Incidence of postoperative hemorrhage in gynecological surgery.*
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\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:"3206",leadTitle:null,fullTitle:"Success in Artificial Insemination - Quality of Semen and Diagnostics Employed",title:"Success in Artificial Insemination",subtitle:"Quality of Semen and Diagnostics Employed",reviewType:"peer-reviewed",abstract:"Artificial insemination has long been the primary tool towards genetic improvement in many domestic animals. 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There is a new onset of fatigue for at least 3–6 months that is not relieved by rest and not explained by other medical conditions. Post-exertional malaise, cognitive difficulties and unrefreshing sleep are present. In addition, a variety of somatic symptoms are commonly present such as headache, abdominal or muscle pain, as well as flu-like symptoms without fever, and symptoms associated with orthostatic intolerance [1, 2, 3, 4, 5]. The key features and symptom patterns in young people have remained consistent [6, 7, 8, 9]. Anxiety and depression may also be present but when compared with population levels, were only mildly increased in prevalence, and generally did not precede the illness. They were understandably associated with diagnosis delay, not being believed or social isolation [8, 10].
There is currently no defined treatment, as the underlying pathology is not well understood [11]. Similarly, there are no known predictors for recovery [10]. When this illness occurs during childhood and adolescence, it is at a period of significant developmental changes. In those that report recovery, the duration of illness has mean of 5 years and range 1–16 years [10]. With long-term follow-up, there is a significant proportion that does not report recovery [10, 12, 13]. There is disruption to their educational, social and physical activities, which create huge challenges for the young people and their families [14, 15]. It is the commonest cause of reduced time at school [16, 17], and has a significant impact on educational functioning [18]. Hence, in addition to managing symptoms, strategies for coping with this chronic illness and its impact on the young person and the family have been central to its management in this clinic [10]. Although there are other chronic illnesses during childhood and adolescence that have physical, emotional, cognitive or educational impacts [19, 20, 21, 22, 23], this illness does affect all these areas. Neglecting these aspects can compound the effect of the illness, and impact on the developmental tasks of adolescence or the transition to or from adolescence. Parents have a role in helping navigate these tasks, as well as trying to manage a child who is unwell [19, 20].
This chapter will outline the management strategies that have been employed in an outpatient setting that have been guided by feedback from young people over a period of more than 25 years; a description of the development since 2012 of an intensive self-management program for those who need additional assistance; and observations about characteristics of participants in the program and their reasons for referral.
The Royal Children’s Hospital is a specialised secondary and tertiary referral paediatric and adolescent hospital that services metropolitan Melbourne and all rural areas for the state of Victoria including bordering areas in neighbouring states. Furthest distances require 4–5 h of car travel. Referrals are received from family doctors or from specialist paediatricians. Victoria has a population of 6.3 million and is multicultural. There is a universal health system that ensures citizens can access health care free of charge to the family. There is also a private health system that can provide partially subsidised health and allied health care.
The CFS clinic has been functioning since 1989. In the early years of the clinic the Holmes definition and Fukuda criteria for CFS were available [2, 3, 21]. However, acceptance of the diagnosis in young people was uncommon in the medical fraternity. It was well recognised that Epstein Barr Virus (EBV) infection (or glandular fever) could run a prolonged course during adolescence. Irrespective of whether EBV was confirmed, it was assumed in some cases, that this was the cause of these symptoms. Alternative explanations that were entertained were depression, stress, school refusal or somatisation disorder or the possibility of undisclosed family difficulties. Parents who were anxious due to concern about the unexplained change in the young person were often considered to be contributing to their illness. Hence many who attended the clinic had experienced unsatisfying encounters with the medical profession.
The reported symptoms were very consistent among the young people attending. The presence of post-exertional malaise (PEM), unrefreshing sleep, cognitive difficulties, persistent fatigue and pain (headache, muscle, abdominal) were all almost universally reported. Sore throats and lymph nodes, feeling hot and cold and symptoms later recognised as associated with orthostatic intolerance were very common. These symptoms were consistently reported even though at the time there was no access to this information in the public arena.
Although the intravenous immunoglobulin trial in young people appeared a promising treatment [22], trials in adults were inconclusive [23, 24, 25], and approval was not granted for its use. Thus options for treatment reverted to general management strategies for chronic illness. We relied on feedback from young people to inform us regarding what was helpful in their management. The service has since expanded to several paediatricians and access to a 4-week self-management program run by the Victorian Paediatric Rehabilitation Service at the hospital.
