiopancreatography (ERCP). It has a high sensitivity when compared to transabdominal ultrasound, especially in detecting the common bile duct microlithiasis and biliary sludge. It has a diagnostic yield of up to 88%. It helps in identifying patients who might benefit from endoscopic retrograde cholangiopancreatography and its therapeutic interventions. The added advantage of endoscopic ultrasonography is that it can be performed beside in unstable ICU patients, pregnant women where CT is contraindicated, and patients with metallic implants where MRCP is contraindicated [6, 7].
Contrast-enhanced computed tomography is the gold standard to detect necrosis and to grade the severity of acute pancreatitis. This imaging modality also helps detecting local complication. CT scan findings range from localized oedema, pancreatic tissue inflammation (Figure 1), necrosis to extensive peripancreatic fluid collections (Figure 2).
Oedematous pancreatitis.
Pancreatitic necrosis.
CT findings of acute pancreatitis are diffuse or segmental enlargement of the pancreas due to interstitial oedema and irregular contour. Contrast non-enhancement represents pancreatic necrosis which is heterogeneous in appearance, peripancreatic fluid collection. Whole pancreatic necrosis is rare, multifocal areas are common. Necrosis is seen seen after 96 hours from the start of symptoms. CT scan performed before 72 hours will underestimate the degree of necrosis. The necrosis pancreas is variable involving the periphery with preservation of the core or involving the head, body, or tail separately or in combination. The outcome depends on the part of the pancreas involved. Necrosis of the entire pancreas has a relatively better outcome when compared to the head of pancreas involvement. Necrosis of the head of pancreas causes obstruction of the pancreatic duct there by an increase in pancreatic duct pressure causing to damage to acinar cells and leakage of destructive enzymes. Necrosis only in the distal portion of the pancreas has a favourable outcome and fewer complications [8]. Figure 2 shows the CT image of pancreatic necrosis.
Haemorrhagic pancreatitis.
Patients in whom the clinical diagnosis is in doubt
Patients with hyperamylasaemia and severe clinical pancreatitis Figure 3 abdominal distension, tenderness, high fever (>39°C), and leucocytosis
Patients with Ranson’s score >3 or the acute physiology and chronic health evaluation (APACHE) II >8
Patients showing lack of improvement after 72 hours of initial therapy,
Acute deterioration following the initial clinical improvement [8].
The modified CT severity index is a modification of the original CT severity index developed by Balthazar and colleagues in 1994. Table 2 enumerates the details of the evaluation of Balthazar’s computed tomography scoring system for acute pancreatitis.
Inflammatory process | Grade | score |
---|---|---|
Normal | A | 0 |
Focal or diffuse enlargement | B | 1 |
Contour irregularity | ||
Inhomogeneous attenuation | ||
Grade B plus peripancreatic haziness/Mottled densities | C | 2 |
Grade B, C plus one ill-defined peripancreatic fluid collection | D | 3 |
Grade B, C plus two ill-defined peripancreatic fluid collection or gas | E | 4 |
Necrosis | ||
None | 0 | 0 |
<30% | 0 | 2 |
50% | 4 | |
>50% | 6 |
Evaluation of Balthzar’s computed tomography scoring system for acute pancreatitis.
0–2: mild
4–6: moderate
8–10: severe.
The two factors that are useful in grading the severity of pancreatitis by CT are the extent pancreatic necrosis and the degree of peripancreatic inflammation. CT finding of necrosis and peripancreatic fluid collection strongly correlates with the complications (morbidity) and mortality [6, 7, 9, 10].
Normal pancreas
Focal or diffuse pancreatic enlargement
Pancreatic gland abnormalities associated with peripancreatic inflammation
Single fluid collection
Two or more fluid collections and/or gas present in or adjacent to the pancreas [10].
Repeat scanning is only indicated if there is any deterioration in clinical condition to rule out/diagnose pancreatic necrosis, abscess or pseudocyst, haemorrhage, or bowel ischaemia or perforation.
Magnetic resonance imaging (MRI) and MRCP are non-invasive imaging modalities. It has several advantages over CT, like no risk from radiation, can detect pancreatic duct continuity and parenchymal changes. It helps diagnose acute pancreatitis and identifying the aetiology of acute pancreatitis. MRI can accurately differentiate between necrotic and non-necrotic tissue.
It is especially useful to visualising the pancreatic duct and detecting lithiasis. MRCP is performed when ERCP has failed. The advantage of MRCP over CT scan is that iodinated contrast agents can be avoided and thereby avoid the risk for acute kidney injury.
\nDisadvantages of MRI and MRCP is transportation of critically ill patients to the MRI suite are limited access to patient during the acquisition of images and longer time to complete the study.
To classify the disease process.
To predict the level of care needed, ICU or HDU for monitoring and supportive care.
To predict the outcome depending the severity of the acute pancreatitis, especially the mortality.
Select patients for specialised interventions as therapy to improve the outcome.
If patients are managed by the nonspecialist clinicians, then the scoring system will help them identify patients who need consultation and transfer to specialist centre.
For comparisons of severity within and between patient series.
In research for rational selection of patients for inclusion in trials.
It helps in intra-, inter-departmental and patient and patient family communication—using the same language.
Severity assessment should be carried out within 48 hours of diagnosis of acute pancreatitis. Patients with a body mass index over 30 are at higher risk of developing complications.
There are various scoring systems in vogue, using the clinical data, laboratory markers and radiological findings to assess and grade the severity of the acute pancreatitis. The scoring systems are of two types: one that correlates clinical features and lab indices and the other being the use of non-specific physiological scoring, namely, APACHE II and III. The commonly used scoring systems are the Ranson’s criteria, Glasgow (Imrie) scoring systems, the APACHE II and III scoring systems (mainly used in ICU), the Simplified acute physiology score, bedside index of severity in acute pancreatitis (BISAP) scoring system, and the CT severity index. None of the scoring systems have a high sensitivity, specificity, positive predictive value or negative likelihood ratio. The scoring systems used at present are often inadequate in patients with severe Acute necrotizing pancreatitis (ANP), which is characterised by rapidly progressive multiple-system organ dysfunction [3, 4, 10].
The Ranson’s criteria were introduced in clinical practice in the early 1970s. It is the most widely used scoring system. Note that, 11 criteria are taken into account. Table 3 enumerates the Ranson’s criteria for assessment severity of acute pancreatitis. They were designed after analysis of 100 patients with alcohol-induced pancreatitis. It makes use of a combination of clinical and biochemical parameters obtained at admission and during the first 48 hours after admission. It reflects the extent of metabolic derangement and estimates the risk for mortality.
|
|
0–2 < 1% 3–4 ≈ 15% 5–6 ≈ 40% >6 ≈ 100% |
Ranson’s criteria for assessment severity of acute pancreatitis.
Drawbacks of the scoring system are that the study was only for alcoholic pancreatitis, do not take into consideration the ongoing treatment and predicts high mortality which is not the case in today’s practice.
\nThe Ranson’s criteria have a sensitivity 74%, specificity 77%, positive predictive value 49% and negative predictive value 91% [3, 4, 10].
A decade after the Ranson’s criteria were introduced, a re-evaluation of those criteria was done and found that the eight of the criteria were most predictive of the severity and outcome. Table 4 enumerates the modified Glasgow criteria (Imrie score) for assessment severity of acute pancreatitis.
|
|
Modified Glasgow criteria (IMRIE SCORE) for assessment severity of acute pancreatitis.
Those eight criteria were renamed as Glasgow criteria or Imrie score. It’s use is limited in Emergency department (ED) as some of the variables are only evaluated at 48 hours. The criteria excluded from the Ranson’s criteria are Lactate dehydrogenase (LDH), base deficit, and fluid deficit, and these were found to be least contributory in assessment of severity and outcome [9, 10].
\nThe Glasgow (Imrie) criteria are valid for both alcohol induced and biliary pancreatitis. A scores 3 or more after 48 hours of presentation indicates severe acute pancreatitis.
It is an acute phase reactant. It should be done after 48 hours of presentation. It can be used both for the assessment of severity and monitoring the progress of the disease. Levels more than 100 mg/L late in the first week after presentation indicate that patient is developing pancreatic necrosis. Procalcitonin will help identifying the pancreatic infection. IL-6, trypsinogen activation peptide, polymorphonuclear elastase, and carboxypeptidase B activation peptide can also be used for assessing the severity and monitoring the progress of the disease, but these are either used as a research tool or not yet routinely available.
\nPersistent high haematocrit is also an indicator of pancreatic necrosis and organ failure. If initial resuscitation is inadequate, then haemoconcentration is not a useful marker [3, 4, 10].
The acute physiology and chronic health evaluation (APACHE) II is (Knaus et al.) used to quantify the severity of the illness in ICU patients. It contains 12 continuous variables, the age and the pre-morbid conditions (which reflect a diminished physiological reserve). Patients with an APACHE II score >8 have severe acute pancreatitis and are likely to develop organ failure. It can be used in monitoring the patient’s response to therapy throughout the patient’s hospital stay unlike Ranson’s and Glasgow, which is assessed in the first 48 hours. Hence, it can assess both the severity and progress/deterioration. Disadvantages being that it is complex to perform and has been evaluated prospectively only in first 24–48 hours after the onset of pancreatitis. In criteria used, factors with most predictive value for mortality include advanced age, presence of renal or respiratory insufficiency and presence of shock. It has a sensitivity of 65%, specificity of 76%, positive predictive value of 43% and negative predictive value of 89%. APACHE III is also been used in predicting the severity of pancreatitis [10].
BISAP score is a beside scoring system with fewer variables than Ranson’s criteria. The data sued in scoring are the basic data recorded during the time of admission or taken from the first 24 hours of the patient’s evaluation. Table 5 enumerates the criteria of bedside index of severity in acute pancreatitis (BISAP) score for assessment severity of acute pancreatitis. It is a prognostic scoring system that predicts the mortality, whereas Ranson’s score predicts persistent organ failure. BISAP scores have the advantages over Ranson’s and Glasgow scores of being calculated within 24 hours of admission, use fewer variables. BISAP score is higher in patients having SIRS, in older patients and in patients with altered mental status. It has the disadvantage that it cannot easily distinguish transient from persistent organ failure [3, 4, 10].
Bedside index of severity in acute pancreatitis (BISAP) score | ||
---|---|---|
Scores | ||
1 | 0 | |
BUN >25 mg/dL (8.9 mmol/L) | >25 mg% | <25 mg% |
Abnormal mental status with a Glasgow coma score <15 | Present | Absent |
Evidence of SIRS (systemic inflammatory response syndrome) | 2/4 | Absent |
Patient age | >60 years old | <60 years old |
Imaging study reveals pleural effusion | Present | Absent |
Bedside index of severity in acute pancreatitis (BISAP) score for assessment severity of acute pancreatitis.
Patients with a score of zero predict a mortality of less than 1 whereas patients with a score of 5 predict a mortality rate of 22%. The way forward may be to use a combination of the Ranson’s score, the radiological scoring systems and a descriptive organ failure score such as the sepsis-related organ failure assessment.
Management of acute pancreatitis should be aggressive and begins early in the emergency department once the diagnosis is made. Initial resuscitation can affect the outcomes of acute pancreatitis significantly.
\nThe treatment can be divided into three major parts as follows:
\nICU admission and management
Treatment of the local complications
ICU/HDU admission is needed in patients with severe acute pancreatitis for close monitoring, organ support, and follow up. It is difficult to decide which patient is a candidate for ICU/HDU admission at the time of presentation. There is a lack of early and adequate predictors of impending organ dysfunction. But the patients present with signs of organ dysfunction like hypotension, respiratory insufficiency, coagulopathy (including Disseminated intravascular coagulation (DIC), and acute kidney injury are definite candidates for ICU/HDU admission. Other than organ dysfunction patients with severe metabolic derangements like hyperglycaemia, severe hypocalcaemia and patients with comorbidities like heart failure, chronic kidney disease where the acute on chronic organ dysfunction may develop are the candidates for ICU admission [10]
Monitoring a patient with acute severe pancreatitis can be divided into the following:
\nMonitoring of vital signs: Heart rate, blood pressure, respiratory rate, oxygen saturation, urinary output and level of consciousness
Biochemical evaluation of organ function: Blood gases, lactic acid, renal function test, coagulation profile, haematocrit, blood glucose and serum electrolyte levels, especially calcium, magnesium, and liver function test. These test may alert impending organ dysfunction, improvement or worsening of the organ function
Development of local complications like pancreatic necrosis and infection, which are associated with increased morbidity and mortality.\n
Pancreatic necrosis is detected by contrast enhanced CT scan
Pancreatic infection needs repeated contrast enhanced CT scan with CT/US guided fine needle aspiration
Intra-abdominal pressure (IAP): Intra-abdominal hypertension (IAH) is related to the development of complications, especially necrosis and infection, bowel oedema. High IAP is one indication for intervention like aspiration or surgery [6, 7, 10].
Hypotension is one of the most common presentations with acute pancreatitis. It is a sign of impending organ dysfunction. The hypotension is due to the third space loss secondary to the inflammatory response, this contributes to hypoperfusion and end organ perfusion dysfunction. Aggressive fluid resuscitation and rapid restoration of intravascular volume are the main stay of the treatment. It requires several liters of fluids. Both crystalloids and colloids can be used as resuscitation fluids. There is no evidence that colloids have any added benefit over crystalloids. Among the crystalloid, use of 0.9% sodium chloride is to be avoided. As it causes hyperchloraemic metabolic acidosis, which is associated with renal impairment, infections and activation of trypsinogen in a pH-dependent manner. Lactated Ringer’s solution is a cystalloid, it is a balanced salt solution, It is fluid of choice it has been found to be less incidence of SIRS compared to normal saline. Both under resuscitation as well as over resuscitation can lead to adverse outcomes, hence very close monitoring is recommended. Over resuscitation can lead interstitial oedema, bowel oedema, Acute respiratory distress syndrome (ARDS) which can lead to organ dysfunction. Monitoring of fluids status should be done by physical examination (clinical condition, vital signs and urine output), volume responsiveness and dynamic parameters by sonography or invasive or semi invasive haemodynamic parameters. Metabolic indicators like serial measurements of blood urea nitrogen and haematocrit [11, 12].
Pleuropulmonary abnormalities are commonly associated with pancreatitis, respiratory dysfunction is rarely seen at the time of presentation to Emergency department (ED) but usually develops after fluid resuscitation. It manifests as acute lung injury or acute respiratory distress syndrome. It is one of the major components of multiple organ system dysfunction syndromes. Other manifestations are bilateral infiltrates, pleural effusion, pulmonary hypertension, and decreased thoracic compliance [11, 12].
\nPatients with acute severe pancreatitis should be monitored closely for early detection of failure. Respiratory support usually initiated by supplemental oxygen and mechanical ventilation is often required depending on the severity of respiratory dysfunction. Nasogastric decompression will decrease the distension and improve the compliance and prevent aspiration. Non-invasive ventilation is poorly tolerated in most of the patients because of abdominal distension and reduced functional residual capacity, careful selection of patient is warranted. Non-invasive ventilation is good choice to start with as it may avoid endotracheal intubation. Acute lung injury and Acute respiratory distress syndrome (ARDS) secondary to acute severe pancreatitis is similar to any other condition using lung protective strategies. Pleural effusion may need ultrasound-guided drainage. Good analgesia will help in chest physiotherapy, early physiotherapy will prevent atelectasis and related complications [11, 12].
Pain is one of the symptoms of acute severe pancreatitis. It causes discomfort and heightened sympathetic activity, impairment of oxygenation due to restriction of abdominal wall movement. Effective analgesia can be provided by the use of opioids and parenteral route, i.e. intravenous route is the preferred route. Analgesia may improve pulmonary dysfunction. In the past, morphine was supposed to exacerbate acute pancreatitis by promoting contraction of the sphincter of Oddi and increase pressure in the sphincter of Oddi dysfunction, but there is no good supportive evidence. Another modality of pain management is use of drugs like local anaesthetics through in epidural route [13, 14].
Acute pancreatitis is a catabolic and hypermetabolic pathophysiological condition. This disease process increases protein demand and the calorie requirements. This altered metabolic state is further deranged by poor oral intake due to pain, ileus or partial obstruction of the duodenum from pancreatic oedema. There are increased protein losses locally in the retroperitoneum due to inflammation and through pancreatic fistulae. These features may be compounded by the pre-existing malnutrition, e.g. in alcohol abuse [11, 12, 13].
\nIf malnutrition and a prolonged negative nitrogen balance are not taken care, it may result in poor pancreatic healing, increased risk of infection, impaired immunity, gut dysfunction leading to translocation of bacteria. Nutritional care and therapy along with other therapeutics measures will results in faster recovery and better outcome.
\nFeeding during severe acute pancreatitis may be challenging. The questions to address during the initiation of the nutritional support are when? How? and what?
\nEarlier concept of feeding in acute pancreatitis: the pathogenesis of pancreatitis is assumed to be perpetuation of premature enzymatic activation. ‘Resting the pancreas’ the approach to avoid stimuli to exocrine secretion from the pancreas was thought to be most physiological method to treat the pancreatitis. Hence, parenteral nutritional was the preferred option to avoid stimulation of the inflamed pancreatic gland. The other hypothesis is that systemic inflammatory response syndrome is caused by the absorption of the pancreatic endotoxins and ultimately leads to multiorgan failure. If the gut mucosal barrier is maintained, then it reduces the absorption of endotoxin. The present concept of nutritional support in acute pancreatitis: the preferred route of nutritional support is ‘enteral route’, it should be initiated as early as possible within 24–48 hours of presentation. Parenteral route is second choice, especially if the presentation is severe and it is unlikely to start oral intake within the next 5–7 days. The advantages of the enteral feeding are improved gut blood flow, maintenance of mucosal integrity and barrier function there by reduction in microbial translocation and pancreatic infection, and better glycaemic control, avoidance of central venous access-related complications are benefits of enteral nutrition. There benefits are translated in lower incidence of infections, multiorgan failure and outcome, i.e. mortality and length of stay when compared to parenteral nutrition [11–13].
If nutritional support is supplemented by the enteral route, then it is usually delivered by tube feeding. There is a controversy about nasogastric versus nasojejunal feeding. But there is not much evidence to support any one over the other. Though traditionally nasojejunal feedings (to be delivered distal to the ligament of Treitz) have been preferred with the concept of less stimulation of the exocrine pancreas, cholecystokinin (CCK) cells that are present in the distal third part of the duodenum get stimulated when food passing through duodenum. It releases CCK that stimulates the pancreas and increased volume of pancreatic enzymes and bicarbonate secretion. This may worsen the course of the disease. Nasogastric tube feedings have now been shown to as safe as the jejunal feeding. Nasogastric insertion can be at bedside. Fluoroscopy endoscopic (endoscopically placed guide wire) and specialist help is not needed. With the Nasogastric (NG) feeding, the standard precautions of aspiration like elevation of head end of bed should be followed.