A diagnosis of CFS is made following an extensive history, to confirm the presence of key symptoms, examination and routine investigations to exclude alternative diagnoses. These symptoms include PEM, unrefreshing sleep and cognitive symptoms as well as additional somatic symptoms [15]. Other conditions including school refusal, somatisation disorder, eating disorders, isolated significant depression or anxiety, connective tissue disorders, coeliac disease or endocrine disorders are specifically checked. An adolescent psychosocial (HEADSS) screen is also conducted where appropriate [26]. Passive standing test was not routinely performed initially. However, upon recognition of the association of orthostatic intolerance with ME/CFS this assessment was included [1].
Routine screening investigations included coeliac screen, thyroid function and antinuclear antibody. Serology for EBV or cytomegalovirus (CMV) is routinely assessed or if there was any likelihood of overseas or tropical infections or if the young person had been in areas where Ross River Virus, Q fever (Coxiella burnetti), Barmah forest virus were endemic, serology for exposure is also checked.
Following diagnosis, the young person is asked to: rate the most troublesome symptom/s that he/she would like help with; outline his/her aspirations prior to illness; describe current school attendance, interests, and previous participation in sport, the family situation and supports including parental work schedule, and means of transport to school or activities. The young person is provided with a brief explanation of our current knowledge, a plan for managing the most severe symptoms, and an outline of a management plan that the young person would devise.
The rationale for the management plan is to minimise the impact of chronic illness while accommodating the specific issues associated with CFS. As CFS affects the educational, physical, social and emotional aspects of their life, it is considered important to not neglect any of these areas. This should include some proactive social contact, academic input, physical activity and a commitment to attend something enjoyable outside of home on a regular basis. None of these activities is to be neglected but the proportion does not have to be equal. The plan needs to be sustainable for at least a month before it is reviewed. For example, some physical activity is required to prevent becoming so de-conditioned that they are unsure whether they are weak and fatigued because they are unwell or because muscles are not being used. Social contact is important to ensure that the social learning that occurs during adolescence (how to respond in different situations, what behaviour is acceptable and how to interpret different social situations and how to understand one’s peers) is not neglected. It can be very daunting later when it is expected that these skills have been acquired. Academic engagement is important so that they feel that their life chances have not been destroyed. The regular enjoyable activity outside of home is something that they have chosen to attend because it is ‘worth it’ and will not result in a prolonged recovery. It removes any prevarication regarding whether they feel well enough, whether they would cope or whether it would be easier not to go. Only if they are unable to move out of bed do they not attend. This hopefully prevents the reluctance to make decisions, to be adventurous or to be reliable.
In addition, young people generally have not had to learn to prioritise their activities during their teenage years but it is needed as developing adults. It is explained that they need to learn this much earlier than most and it is a very useful skill to acquire. Some activities, for example, attending school for an enjoyable subject could fulfil social, academic and enjoyable activities and also require some physical activity. If their important social network was outside of school then there needed to be an effort to engage with that group for a period of time that was manageable. If some young people felt that ‘life was not worth living’ if they could not play sport, as this was their main social connection, then adjustments could be made. They could be part of the team by ‘coming off the bench’ for a few minutes or not being required to actively train. They could be moved to a team position that did not require a lot of stamina. On the other hand, for some, physical activity may be a few activities of daily living spaced over the day, or once they are able to do some activity and have increased their strength, they often chose a variety of activities that they enjoy.
Their aspirations (prior to becoming unwell) play a key role in the decisions regarding their education. Attending school for set hours, rather than for specific subjects is difficult to sustain. Reduction in the school subject load to include subjects and teachers they liked, as well as subjects that are pre-requisites for what they want to do as a career is crucial. Trying to keep up with all subjects when only given minimal information is a source of unnecessary stress, and this rarely succeeds. A planned timetable ensures that the arrangements provide some consistency and predictability for the family (and for the teaching staff) and be manageable for the young person. If the symptoms are severe, the extent of ‘academic input’ may be reduced to reading about a hobby or reading a story that they are already familiar with.