\nThe indication for nasojejunal feeds is when patients cannot tolerate gastric feeding due to ileus and slow bowel transit time. Nasojejunal (NJ) tube placement needs fluoroscopy, endoscopic, and specialist help. NJ tube may get displaced back into the stomach. Prokinetics and right-lateral positioning pass the tube through the into-duodenum. The correct positioning of the tube should be ascertained regularly by radiography [2, 7, 13].
No specific enteral nutrition supplement or immunonutrition formulation had any advantage. Low fat formulas with medium-chain triglycerides should be used enteral because it helps in better assimilation by direct absorption into the portal vein as there is lipase deficiency.
The common complications are metabolic and splanchnic. They are as follows:
\nHypertriglyceridemia is usually due to overfeeding. Monitor serum triglyceride level and titrate fat content.
\nInfection is common in pancreatic necrosis, it occurs in approximately 40–70% of patients. Infection causes an increase in morbidity and mortality. There are various theories proposed for the mechanisms of infection in severe acute pancreatitis, namely bacterial translocation from the colon, via the biliary tree, especially in biliary pancreatitis, bacterial migration through the pancreatic duct from the lumen of the duodenum and haematogenous spread from bacteraemia due to other causes like infected central venous lines [5, 9, 10].
\nProphylactic antibiotics in severe acute pancreatitis have been a topic of debate in the last 4–5 decades. Pancreatic necrosis more than 30% increases the chances of infection. The right choice of antibiotics is very important, those which have high penetration into pancreatic tissue. Carbapenems are both broad spectrum and excellent pancreatic penetration properties. Other antibiotics, which penetrate well in the pancreatic tissue, are cephalosporin, ureidopenicillins, fluoroquinolones, metronidazole and imipenem. Aminoglycosides have a poor penetration ability. Patients with mild pancreatitis do not benefit from antibiotics. In a meta-analysis by Sharma et al. [16], use of prophylactic antibiotics has shown mortality benefit in patients with Acute necrotizing pancreatitis (ANP) confirmed by contrast-enhanced CT (21–12.3%). Ref. [15, 16] prophylactic antibiotics use has not shown to decrease the need for interventional and surgical management but no effect on mortality.
Fungal infection in severe acute pancreatitis is associated with high morbidity and mortality.
\nIt has been noted that the incidence depends on the severity of the disease, extent of necrosis and use of broad spectrum antibiotic administration. Prophylactic use of fluconazole has shown to be effective in decreasing the morbidity but not the mortality [10].
The presence of non-viable tissue in the pancreatic parenchyma, which is detected by the non-enhancement on the contrast-enhanced CT, is called as pancreatic necrosis. It can be focal or diffuse with associated peripancreatic involvement. It can be sterile necrosis or get infected in approximately 70% of the cases. The diagnosis of infection of the necrotic pancreas is difficult. Infected necrosis is diagnosed in the patients who show no signs of improvement, signs of sepsis (leukocytosis and fever are confounded by the SIRS), worsening of clinical condition, especially after improvement. The lab data to confirm the infection of the necrotic pancreatic tissue are not reliable. Biomarker like CRP is usually high in severe acute pancreatitis, but procalcitonin can be used as a marker, but still it is not specific because in patients who are critically ill, there are other infection like Central Line-associated Bloodstream Infection (CLABSI), Ventilator-Associated Event (VAE) (Ventilator-Associated pneumonia (VAP)), Catheter-associated Urinary Tract Infections (CAUTI), etc. wherein procalcitonin is raised.
\nThe best method to confirm the diagnosis of infected pancreatic necrosis is CT/US guided fine needle aspiration, Gram’s staining, and culture. Multiple samples from all pockets should be taken or sampling needs to be repeated. Pancreatic abscess is a collection of pus in close proximity to pancreatic necrosis, which develops as a local infection of the necrotic pancreatic tissue after severe acute pancreatitis.
Sterile pancreatic necrosis is usually managed conservatively (non-operatively). Earlier in the 1990s, all necrotic pancreatitis use to undergo necrosectomy. Surgical intervention in sterile pancreatic necrosis may increase the risk of infection and thereby an increase in the mortality. Patients with sterile pancreatic necrosis need close observation for evidence of infection. In selected patients with extensive necrosis may need surgical intervention if they do not improve for more than 6–8 weeks [3, 8, 11, 12].
Infected necrotic pancreatitis requires debridement and there is a consensus on surgical intervention in such cases. There is still a controversy about the best approach for debridement of the infected necrotic pancreatic tissue.
\nThe aim of the intervention is removal of the infected necrotic substance. To achieve this goal, there are several techniques suggested. It ranges from drainage, debridement, lavage laparoscopy to laparotomy and packing.
Anterior
Retroperitoneal
This can be done when there are infected fluid collections or pus. It will be difficult to drain if it is just infected necrotic tissue or fluid/pus is too viscous. It has to be done CT/US guided and needs expertise. Complications are rare in expert hands. Usual complications with percutaneous drainage are bleeding, viscous perforation, fistula formation and super infection [3, 11, 12].
Minimally invasive
Open surgical
These procedures can be performed transperitoneal or retroperitoneal which is decided on the location of necrosis and collections. Some patients need multiple sitting and planned relaparotomies. The open surgical approach carries higher risk of morbidity and mortality when compared to laparoscopic technique. There is higher risk of bleeding, perforation multiple organ failure, enterocutaneous fistula, incisional hernia, and new-onset diabetes mellitus [13, 14]
There is very few or nothing to do for the etiological management other than biliary pancreatitis. The treatments depend on the severity of the pancreatitis. In severe pancreatitis, there is no role of surgery. Surgery increases the morbidity and mortality. ERCP (endoscopic retrograde cholangiopancreatography) with sphincterotomy is indicated in patients with acute cholangitis. This will help in decreasing the pressure in pancreatic duct and lessens the severity of the disease. ERCP with sphincterotomy decreases the morbidity but not the mortality [13, 14].
Change in dietary habits and consumption of balance diet will prevent the gall stone formation, earlier cholecystectomy will prevent the recurrence of pancreatitis. Regular exercise, avoiding the high caloric intake, regular use of low fat diet will control the serum triglyceride levels and early introductions of statins will help in preventing the hyperlipidaemia associated pancreatitis. Moderation in alcohol intake will reduce the incidence of alcoholic pancreatitis [13, 14].
The aim of this chapter is to provide the reader with a deeper understanding of current realities in refugee contexts and the adversity that children, parents, and families face. We discuss parenting and early childhood protective factors and review factors that cause families to flee from their home. We advocate for the need to consider parenting through an anthropological, cross-cultural, asset-based lens. Based on first-hand accounts of individuals in the Middle East, Europe, and the United States, this chapter explores how parent/caregiver circumstances and well-being impact their ability to parent in emergency settings and the factors and strategies that reduce negative impact and foster resilience. We highlight the voices of parents navigating challenging circumstances in three contexts: refugees within their own country, refugee camps outside of their country, and refugees who have resettled in a host country. While similarities exist across the three groups, it is important to understand how their experiences and challenges differ if order to best meet their needs. The recommendations provided are relevant to policy makers, nonprofit organizations, aid agencies, mental health professionals, educators and educational institutions who can help families foster resilience at various stages of the refugee and/or resettlement process.
\nApproximately 28 million children are displaced by armed conflicts and violence around the world [1]. Where violent conflicts and unpredictable circumstances and situations are the norm, the lives of young children and their families are significantly disrupted and parents and caregivers report struggling to offer the sensitive and consistent care that young children need for their healthy development [1]. Only about 3% of humanitarian crisis funding goes toward education and a fraction of that to early childhood needs, parenting skills and protective factors [2]. The challenges refugees face before, during, and after displacement have serious consequences for families. Families with children between the ages of 0 and 8 are the largest group affected by today’s global emergencies (war, conflict, natural disasters) and often face the most dire consequences [3]. Apart from death and injury, consequences include displacement, malnutrition, increased prenatal and infant mortality, family separation, sexual exploitation and abuse, trafficking, impoverished living conditions, contagious diseases, reduced life expectancy, and adverse psychological, social, and economic impact. Distinguishing between the effects of emergencies, pre-migration stress, separation from family, displacement stress, socio economic hardships, and acculturation difficulties during resettlement is challenging [4]. Adverse prenatal impacts include exposure to prolonged stress, environmental toxins, nutritional deficits, boredom, and depression. These experiences can chemically alter the epigenetics and the genes in the fetus or young child, which may shape the individual temporarily or permanently [5, 6]. Violence and maternal depression can impair child development and mental health [7]. Prolonged stress during pregnancy and/or early childhood can have even greater toxic stress impact and, in the absence of protective parental and caregiving relationships, may result in permanent genetic changes in developing brain cells. Research shows that toxins and stress from pregnant mothers cross the placenta into the umbilical cord [8], leading to premature and low birth weight babies [9] which increases the stress of parents and caregivers with additional parenting requirements. The severity of the impact depends on diverse factors including previous life experiences, coping ability, severity of the trauma, age, gender, poverty, education and support from family, friends, and professionals [10, 11, 12, 13]. These negative impacts undermine the physical, emotional, cognitive, and social development of young children. Apart from physical injury, the loss of family, friends, and neighbors can severely disorient parents and caregivers and the loss of home and possessions disrupts daily routines, further undermining the foundation for a healthy and productive life [14, 15]. According to the Palestinian Counseling Centre, Save the Children [16], even 6 months after the demolition of their homes, young Palestinian children suffered from withdrawal, somatic complaints, depression/anxiety, unexplained pain, breathing problems, attention difficulties and violent behavior [16]. Parents and caregivers experience loss of loved ones that can not only cause trauma, but also result in lost caregiver support. Adverse early experiences often stem from inequity between and within populations. The impacts of poverty, inadequate cognitive stimulation, stunting, iodine deficiency, and iron-deficiency anemia prevent millions of young children from attaining their developmental potential. Though Adverse Childhood Experiences (ACEs) and wellness data has become more prevalent, much of the research samples populations from high-income countries. ACEs can and do affect
Research increasingly focuses on strengths and protective factors that bolster resilience in life [22, 23]. Not all children with emergency situations such as conflict and natural disaster exposure develop post-traumatic stress disorder (PTSD) (Dempsey, [10]) and reactions may vary over the first days or weeks following a crisis; mainly dependent on the parents or caregiver’s emotional state and availability to their children. Consistent, predictable, quality care can alleviate the psychosocial impact of conflict and disasters by giving children a sense of normalcy, stability, structure and hope for the future. However, emergency and conflict situations often lack quality services and resources. In most conflicts, care and education infrastructure are often targets of violence because of the stability and support it provides. Pre-schools and schools are often destroyed or closed due to hazardous conditions, depriving families and children the opportunity to learn and socialize in a safe place with a sense of routine [24, 25]. An affectionate family, positive shared emotional interactions, social support, shared ideology/religion, and a sense of community during adversity contribute to the development of family and child coping skills, mental health, and academic achievement, [26]. Zahr [27] found a relationship between the availability of parents and the development of secure attachment in Lebanese kindergarten children exposed to war. Barber [28, 29, 30] showed that young Palestinian and Balkan children’s emotional well-being and development were protected from the negative impact of military violence by positive and protective relationships with caregivers. Palestinian children whose parents used positive styles of comforting were found to be resilient, and those who had loving, non-rejecting parents were more creative and efficient [31, 32, 33]. When exposed to frightening events, resilient children can regain their secure base by bonding and being with loving, protective, and responsive caregivers. Massad et al. [34] studied mental health of young children in Gaza and found that resilience in children was associated with the parents’ or caregivers’ health and a higher maternal level of formal education. Studies show that children who are supported by a caring and responsive parent and/or caregiver at a young age, cope with stress more effectively [35]. A supportive relationship can reduce a child’s reaction to stress and help to build the foundational resilience fundamental to long-term health development [36].
\nIt is essential to understand protective factors to promote strategies and supports that foster resilience and reduce negative consequences. With an increasing number of refugees around the globe, and an ever-deepening understanding of neuroscience of early childhood adverse influences, we argue that more research is needed so policy makers, nonprofit organizations, aid agencies, mental health professionals, educators and educational institutions can make informed and culturally relevant decisions/policies that truly help families be resilient at various stages of the refugee and/or resettlement process. While there may be some aspects of the refugee experience that are universal, we include three populations with different socio-political histories because their challenges and needs can differ. As very few studies have specifically examined parenting in refugee contexts, this exploratory study highlights the voices of parents navigating difficult circumstances in three contexts: refugees within their own country, refugee camps outside of their country, and refugees who have resettled in a host country.
\nParenting beliefs and practices vary with roles, familial relationships and expectations influenced by political, social, cultural, economic, religious, and community situations and cosmologies. Constructs that very across cultures include: the way moral context for parenting is negotiated in families and passed down to the children, definitions of good parenting, reproductive rights and resources, the relationship between intimate family life and the wider culture, and roles for parenting and work outside the home.
\n“Scholarly” definitions of parenting can differ from that of experienced parents with multi-generational knowledge and skills. In the Western World over the last century, the importance of expert recommendations for parenting practices has been elevated [37]. For example, TV shows and commercials in the 1930s promoted “expert”-informed mothering as a methodological occupation that should be learned [38] whereas previous generations of new mothers learned parenting skills through informal networks within community, and family members. Although current North American parenting discourse elevates experts who prescribe parenting practice, we must critically examine this notion of “expertise” devoid of contextual and cultural considerations.
\nAnthropological perspectives of parenting see cultural variability as historically and socially situated. As Mead [39, 40] states the tasks of bearing children and parenting have similarities the world over; babies are born and require warmth, nourishment, protection from predators, and an induction into social mores and systems. Yet
Infants everywhere have the same biological needs and must succeed at many of the same developmental tasks. Parents/caregivers guide them in developing their first social bonds, learning to express and read human emotions, and making sense of the physical world. The amount of interaction between parents and offspring is greatest in infancy, a time when we are especially susceptible to the influences of experience, i.e. culture, language, and trauma [43]. Almost all young infants’ worldly knowledge is acquired from interactions they have with their parents/caregivers. Social competence in children has origins in specific socioemotional characteristics of the parent–infant relationship [44]. Refugee children carry these socio-cultural influences long after they leave their country of origin. Factors such as conflict, migration, relocation, and the loss of kinship relationships and community stability have a direct impact on child development. Most contemporary parenting literature originates from Western, educated, industrialized, rich and democratic countries and the fields of Education, Early Childhood and Human Development sorely lack a global perspective on parenting.
\nIn the US, many parenting practices align with how children will succeed according to the standards held by public schools and other state institutions. The standards typically reify a Caucasian, middle-class values and ways of life. U.S. Media, schools, and public institutions reinforce these norms of child behaviors. When parents resettle in the US, many enrichment programs are provided for parents, with an underlying agenda to reprogram families’ childrearing practices. Such programs can alienate refugee families if they are pressured to adopt different parenting norms for discipline and guidance and different cultural norms regarding ethnic identity and individualism.
\nWhen these external forces (rather than familial, community and historical practices) shape parenting expectations, a mismatch and/or tension can arise. Parents may resist these influences that will change their parenting practices and strive to keep their values, beliefs and cultural and linguistic identities alive. Cultural bias and discrimination can occur, which adds to social alienation However, some families adopt new modes of parenting and readily apply new knowledge in their home lives. This often requires a shift in childrearing priorities and poses challenges for families. Our understanding of enculturation and acculturation as a multidimensional family and community-level construct is key to understanding the diversity of refugee and immigrant groups.
\nA global perspective of parenting recognizes the impact of globalization and global power inequities. As people migrate around the world, localized constructs reveal great diversity in what is considered “good parenting”. As refugees navigate new realities, they do so within the context of a host country with greater global dominance. Thus, parents’ ideas of values, priorities, belief systems, kinship and the roles of kinship, are challenged. Evidence suggests that parenting is becoming more child-centered, resource intensive, and focused on the maximization of individual achievement potential in countries with rising or strong capitalist economies such as Chile [45], Brasil [46], the US, Canada, Europe, and Australia. Schooling in these contexts often focuses on cultivating workforce readiness, citizens who embody individualism, and economic social mobility [47]. As parents/caregivers remake themselves and their families through processes of crossing borders, they contend with the hegemony of national and state visions of “best parenting practices” that can position them as deficient and “at risk” of not succeeding.
\nThe authors (the term authors and interviewers are used interchangeably in this section) used purposeful sampling, selecting parents from refugee populations where they lived. Purposive sampling is a non-probability sampling method when the respondents are limited. The respondents were from a homogeneous sample, and shared a refugee status, similar context (same camp or relocation community), and shared language. The respondents volunteered to be interviewed and freely agreed to share their stories and opinions. Purposeful sampling was used to select parents who were knowledgeable about and experienced in parenting in a refugee context. The criteria for respondents was that they were parents, refugees, and have moved from the home or origin.
\nAn unstructured focused interview was used as the data collection format. Interviews were used to collect the data and parents were encouraged to reflect on their experiences and offer their opinions. The authors first jointly developed guiding interview questions, taking care to phrase the questions to reduce the feeling of intrusion and to recognize the resilience families have.
\nThe interviews started by the author reading a confidentiality statement. Not all respondents were literate so oral agreement was taken. Due to the sensitive nature of the settings, no names were ever used in the notes. The interviews were conversational and respondents were able to express in their own way and pace, with minimal interruptions from the interviewers. Interviewers respectfully listened to respondents and if respondent deviated from the main topic, the interviewer gently refocused the respondent through the use of probing questions. Interviewers were experienced professionals well versed in contingent follow-up during the interview. By using guiding questions, interviewers at each site had flexibility to be responsive to the various contexts and to avoid interview fatigue. People living in adverse conditions are often asked to share their stories which can be re-traumatizing and does not provide them with any particular benefit.
\nThe guiding questions included topics of: family makeup and structures in the place people left, shifts required due to family movement or relocation, major influences in parenting practices, parenting experiences in place of origin compared to the new place, willingness to ask for help, coping mechanisms, persistence, and attitudes. An asset-based lens was used to center resilience and parents were asked about what parenting support or resources would be beneficial. Parents were also invited to share their feelings about their decisions to make a move.
\nInterviewers took short field notes that were shared with the interviewees who had opportunities to expand their notes within 24 hours of the interviews. We did not record the interviews, as the respondents in all three contexts had concerns abound safety and local authorities. Stories were collected in the respondents first language and in the case of Colorado, interpreters from the parent group and chosen by the parent respondents themselves were used. The use of semi-structured interviews allowed us to collect stories and expand our understanding of parenting in three different refugee settings. The authors wanted to glean insights to increase refugee service providers’ (NGOs, INGOs, policy makers, community resource services, educators) knowledge and efficacy. \nTable 1\n outlines the demographic data for the interviewees.
\nCountry | \nGender | \nAge range of interviewees | \n|||
---|---|---|---|---|---|
Female | \nMale | \nAge 15–23 | \nAge 24–44 | \nAge 45–60 | \n|
Palestine | \n7 | \n4 | \n\n | 3 = F | 1 MM | \n4 = F | 3 = M | \n
Greece (16 families) | \n42 | \n16 | \n22 16 = F | 6 = M | \n20 14 = F | 6 = M | \n16 12 = F | 4 = M | \n
Colorado | \n66 | \n8 | \n8 = F | \n46 = F | 4 = M | \n12 = F | 4 = M | \n
Respondents’ demographic information by country, age, and gender.