It is explained to the young person that these consequences of illness can be more damaging than the illness itself and can occur with any chronic illness. Neglecting these areas creates significant hurdles to recovery such as: navigating social anxiety and social learning; entering the workforce without a potentially enjoyable, satisfying or more lucrative, less physically demanding job; needing to increase strength, or not having the confidence or resilience to know how they are able to manage their life. The young person is asked to estimate how they can balance these tasks within the bounds of the amount of energy available over the period of a week. The young people make those decisions over the subsequent few weeks and discuss their plan with their parents.
Only the most severe one or two symptoms are treated initially. Often treating one symptom such as sleep disturbance, and allowing them to take control of their life with the management plan reduces the severity of some of the other troublesome symptoms. Despite the prominent fatigue, malaise and concentration difficulties, the complaints of headache and sleep disturbance or dizziness and nausea due to orthostatic intolerance, can often be managed effectively.
Difficulties with sleep initiation, sleep phase shift, frequent waking and disturbing nightmares are actively managed with sleep hygiene techniques and melatonin or low dose tricyclic medications such as dothiepin or amitriptyline. Simple migraine prophylactic medications such as pizotifen or periactin are anecdotally effective in reducing the severity of headache. Simple measures such as increasing salt and fluid intake, including electrolyte drinks, and encouraging lower limb exercises and gentle exercise can assist with orthostatic intolerance. Similarly, muscle pain and fibromyalgia can be helped by reducing sleep disturbance and encouraging gentle exercise or physical therapy.
Residual difficulties with concentration, recognition of depression, persistent severe dysmenorrhoea associated with exacerbation of CFS symptoms, ongoing nausea, abdominal discomfort or persistent orthostatic symptoms are usually addressed after review and the implementation of the management plan.
A 6-week follow up appointment is usually scheduled for review of their plan and whether the logistics are sustainable. Residual symptoms are checked including whether the symptom management is appropriate. Any further queries from the young person are addressed. Once a decision had been made regarding the schedule for education, appropriate explanation, documentation, advocacy, extra support, special provision or special consideration is provided or requested. A specific education program to ensure maximum possible opportunity to participate is therefore implemented. Sometimes this requires a combination of Distance Education and school attendance for 1–2 subjects, or attendance for a few classes with visiting teacher assistance. If necessary, the minimum requirements are negotiated to ensure the year level is passed so that they can progress with their peers. Additional details regarding educational strategies used by the Visiting Teacher Service have been documented [27]. If adjustments to sport schedules are required, these are provided and coaches and staff are usually very accommodating once they understand the reasons for the requests.
Generally 3-monthly reviews are arranged to assess progress, educational issues, symptom management and review of goals. Young people are seen more frequently if necessary. Occasionally young people are followed up by a local paediatrician.
In addition, parents often need help navigating the difficult adolescent period and uncertainties regarding assisting with the tasks of adolescent development in the context a chronic illness that is generally not well understood. The developmental tasks (19) of adolescence may fail to progress during the illness and may need to be addressed during management, or time allowed for some catch up when the young person is well enough. Such tasks can be difficult for any parent to navigate but even more difficult when the young person is clearly unwell and not able to manage some simple activities of daily living.
These tasks include increasing sense of independence and responsibility for their actions, peer relationships, sexual identity and development, assessment of risk, sense of self-worth and hope for the future. Persistent dependence, uncertainty about what is required, social anxiety and withdrawal, extreme caution in making decisions, poor self-esteem and depression regarding the future can be the consequence of the limitations imposed by chronic illness. Parents are not sure if they should be defending, protecting and trusting the young person’s judgement or cajoling, setting limits and allowing the young person to make mistakes. Many parents put their life ‘on hold’ to care for the young person with the attendant complications for the whole family, and this often adds significant stressors. For many young people, doing some small chores that do not require much effort is important in order to be part of the family and reduce tensions with siblings.
For younger patients, there are concerns regarding persistent dependence on parents, and anxiety regarding the illness, such as concerns about what was actually wrong and whether there would be recovery. They worry about managing at school, as well as social anxiety when they are absent from their social network for some time. There may also be depression and a sense of helplessness and powerlessness, especially if some family members, the medical profession or teachers do not understand. In addition, the transition into adolescence and secondary school is exacerbated when they are not able to attend frequently enough to engage socially.
Feedback from young people regarding their management was sought on many occasions over the years and has been reported in detail [28]. This feedback modified management. Feedback affirmed that being believed by the clinician, family and school staff and feeling as if they had an advocate to help them navigate the education system were central to their overall ability to cope and their general well-being. Having a management framework within which they could organise their priorities was seen as key to feeling as if they could have some control over their life again. Of note, assistance with being able to continue with education was valued as important as their medical management. Continuing social engagement as part of their self-management was crucial for continuing social learning. For those where outpatient support has not been sufficient, there is now access to a 4-week intensive self-management program.