The interviewers knew the respondents and lived in or near the same geographical areas as the respondents. In Palestine, the interviewers had known the respondents through previous work or through friends of friends. A number of respondents also sent out a request to parents in their community to include other community members. In Greece, the interviewer worked with the refugees in the camps. The interviewer asked for volunteers and 16 families agreed to share their stories. The 16 families interviewed had at least 3 family members in each family. The families were also asylum seekers living in the camps. The parents and children were involved in the conversation, with the parents responding over 80% of the questions. In Colorado, the interviewers were working with a group of 85 refugee parents, and 74 parents volunteered to share their stories. There were eight males and sixty-six females. The age range was from 27 to 52. All interviews were conducted in an informal setting, interviewers went to the respondent location.
\nThe interviewers were the authors of the chapter. The interview data were first compiled and coded by the in-country authors, going line by line of the interview notes. They created and inductively assigned codes to categorize the data from their county. They then categorized the codes. Subsequently, all the authors met to discuss the codes and categories and agreed upon three major themes based on the patterns that emerged. Authors outside of the country depended on cultural interpretation from in-country authors for clarification when needed by the.
\nAuthors noted similarities and differences in the stories of individuals in the three contexts with some themes cutting across cultural and contextual variations and others being unique. In the case of Colorado there were three groups with different countries of origin. The authors in Colorado returned to the respondents to reflect on their understanding and interpretation of the data sets to ensure their stories were represented correctly. At the end of the interviews in Colorado, representatives from each of the three groups came together to discuss the similarities and differences found in their stories. The respondents shared (using interpreters) that even though there were great cultural differences between the three countries of origin, that their experiences in resettling in Colorado were quite similar.
\nThough not the specific focus of this chapter, we believe that from a social justice and human rights stance, the multiple reasons people are forced to or choose to leave their homes must be named. It is highly problematic to only center narratives of the refugee experience and
In Palestine the refugee population continues to grow, and some families have lived in a refugee camp for over 70 years. There are 58 Palestinian refugee camps in the West Bank, Gaza, Jordan, Syria and Lebanon. Palestinian refugee children and families are especially at risk with most living in refugee camps rife with ongoing conflict, violence, and discrimination. Palestinian families lack representation of their rights, experience overcrowding and lack resources and basic services such as education and health care [49]. UNHCR estimates that the average length of major protracted refugee situations has increased from 9 years in 1993 to 17 years at the end of 2003 to [50]. Until the recent Syrian crisis, one in three refugees in the world are Palestinian. The Syrian refugee situation echoes much of the Palestinian plight. Identifying both successes and gaps can provide information to better support the unique needs of families living in refugee camps throughout the world.
\nMany of the camps were created in 1948. More were added after the wars in 1967 and 1973 and more recently after the war in Syria for Syrian Palestinians. Palestinians are in a unique situation as United Nations Relief and Works agency for Palestinian refugees [49] was created just for refugees from Palestine. They define a refugee from Palestine as “persons whose normal place of residence was Palestine during the period of June 1st 1946, to May 15th 1948, and who lost both home and means of livelihood as a result of the 1948 conflict [49].” The descendants of Palestinian refugee males, including adopted children, are also eligible for registration. The Agency began operations in 1950 to address the needs of about 750,000 Palestine refugees. Today, some 5 million Palestinian refugees are eligible for UNRWA services. The 1951 Convention for Refugees focused on people who had lost their homes and livelihoods because of World War II. The revised 1967 Protocol eliminated time limits and geographical boundaries. Though the definition of a Palestinian refugee was originally a stopgap measures for a temporary problem, laws have not been changed in this protracted situation.
\nThe stories in this section come from camps in the West Bank, where about 775,000 refugees live. The camps are overcrowded, lack basic infrastructures such as roads or sanitation, and often during times of crisis, can go months without electricity. Even when electricity is available, it is inconsistent. Unemployment and under employment levels are high and typically half of a family’s income goes just to food. Many families depend on the income of family and friends working in Israel. The frequent raids on Palestinian towns, refugee camps, and villages result in no predictability or security for people in the West Bank and Gaza. Despite the lack of infrastructure, trained teachers, and access to school, the Palestinians in Palestine have one of the highest literacy rates in the Middle East [51]. This resilience is even more remarkable considering that Israeli Military can block children from attending school at any time and have entered schools and taken children to prison. UNRWA provides educational resources for half a million children in the various Palestinian refugee camps. The insufficiency of international donations became starkly clear when the US cut $300 million from UNRWA’s budget and many schools in the camps were closed, classes were combined and teachers were laid off [52].
\nGreece has been struggling to deal with the massive influx of migrants from war-torn nations of the Middle East and Africa who are experiencing deplorable conditions in detention centers [53, 54]. Greece currently hosts approximately 60,000 refugees with about 40,000 on the mainland and 20,000 on the islands of Lesbos, Chios, Kos, Samos and Leros. Since 2015, people fleeing conflict in the Middle East and South and Central Asia viewed Greece as a possible entry point to safety and Europe. Today, Greece has become a place to hold people seeking asylum. The European Union currently has adopted border restrictions and other edicts that prevent people seeking sanctuary from entering Europe. For various political and COVID-related reasons, the refugees in Greece can no longer legally travel to other parts of Europe. Therefore, many of the refugees are likely to remain in the country resulting in Greece shouldering much of the responsibility for those seeking refuge and safety.
\nThe camps are overcrowded conditions and lack basic amenities. In cold months, refugees have built fires in their tents which lead to fatalities as well as health conditions. Moria camp on Lesbos was built for 2200 people, however, until the fire in September 2020, 18,300 people were living in the camp. In addition, unaccompanied minors, women traveling with young children are especially vulnerated and need protection from discrimination, inadequate medical care, violence, gender-based violence, and trafficking.
\nThose seeking asylum and not living in camps are held in detention centers or have moved to urban areas. Those in the urban areas rarely find work to support their families [55, 56]. Integration is key to ensuring refugees and asylees build successful lives in their new home. This is a big challenge in any country and exacerbated in Greece because of its ongoing economic difficulties. The detention centers are overcrowded and lack sanitary conditions, “all significantly below international and national standards and may amount to inhuman or degrading treatment” according to the 2021 Amnesty International Greece 2020 report. Almost all the refugees have witnessed or directly experienced violence, have been traumatized and require psychosocial support, medical aid and other human services. Greece and Italy cannot be expected to bear this responsibility on their own.
\nResettlement is not a decision that families make lightly, as a refugee typically cannot return to their home country for years, or sometimes forever. Resettlement often entails permanent separation from friends and relatives. Parents make tremendous sacrifices to escape war and violence, and to seek a safe place to raise their family. More than 3 million refugees have been resettled in the United States since 1975 [57]. Refugees arriving in a new country face a multitude of changes. Often highly educated professionals such as doctors end up driving taxis, or professors work in retail. Working these temporary, low-paying jobs adversely impacts individuals’ professional identity. Being resettled, people come with hope and perhaps dreams, but loss of family, friends, and homes bring challenges even among that hope. Refugee families have often survived atrocities beyond imagination and their oppression does not end with the initial flight.
\nFamily adjustment in a country of resettlement can be quite difficult. Family members are often reluctant to discuss assaults and other harmful acts, as they can face ostracism from their family, other refugees, and host communities.
\nTo survive and ‘fit in’, parents/caregivers who are resettling may adopt and adapt superficially to the messages of institutional and state agents, but at the same time remake these messages and transform them into ideas that are more culturally comfortable [58]. Due to the economic stress refugees and asylees face, women report finding themselves in a particularly stressful position. The families typically need both parents to work outside the home to pay for their bills.
\nRefugees who resettle in the U.S. have a wide range of experiences. No matter where refugees land, it is best if they are met at the airport when they arrive and are oriented and welcomed to their new home. Families must start over where life is completely different. They have left their family and friends behind, and many families have witnessed and/or experienced violence, war, unsanitary conditions, and food insecurity. Unfortunately, many people in the U.S. see refugees as people who pose a threat to: national security, jobs and economic stability, their children’s exposure to diversity. Additionally, negative media portrayal of immigrants contribute to deficit stereotypes and religion discrimination toward Muslims was fomented in the US’s last administration [59].
\nSome refugees have special immigrant visas, such as offered to Afghans and Iraqis who assisted the U.S. military forces in their home countries and who now face retribution. Refugees without special immigrant visas are subject to intense scrutiny, including multiple interviews, ongoing background checks and biometric checks run through Interpol’s international police databases. Refugees must do interviews with U.S. Homeland Security agents who often apply arbitrary criteria. (For example, if the agent does not like the way you talk or the way you dress, you can be denied entry) [60]. Each refugee receives a one-time payment of $1125 to set up their new life in a new country and aid agencies provide acclimation support for the first 90 days in the country. Employment assistance lasts 180 days, or until a refugee is offered the first available job. Refugees are required to pay back the airfare for the flight to the United States, and few airlines provide discounts.
\nWe hope our findings will inform future research on how to best meet the needs of refugees. Considered. The authors first coded the data individually and then worked together to reconcile differences. From that phase of data reduction, three main themes emerged.
\nEach of the three themes were a type of stressor for which there were subthemes. The first theme, infrastructure, refers to the external factors such as the dearth of or limited access to services. Second, cultural differences emerged as a theme and encompasses factors such as language, discrimination, values, norms, and roles. The third theme of mental health consists of the different intra and interpersonal socio-emotional stressors of various refugee and resettlement experiences. \nTable 2\n provides an overview of findings for which kinds of stressors impacted each context.