In 2012, the Victorian Paediatric Rehabilitation Service (VPRS) at the RCH in Melbourne commenced multidisciplinary management of adolescents with CFS. This followed a state government review of services available for young people with CFS, and the recognition that outpatient services required additional support and a more coordinated approach. A systematic review by Knight et al. [29], of the limited literature available on paediatric interventions, indicated some support for cognitive behaviour therapy (CBT) and limited support for multidisciplinary intervention. However, the quality of these studies, did not allow firm conclusions to be drawn.
Thus it was decided that the new program would have a CBT framework, be goal-focused and strongly encourage self-management. Following ongoing evaluation and feedback, it was noted that some aspects continued to work well, while others needed modification. With the implication that there is no known ‘cure’, there needed to be a change in approach from the typical rehabilitation aim of assisting with the reduction of suffering as the sole focus. Feedback from families and participants found this approach to be disempowering. This ensured that, rather than being viewed as an illness to be endured it could be a more hopeful, dynamic and positive process. Recovery was possible and at the very least, there could be an improvement in functioning and some participation in important stages of adolescent development.
In the early years of the program, there was minimal involvement of families in program sessions, with the focus solely on the young person and engaging them in self-management. There was some inflexibility and a more rigid approach where all participants were encouraged to engage in activity on non-program days with little individualization of the program. Often participants were too exhausted at the end of relatively long therapy days to convey to parents what they were keen to practise and how they needed to be supported at home. This resulted in confusion within families about plans and expectations on non-program days, repetition of the same information to multiple people and reduced understanding by parents of the clinical reasoning behind the program. This was an unfortunate approach and much was learnt from patients and families at this time. More flexible, individualised guidance in setting up a management plan was preferred. It allowed for flexibility, review and adjustment when progress occurred. It was noted that family involvement was required to improve participant engagement and successful carryover of effects after the program.
In addition, increasing recognition of the association of postural orthostatic tachycardia syndrome (POTS) in the referrals required a change in the focus of exercise therapy within the program. Cardiologists became an important part of the medical management alongside the CFS medical team.
The aim is to encourage ongoing, self-directed learning and management of the illness, so that participants and families have the strategies and confidence to reduce the chaos, uncertainty and loss that underpins living with CFS during adolescence. They are encouraged to re-engage in key areas of life that have been neglected or problematic.
The VPRS CFS Self-Management Program runs for 3 days per week, for a 4-week period and is located in an outpatient setting within the hospital. Four staff, an occupational therapist, a physiotherapist, an education consultant and a clinical psychologist provide interdisciplinary care. Each therapist covers 2 days of the 3-day program. They also meet weekly with referring doctors to discuss participant progress.
A typical day is runs from 9.30 am to 3 pm. Each participant identifies his or her own goals and these are used to establish a framework to work within over the 4 weeks. They continue to work with this framework after the program.
The program is structured around individual and group sessions. The structure of the sessions allows for key content to be explored and built on over the weeks. During the non-program days (two weekdays and the weekend) they are encouraged to practise and to implement what they have learned. Participants are encouraged to be open-minded and to consider new ways of looking at and living their life.
For many participants and families it is an enormous undertaking to attend the program. It varies how feasible it is to practise new skills on non-program days. For most, the opportunity to try out new activities and routines in a considered, modified way is attainable. For some, however, the goal is to engage during program days, learn the theory and skills within the three-day structure and have quiet days in between. Much of the practising then occurs post-program when they can spread their energy availability over a week at a less intense pace. This approach is flexible, individualised and sustainable as they learn self-management tools that continue well beyond the four-week program.
Participant inclusion criteria used by referring doctors from the CFS Outpatient Clinic is as follows:
10–18 years of age.
CFS is the primary diagnosis and the patient accepts this.
Display motivation to engage in the intensive nature of the program.
Enrolment in education.
Physically able to manage 3 days per week of engagement for 4 weeks without significantly worsening their symptoms as a typical program day requires participants to walk approximately 700 m to access the treatment areas from the hospital entrance.
Tried doctor-led outpatient guidance in the first instance.