\nMental Health | \nContext | \nCultural Differences | \nContext | \nInfrastructure | \nContext | \n
---|---|---|---|---|---|
ACES | \nP, C | \nDifferences in acceptable behavioral norms | \nP, G, C | \nAccessing education | \nP, G, C | \n
Boredom | \nP, G, C | \nKnowing cultural norms for accessing services | \nP, G, C | \nAccessing health services | \nP, G, C | \n
Camp conditions | \nP, G | \nChild rearing challenges | \nP, G, C | \nNo or few basic services | \nP, G | \n
Chronic pain/somatic complaints | \nP, G, C | \nGender role shifts | \nP, G, C | \nNo or few education services | \nP, G | \n
Coping strategies | \nP, G, C | \nHealth practices unfamiliarity | \nP, G, C | \nNo or few health, dental, mental health services | \nP, G | \n
Depression | \nP, G, C | \nEducation levels | \nP, G, C | \nNoises | \nP, G, C | \n
Discrimination | \nP, G, C | \nHost country animosity | \nG, C, | \nOccupation - soldiers and settler | \nP | \n
Economic instability | \nP, G, C | \nLanguage barriers | \nP, G, C | \nOvercrowding | \nP, G, C | \n
Fatigue | \nP, G, C | \nLoss of respect for elders | \nP, G, C | \nSafety | \nP, G, C | \n
Fear (Occupation and raids) | \nP | \nReligious differences | \nG, C | \nSanitation | \nP, G | \n
Isolation | \nP, G, C | \nSocial Networking | \nP, G, C | \n— | \n— | \n
Lack of purpose | \nP, G, C | \n— | \n— | \n— | \n— | \n
Not enough time to complete daily tasks | \nP, G, C | \n— | \n— | \n— | \n— | \n
Unpredictability/uncertainty | \nP, G, C | \n— | \n— | \n— | \n— | \n
Major themes, patterns within the theme, identified within country, P = Palestine, G = Greece, C = Colorado.
Through interviews with 11 parents (seven females and four males aged 24–60 years) the patterns that emerged included some overlap with the other two field sites and some that were unique to Palestine. Regarding the infrastructure theme, all parents mentioned overcrowded conditions. As for cultural differences, respondents reported that their children were losing respect for their parents as they did not obey them as they obeyed their parents when growing up. In terms of the mental health theme, six of the seven women felt isolated as their husbands worked all day and many times outside the camp. All parents reported that their situation felt uncontrollable, they were fatigued and struggled to be patient with their children. Nine of the 11 parents reported that they faced boredom and lack of meaningful ways to spend time. All three respondent groups reported the need for social and mental health support.
\nThe unique pattern that emerged from all in Palestine was the impact of occupation. They expressed daily fear of not knowing if everyone in the family would return home from work or school, or if they would be woken in the middle of the night by soldiers and family members taken. Ongoing uncertainty of daily life and dwindling hope of returning to their homes permeated the stories. All parents in the Palestine groups believe that education is the most important thing in the lives of the children. One of the respondents was from a family that has lived in the camp for five generations, still holding the keys from their home as a sign of hope. He stated:
\n\n
A different parent reported what provided them the resilience to continue to move forward. “My life inside the camp is special, safe, and warm. I had never thought that my life out of it would be better than it is, I have nice neighbors and relations that make me very privileged and lucky woman … .my life inside the camps gave me an evidence that the good people are being good regardless where they live. I learned a lot from my friends in the women’s center, who taught me how to spend my time doing useful things that make life valuable.”
\nWhen asked to share more about this response, the respondent stated it was very important to do purposeful things. From this response, the interviewers ask other parents about how they filled their time. People who felt they had purposeful work showed more ability to adapt to adversity and increased resilience. In addition, having at least 2 close friends outside the family was positively correlated to increase resilience. Three women reported how their attitude toward more conventional gender roles had changed due to the challenges of the occupation, and had helped in terms of their ability to address the adverse situation they live in One woman reported
\n\n
Another woman responded joining a women’s center activities positively impacted their physical and mental health and helped them overcome challenges. We see changes in terms of gender roles, and also the impact of having purposeful work to reduce the fears that align with occupation.
\nIn Greece, the interviewer worked with the refugees in the camps. The camps are a temporary holding place until the families have been provided permission to move on. People typically stay in the camps anywhere from one to 3 years. The interviewer spoke with 16 asylum-seeking families. The parents and children were involved in the conversation, with the parents responding over 80% of the questions. The theme of infrastructure issues was prevalent in the Greece context with lack of basic services exacerbating mental health issues.
\nOne parent reported:
\n\n
All the respondents reported they wanted their children to have educational experiences, yet in the camp there were very few educational opportunities and most of those were informal. All reported unsanitary conditions, overcrowding, and lack of health care. Currently, food is being withheld with children comprising 40% of the camp population. This lack of infrastructure exacerbates mental health challenges [61, 62].
\nIn terms of the theme of cultural differences, one pattern unique to Greece was how the conflict the families tried to escape seemed to follow them in the camps. There are people from other areas of conflict, many fled the same conflict, but on different sides, continuing the violence and fear from which they fled. Additionally, respondents reported high hostility between local Greeks and the refugees. Accessing benefits and sustaining hope of resettlement is challenging. Changes in gender roles due to the loss of family members and deteriorating respect for elders and parents contributed to familial stress. Over 90% of the adults reported that the children do not obey and listen to parents as was expected of them when they were young. Few social networks exist in the camps in Greece, leaving families feeling isolated and lacking a sense of belonging.
\nAs for the mental health theme, the main patterns that emerged included parents being tired and worn out from being on the move and the uncertainty of their future. There is nothing to do in the camp, the children were very bored and the adults did not have the ability to engage and have patience with the children and were worried about the long-term impact on their children. One family reported:
\n\n
\n
A family from the Democratic Republic of the Congo reported:
\n\n
All families reported they wanted mental health and parenting support and felt a lack of safety. One woman reported that “Children and women are afraid of going to the toilet at night, it is dangerous here.”
\n\n
Unsurprisingly, the theme of infrastructure in resettlement pertains less to the existence of resources and services and more to the ability to navigate systems and
The theme of cultural differences appeared frequently, provoking and/or interacting with mental health stressors. Parents and children face language barriers that impact their occupational and educational opportunities and experiences. Families’ religious beliefs and values differ from those of these new societal and educational contexts. Children face bullying in schools and must navigate the mismatch between their home country’s values and beliefs and the new cultural norms of schools. As one father stated, “The children begin to learn new ideas from being part of the community around them. We try and make meaning of what they are learning with our own ideas of how to be parents and what children should or should not do. It is so hard, as what they learn is not always what we believe is good.”
\nOne parent from Myanmar shared, “Our kids are learning things from kids born in the US and are not showing respect to us. This is important in our culture. They begin acting like American kids and calling people by their name rather than their title. They say they cannot share their food, when we always share our food together. They start doing things like other kids and rejecting us. Our language is being lost”. An Arab Muslim parent commented,
\n\n
These quotes exemplify a common conflict for refugee and immigrant parents raising children in a new country. Refugee and immigrant families show resilience and adaptability as they bridge two cultures and languages while often facing racial and/or religious discrimination. Balancing traditional and new ways of being in healthy ways requires tremendous navigational capital [63].
\nThat U.S. culture values independence over interdependence impacts families. As one parent stated, “When children learn to take care of themselves, that is good. But when it undermines the parents’ authority it is not good. We are not used to having a family separated. We lived close together. Now when children are grown, they think about where to move, move away. How will our language and culture be remembered? In our culture, decisions are made based on what will happen to everyone, not just one person. We believe we take care of children and when we get old, they take care of us. That is not what happens here in the US”. An Afghani parent stated, “Many times children talk back to their parents, that would not happen back home”.
\nMany parents reflected upon differences in how children are disciplined and supported in their learning. As with the other two contexts, parents lament not being able to control their children and the lack of respect and honor toward elders. Many have previously used corporal punishment to teach children right and wrong yet in the US that is viewed as wrong and ineffective. Families shared that they see advantages and disadvantages of raising children in a new culture. One example includes the shift in gender roles. Roles within the family change as women go out to work for the first time while men assume tasks such as chores in the home, child rearing and greater involvement in children’s education. While the expanded options for women could be seen as a beneficial change, one challenge is the negative impact it can have on men’s identity. This shift results in men feeling alienated and depressed as these shifts cause them to question their self-worth. About 60% of the women reported their husbands resent their employment. “My husband cannot find a good paying job, so I bring the money home into the family. He is depressed and cannot get out of it, so he drinks. He is always drunk and abusive. But if I leave him, I think he will not make it.” Women working outside of the home face time constraints in fulfilling their traditional roles of caring for the home and child rearing expectations.
\nAnother cultural difference is the accelerated pace of life in the U.S. which alters priorities of how families spend their time. “When we come here – we have so much to do and no time. We do not get to sit with our families and talk and tell stories. Our values are being lost as our stories are lost. We lose ourselves when we cannot take care of our family as we want. My children have to help with the cooking, sons and daughters, but back home sons do not cook.”
\nParents also reported concerns that their children are moving away from traditional religious beliefs. Many children try to keep their religious identity private due to discrimination. Palestinian refugees reported the negative impacts that discrimination had on their mental health [64]. Discrimination is not only religious as refugees and asylees systemically face inequities in housing, education, and health care. Parents reported that the laws and rules are not clear. One parent reported fear of taking their child who has special needs to the doctors, as they thought the doctor would report them for child abuse. Several families reported not seeking mental health services for fear of being accused of child abuse and losing custody of their children.
\nIn schools, parents report that language is associated with intelligence. Parents feel ignored or treated in an ‘unfriendly’ manner. One mother reported, “The teacher calls me almost every day to say my 4 year-old is hitting others in her preschool/kindergarten class. Last year in her preschool she was loved, cared for, and she was happy and played with all the children. They spoke Arabic in her other preschool. Now the teachers only speak English, and they think she is a bad girl. I do not know what to do.” The teacher also stated that she did not have the time nor the knowledge to address the needs of the girl and suggested the girl change schools. Schools can be spaces where racial, ethnic, religious, gender, socio-economic and language discrimination and xenophobia intersect. School personnel who hold these biases tend to view refugees’ parenting through a deficit lens.
\nAdditionally, the sense of belonging and identity impact resettlement. As one Arab Muslim father shared, “My family and I often feel like outsiders growing up in the US. We struggle to find balance between our Arab Muslim, identity and our US American identities. Some of our children still struggle even thought they were born and raised here. They should not have to struggle with their identity in school but unfortunately, they do. It is very sad as a parent to watch your child try to be something someone else wants them to be…When we find other families from our home country, we tend to stay together. At least there is an understanding of what we are going through, as we try to make Colorado our new home. Now we live in a community that is very limited in access, resources, services, and our children are many times blamed for mistakes or inappropriate behavior at school. Our families and children continue to live under stress, this makes parenting so difficult as we do not always have patience with our children when we cannot afford to pay our rent or we lost our jobs due to COVID. Many of us are the first to go when it comes to being laid off at work. Then the children feel bad about themselves. This is not what we want. We want to be proud of our culture, our history and we want to make our home good in the US. We live between two worlds, and it is very hard”.
\nFinally, several refugees discussed the significant trauma women and children experienced due to assault in transit, and in their country of asylum. Even in refugee camps, they are sometimes forced to provide sexual favors just to obtain the aid to which they are entitled.
\nIn all three contexts, individuals face the chronic stress that comes with great daily uncertainty. Lack of resources and capacity to earn a living were challenges in all three contexts. One difference is that in Palestine, there is a constant imminent threat of violence, mostly from the Israeli armed forces. This leads to extremely high stress levels and challenges to parenting.
\nSimilar in all contexts are parents’ desire to make the best choices for their children and their families along with seeing the importance of education. Parents want their children to learn and have greater opportunities in the future. Resettled individuals face unique challenges, yet often have more choices about how to lead their lives than those in the camps. For individuals in the camps in Greece, they are in a state of perpetual limbo, not knowing their prospects for relocation. This poses unique challenges to parenting as it is extremely difficult to sustain a future orientation/vision. In Palestine, the camps have been established for such a long time, that it can be difficult to have much hope for their circumstances to change. Greece and Palestine respondents are still living in camps whereas the U.S context is one of final resettlement.
\nIn the US, parents shared stories of how they had to contend with the hegemony of what best parenting is. The refugees resettled in the US shared feelings about being seen as deficient and having to hide their parenting values. Societal hidden agendas wield power in determining what is “best” for their children and felt pressure to assimilate to US culture. In all the field sites, reports that children did not obey their parents as the parents obeyed their parents were reported. However, in the US, children felt pressure to be accepted by school and society. Parents reported their children came home with ideas contradictory to their home culture (regarding things such as tattoos, piercings, talking about reproductive health and displays of intimate relationships in public).
\nA common theme in the Greece and Palestine camps is boredom and lack of purposeful play or work. Children do not have spaces to play and run and be children and camps lack infrastructure to provide enriching childhood experiences. Families resettled in the US sometimes, but not always had more opportunity to find purposeful work. Unemployment and underemployment were common themes in all three sites. The camps however, pose a greater challenge to establishing and maintaining the predictable routines that can be a protective factor in child development. In contrast, resettled individuals can establish routines, but feel the fast pace of U.S. life does not leave time for more traditional familial activities.
\nIn Greece and the U.S. individuals carry a greater sense of guilt as they have left loved ones behind. Additionally, many individuals in the Greece camps expressed a sense of self-doubt and guilt, wondering if they had made the right choice for their family. As their lives are in limbo, it becomes impossible to determine whether the sacrifices they made were worth it. A unique challenge parents in Greek camps discussed is the tension with host countries and local resentment of resource allocation. In the US, refugees feel social isolation and National reports suggest that 50% of the people in the US are resentful and empathetic at the same time [65]. In all three cases, the feelings of social isolation, the need for mental health, parenting support, and purposeful work were reported as strong patterns.
\nWhile ample literature documenting refugee experiences exists, work explicitly focusing on parenting in refugee contexts is scarce. Our work is an initial contribution to the fields of Early Childhood Education and Parenting. By understanding the nuances of different refugee experiences, we can develop evidence-based policies and procedures to foster resilience in future generations.
\nMarope and Kaga [66] assert that disadvantaged families generally require multi sectoral support to cope with sudden changes in their circumstances. Such support is made possible through the collaboration of various agencies addressing inequities which cause diverse vulnerated situations related to housing, health, welfare, family support, employment, and education. Key supports include: overcoming language and communication barriers, mental health, access to education, purposeful work, access to professional development, and learning English. In the US, a main recommendation is providing pathways to education and career advancement that is not contingent on immediate mastery of English. For example, bridging opportunities in the U.S where access to higher education is scaffolded to include the use of the parents’ home language have shown to be extremely beneficial. To make a more significant impact, agencies must provide more opportunities and pathways for purposeful work.
\n“Having the opportunity from the Pamoja program has given me the chance to make friends with other refugees from the Arab world. Also to enter education where I can learn in my own language. I feel like no one understands me and thinks I do not know anything because I do not speak English well. But now I am learning how to take care of children as a teacher and learning English. I can now work in a job that my husband thinks is okay and can bring some money home to pay our bills.” (Mother resettled in the U.S.) Ideally refugees’ short-term and long-term outcomes are achieved in solidarity, free from discrimination, and with support of language access and justice.
\nHealing-focused interventions help children and parents develop the ability to express and regulate their emotions, improve self-control and self-esteem, recover and build resilience so that they are ready to learn. Building parent and caregiver capacity to assist children appropriately during the early stages of crisis response and emotional recovery is essential. Refugee families often need support to implement positive parenting practices because they are also managing their
Classes in camps that provide purposeful active learning and engagement for both the children and the parents are beneficial. For example, holding classes outdoors where young children and parents can work and learn together in activities such as weaving, gardening, and storytelling, connect families and strengthen the connections between parents and children. Parents and caregivers benefit from learning about positive child interaction, ‘shared and sustained thinking’ [68], ‘serve and return’ [69], and ‘sensitive responsiveness’ [70]. These strategies nurture self-worth and wellbeing and promote successful learning and socialization. Parents and caregivers affected by emergencies and conflicts, can recover and thrive when supported in offering routine, structure, a sense of normality and a safe space to express feelings. We must acknowledge and value how parents/caregivers are children’s first educators and constitute a major influence on the family and child’s development.
\nBritto and Engle, [71] refer to five, interdependent domains of parenting: caregiving (health, hygiene and nutrition-related practice), stimulation (interactions, learning activities, modeling), support and responsiveness (trust, attachment, sense of security), structure (discipline, supervision, protection from harm) and socialization. Importantly, research shows that the quality of parenting and home environment is predictive of later social emotional health, academic achievement, and overall life success. Informal education, adult literacy, primary healthcare, and wellbeing structures are key. Welcoming, culturally sensitive programs that value parents/caregivers are essential to build positive family relationships. In the authors’ experience, these are the kinds of services are the least likely to be funded/prioritized despite their immense potential for impact.
\nParents and caregivers impacted by war, conflict, and disaster require support systems specifically targeting parenting and caregiving as a public good. This requires public investment, commitment, and leadership. Appropriate policy and program designs informed by refugee parents/caregivers voices are crucial to ensure their unique needs are addressed. Consistent, predictable, quality education can alleviate the psychosocial impact of conflict and disasters, but emergency situations undermine the quality of educational services available to refugees. Shortages of materials, resources, and personnel limit families’ access to quality education. In most conflicts, education infrastructure is typically a target for destruction because of the stability and support it provides. Pre-schools and schools are often destroyed or closed due to hazardous conditions, depriving families and children of the opportunity to learn and socialize in a safe place with a sense of routine [1, 25]. “The programs offered in the camp are not enough. They help but we need more. My children and I are bored. The teachers who give classes here do not teach like they do at home, but at least there is somewhere my children go. I also learn ways to help myself and how to take care of my own stress. This means I can be a better parent.” (Mother in camp in Greece)
\nIndividuals working in the camps described the extensive efforts of all stakeholders (charities, athletic clubs, social and cultural centers, public figures) to eradicate negative phenomena, and apply reforms. While these stakeholders are typically under-resourced, one aid worker stated, “We couldn’t see the impact yet, but we hope the next generations will. We believe that psychological support for all population segments should always be on the top of the list for any support provided to refugees. We must not underestimate this type of support and its role in supporting our efforts to combat negative phenomena in the camp, and try to overcome the bad demographic, socio-economic reality inside the camp”.