Stable mental health
This assessment consists of a 45-min psychology assessment, 45-min education assessment and a combined 90-min occupational therapy and physiotherapy assessment. The patient attends the assessment with at least one parent or guardian present. In addition to detailed assessment about CFS, there is exploration of the young person’s motivation to participate in a group program setting and their attitudes and beliefs about CFS are recorded. This is to ensure a group program is a suitable ‘fit’ for the young person. The philosophy and structure of the intervention is explained and goal setting is completed.
We have also noted that if any of the above criteria are not met, the likelihood of positive engagement is poor. In particular, where motivation to participate is parent rather than patient led or if CFS is not the primary diagnosis, the group dynamic is affected.
It is clear that the intensive program is not suitable for all young people with CFS. Those who are unable to attend the program in person for all the required days without significant worsening of symptoms are not appropriate. These patients are encouraged to continue with the doctor-led outpatient guidance in conjunction with a physical therapist that can provide therapy in time frames and intensities that are a better fit for the patient.
Currently the program is moving towards offering pre-program conditioning and guidance to streamline the process of starting a program so that many months are not spent with the young person in limbo.
Outcome measures are completed at initial assessment, 6 weeks post-program and 6 months post-program. The current outcome measures are:
Canadian Occupational Performance Measure (COPM) [30]
Depression Anxiety Stress Scales (DASS) [31]
Physical measures—Day 1 sub maximal treadmill test and plank hold
School attendance
From 2012 to 2018, the psychological measure was the Beck Youth Inventories measure [32].
The VPRS therapy team meet post-assessment to discuss findings. Provided the patient meets inclusion criteria and the family are keen to participate, an offer is made to participate in an upcoming program. The wait list is usually 2–4 months. If either the family or the VPRS therapists do not feel the 4-week intensive program is an appropriate match for the family, alternatives in the community are explored. We have found that these alternative options are particularly appropriate in cases where families find it too difficult to be at the hospital for the required time due to work, sibling needs or their own health issues.
In addition, as several participants are in each program, every effort is made to match participants based on age, educational stage and likely group dynamic and, to a lesser extent, current function and engagement in life.
Program information is emailed to families soon after an offer is made. This information includes logistics as well as a proposed timetable so that families can forward plan. A blank activity record is also sent to be completed the week prior to the program so that the therapy team have a current record of how the participant is spending each day with regard to sleep, activity, social contact and study.
To give participants the smoothest transition to the program and ultimately an effective intervention, a VPRS therapist via telephone, or in person, conducts a pre-program readiness interview, in the 2 weeks prior to the program. The previously identified program goals are clarified and changed if requested. It has been noted that without adequate time to prepare mentally and physically for the program, it takes longer for participants to settle in and co-operate with the program’s agreed expectations.
Participants work as a group to learn and implement core functional activities of daily living into their weekly schedules. Topics covered include sleep hygiene, balancing activity, leisure, memory and concentration, diet, pacing and energy conservation and setback planning. Participants learn to formulate a weekly planner, where they plan a balanced week of both ‘need to do’ activities and ‘want to do’ activities. This is to ensure that they plan a manageable week in line with their current baselines of their CFS physical and mental capabilities. During the program, participants embark on an outing as a group in order to practise these concepts and strategies, as also planning and cooking a meal to do the same.
Goal setting sets the framework for the program. Goals are revisited regularly and progress tracked. Weekly individual goal review and progression sessions occur with the Physiotherapist and Occupational Therapist. Weekend planning and weekend review sessions, help to build skills of incorporating structure into to daily routines. These are group sessions and peer feedback is encouraged. In the planning sessions participants generate ideas and suggestions of what is helpful to include in weekends. A key feature of weekend planning is to include leisure activities that the young person has previously enjoyed or is keen to participate in. Weekends are also used for practising independence, perhaps in driving lessons with a parent, taking public transport or helping cook a meal. They are also important opportunities for achieving sleep routine consistency and pacing activity. They also provide an opportunity to practise challenging thoughts and to practise mindfulness and clear communication with family and friends.
Educational engagement is once again identified as the most significant part of life affected by CFS. The effects in a young person’s life when school attendance is limited or absent are devastating, affecting self-esteem and mood from social isolation and compromised learning outcomes. Prior to the program the education consultant liaises with participants’ school contacts to establish communication. It has been noted that the variability in school engagement prior to the program improves afterwards with schools taking a much greater interest in learning about CFS and how they can assist the young person to engage in school.