\nOur final recommendation shifts the focus away from the refugees and toward those working alongside refugee population. Teachers must be trained to be culturally responsive and implement culturally sustaining pedagogy [72, 73, 74]. Culturally-responsive programs that enact a culturally humble approach can support resilience, cultivate bi-multicultural, bi-multilingual communities and reduce the negative impacts of discrimination and invisibility. Service providers, (health, education, social services etc.) must approach their work with genuine curiosity, humility, and reciprocity if they wish to support healthy family structures where parents impacted by violence, war, and conflict can heal and thrive. As one teacher in Greece stated, “I really like being a teacher in the camp, but the parents want me to teach like they were taught. This makes it hard for me. I need to learn more, I need more support of how to teach, I want to be able to go to school so when I leave the camp, I can teach somewhere else.” In resettlement contexts, there is a great need to provide professional development to educators to understand diverse cultures and the lived experiences of immigrants. There is also a tremendous need for highly qualified providers and educators from
The authors recognize the limitations of purposive sampling and interviews as they are susceptible to interviewer judgment errors, low levels of reliability and limited generalizability of findings. The interviews are subject to bias as they are subjective in nature and do not provide an exhaustive view of the families’ experiences. Another limit of using semi-structured interviews, is they are time consuming and thus the sample size is smaller but do allow for more in-depth sharing/understanding of lived experiences which can provide a strong baseline for further study.
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Mucuna should always be taken under medical supervision.",book:{id:"6406",slug:"parkinson-s-disease-understanding-pathophysiology-and-developing-therapeutic-strategies",title:"Parkinson's Disease",fullTitle:"Parkinson's Disease - Understanding Pathophysiology and Developing Therapeutic Strategies"},signatures:"Rafael González Maldonado",authors:[{id:"214658",title:"Dr.",name:"Rafael",middleName:null,surname:"Gonzalez-Maldonado",slug:"rafael-gonzalez-maldonado",fullName:"Rafael Gonzalez-Maldonado"}]},{id:"19700",title:"Physiotherapy for Children with Cerebral Palsy",slug:"physiotherapy-for-children-with-cerebral-palsy",totalDownloads:21719,totalCrossrefCites:1,totalDimensionsCites:3,abstract:null,book:{id:"630",slug:"epilepsy-in-children-clinical-and-social-aspects",title:"Epilepsy in Children",fullTitle:"Epilepsy in Children - Clinical and Social Aspects"},signatures:"Mintaze Kerem Günel",authors:[{id:"38412",title:"Prof.",name:"Mintaze",middleName:null,surname:"Kerem Günel",slug:"mintaze-kerem-gunel",fullName:"Mintaze Kerem Günel"}]},{id:"51151",title:"Association Between Multiple Sclerosis Risk and Human Immunodeficiency Virus Infection: Insights and Challenges",slug:"association-between-multiple-sclerosis-risk-and-human-immunodeficiency-virus-infection-insights-and-",totalDownloads:1976,totalCrossrefCites:0,totalDimensionsCites:1,abstract:"Multiple sclerosis (MS) is a convoluted autoimmune and inflammatory disease of the central nervous system (CNS) in which the protective myelin sheath is eroded and the underlying nerve fibers are damaged. There is no conclusive knowledge on the role played by different etiological factors in its development, and studies have shown that it primarily results due to complex interactions between the genetic, geographic and infectious components. Among the risk factors reported to have a possible role in MS development, retroviruses also appear to influence it. Studies suggest human immunodeficiency virus (HIV) infection to be inversely related to MS risk, but to date, the association between the two remains enigmatic. This protective inverse association has become an area of active research and the most plausible explanations for this may be immune suppression and/or antiretroviral medications. The purpose of writing this chapter is to provide background information on the unfathomable relationship between HIV infection and the risk of developing MS while at the same time providing description of the insights garnered from recent studies. While highlighting the application of ART (antiretroviral therapy) as budding future alternative for MS management, this chapter provides momentum for further studies.",book:{id:"5156",slug:"trending-topics-in-multiple-sclerosis",title:"Trending Topics in Multiple Sclerosis",fullTitle:"Trending Topics in Multiple Sclerosis"},signatures:"Ehtishamul Haq, Insha Zahoor and Mushfiquddin Khan",authors:[{id:"181077",title:"Dr.",name:"Ehtishamul",middleName:null,surname:"Haq",slug:"ehtishamul-haq",fullName:"Ehtishamul Haq"},{id:"185233",title:"Dr.",name:"Insha",middleName:null,surname:"Zahoor",slug:"insha-zahoor",fullName:"Insha Zahoor"},{id:"185234",title:"Dr.",name:"Mushfiquddin",middleName:null,surname:"Khan",slug:"mushfiquddin-khan",fullName:"Mushfiquddin Khan"}]},{id:"63824",title:"Plasmapheresis in Treatment of Myasthenia Gravis",slug:"plasmapheresis-in-treatment-of-myasthenia-gravis",totalDownloads:1329,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Treatment of myasthenia gravis is still a rather difficult task, since there is no single tactic to use different drugs (corticosteroids, rituximab, immunoglobulins), especially since it is associated with a number of side effects. They are not able to remove the accumulating autoantibodies and immune complexes, the large size of which does not allow them to be excreted by the kidneys as well. Special problems of treatment arise when myasthenic crises develop associated with respiratory failure requiring artificial lungs ventilation. Plasmapheresis can help to solve this for it is possible to remove antibodies and other pathological metabolites. In addition, regular plasmapheresis is able not only to prevent exacerbations but also to reduce doses of the maintenance therapy with less risk of their side effects, which is confirmed by our own experience.",book:{id:"7160",slug:"selected-topics-in-myasthenia-gravis",title:"Selected Topics in Myasthenia Gravis",fullTitle:"Selected Topics in Myasthenia Gravis"},signatures:"Valerii Voinov",authors:null}],onlineFirstChaptersFilter:{topicId:"1056",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:106,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"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. 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He received his Ph.D. in Environmental Analytical Chemistry from Assiut University, Egypt, in 1989. His research interest is in analytical and environmental chemistry with special emphasis on: (1) monitoring and assessing biological trace elements and toxic metals in human blood, urine, water, crops, vegetables, and medicinal plants; (2) relationships between environmental heavy metals and human diseases; (3) uses of biological indicators for monitoring water pollution; (4) environmental chemistry of lakes, rivers, and well water; (5) water and wastewater treatment by adsorption and photocatalysis techniques; (6) soil and water pollution monitoring, control, and treatment; and (7) advanced oxidation treatment. Prof. Rashed has supervised several MSc and Ph.D. theses in the field of analytical and environmental chemistry. He served as an examiner for several Ph.D. theses in analytical chemistry in India, Kazakhstan, and Botswana. He has published about ninety scientific papers in peer-reviewed international journals and several papers in national and international conferences. He participated as an invited speaker at thirty international conferences. Prof. Rashed is the editor-in-chief and an editorial board member for several international journals in the fields of chemistry and environment. He is a member of several national and international societies. He received the Egyptian State Award for Environmental Research in 2001 and the Aswan University Merit Award for Basic Science in 2020. 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He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. 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The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. 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She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}},{id:"338856",title:"Mrs.",name:"Nur Alvira",middleName:null,surname:"Pascawati",slug:"nur-alvira-pascawati",fullName:"Nur Alvira Pascawati",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universitas Respati Yogyakarta",country:{name:"Indonesia"}}},{id:"441116",title:"Dr.",name:"Jovanka M.",middleName:null,surname:"Voyich",slug:"jovanka-m.-voyich",fullName:"Jovanka M. Voyich",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Montana State University",country:{name:"United States of America"}}},{id:"330412",title:"Dr.",name:"Muhammad",middleName:null,surname:"Farhab",slug:"muhammad-farhab",fullName:"Muhammad Farhab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"349495",title:"Dr.",name:"Muhammad",middleName:null,surname:"Ijaz",slug:"muhammad-ijaz",fullName:"Muhammad Ijaz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}}]}},subseries:{item:{id:"12",type:"subseries",title:"Human Physiology",keywords:"Anatomy, Cells, Organs, Systems, Homeostasis, Functions",scope:"Human physiology is the scientific exploration of the various functions (physical, biochemical, and mechanical properties) of humans, their organs, and their constituent cells. The endocrine and nervous systems play important roles in maintaining homeostasis in the human body. Integration, which is the biological basis of physiology, is achieved through communication between the many overlapping functions of the human body's systems, which takes place through electrical and chemical means. Much of the basis of our knowledge of human physiology has been provided by animal experiments. Because of the close relationship between structure and function, studies in human physiology and anatomy seek to understand the mechanisms that help the human body function. 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His interest later turned to the molecular mechanism and attenuating strategy of sarcopenia (age-related muscle atrophy). His opinion is to attenuate sarcopenia by improving autophagic defects using nutrient- and pharmaceutical-based treatments.",institutionString:null,institution:{name:"Tokyo Institute of Technology",institutionURL:null,country:{name:"Japan"}}},editorTwo:{id:"331519",title:"Dr.",name:"Kotomi",middleName:null,surname:"Sakai",slug:"kotomi-sakai",fullName:"Kotomi Sakai",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000031QtFXQA0/Profile_Picture_1637053227318",biography:"Senior researcher Kotomi Sakai, Ph.D., MPH, works at the Research Organization of Science and Technology in Ritsumeikan University. She is a researcher in the geriatric rehabilitation and public health field. She received Ph.D. from Nihon University and MPH from St.Luke’s International University. Her main research interest is sarcopenia in older adults, especially its association with nutritional status. Additionally, to understand how to maintain and improve physical function in older adults, to conduct studies about the mechanism of sarcopenia and determine when possible interventions are needed.",institutionString:null,institution:{name:"Ritsumeikan University",institutionURL:null,country:{name:"Japan"}}},editorThree:null,series:{id:"10",title:"Physiology",doi:"10.5772/intechopen.72796",issn:"2631-8261"},editorialBoard:[{id:"213786",title:"Dr.",name:"Henrique P.",middleName:null,surname:"Neiva",slug:"henrique-p.-neiva",fullName:"Henrique P. 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