During the 4-week program, eight supervised group-learning sessions occur in the Education Institute Learning Space at the hospital where participants undertake private study and complete activities set by their school. They also apply memory and concentration techniques learnt during the program to assist with concentration, pacing, homework and study management. Four individual consultations provide strategies and recommendations for support upon returning to school. These are discussed with the student, family and school personnel. The education consultant continues to support participants and schools well beyond the program to assist with challenges that inevitably arise.
The participants receive group psychology sessions weekly wherein they learn the following: (1) understanding how CBT can help; (2) monitoring and challenging thoughts; (3) understanding emotions, stress, anxiety and mood; (4) relaxation strategies for stress and anxiety; (5) coping strategies for low mood; (6) building motivation and (7) engaging in assertive communication skills and family conflict management. In addition to this, they receive individual psychological reviews each week. This builds on the group session work and focuses on assisting with interventions for the interaction between CFS symptoms and mental health.
The physical therapy component of the program consists of individualised goal setting and program planning based on the initial assessment. It is refined and revised as the program progresses. There is a group theory component as part of some sessions, covering topics such as chronic pain, Postural Orthostatic Tachycardia Syndrome (POTS) and progressing movement and exercise safely in order to minimise the likelihood of post-exertional malaise.
Post-exertional malaise (exhaustion and malaise after activities, either physical or mental, that previously were tolerated well) is a hallmark feature of CFS. It greatly reduces young people’s ability to participate in physical activity as previously enjoyed.
Early in the program, participants begin an individualised movement program, delivered in either an individual or small group setting. This starts with gentle stretching and strengthening and for those where it is appropriate, short duration cardio activity. Participants and families are actively involved in all decisions regarding types of reconditioning and pathways of progression.
Participants are given a choice of a range of approaches to movement and re-conditioning. They are encouraged to choose activities they have previously enjoyed and would like to incorporate such as shooting goals in basketball outside for a set time with another participant, or completing movements on the pilates reformer machine. Movement tasks are incorporated into weekly plans and are aimed at being meaningful in the young person’s life such as walking 5 min to the local shops to buy ingredients to bake or taking the family pet for a walk around the block. Some participants much prefer this approach while others are more aligned with an athlete rehabilitation approach with more conventional exercise. Careful consideration and monitoring is applied to all patients.
In recent years, a high number of participants have a diagnosis of POTS alongside CFS. These patients need very specific management in physical therapy sessions. POTS symptoms come on with standing and are relieved when becoming supine. Heart rate increases by 40 beats per minute or more and there can be a blood pressure change. Associated autonomic symptoms include sweating and blueness/swelling in the feet. There are often palpitations, fatigue, exercise intolerance, nausea, near syncope, syncope, ‘brain fog’ and chronic pain. Doctors may prescribe medications and the exercise component of treatment is critical.
The physical therapy for these patients has four components:
Psychology support in POTS patients appears to be very helpful, in particular assisting patients coping with the significant heart rate increases and adrenaline released on upright standing. These physical symptoms mimicking anxiety can be confusing for patients, particularly those where anxiety has not previously been present.
Pain is a common symptom in CFS. This can be headaches, joint pain or abdominal pain. Very often these pains do not respond to medication. Sometimes pain is present due to long periods of physical inactivity. For other patients the protective function of pain is no longer serving that purpose and patients may develop a central sensitisation.
The approach taken in the program in the first instance is to ascertain a patient’s concept of pain. Once this has been established, using questioning and simple quizzes, a pain curriculum is developed. While some initial pain theory is covered in the group setting, further exploration of possible contributing factors to the young person’s pain is explored on an individual basis in both physiotherapy and clinical psychology sessions. The treatment approach is based on the work of Lorimer Moseley and David Butler of the Neuro Orthopaedic Institute Australasia [33]. Its focus is on understanding chronic pain as one of many outputs of the brain in response to a range of inputs. It seeks to establish the interactions between the mind, the body and the environment and the complex interaction with the nervous system that occurs.
Patients are reviewed at 6 weeks and 6 months post-program. There is weekly email or telephone contact in the first 6 weeks post-program with a face-to-face review at 6 weeks. Patients and families are able to access ongoing support from the team for advice and direction. There is limited scope to offer therapist face to face sessions beyond the program outside of the scheduled reviews. All patients return to the care of their referring paediatrician post-program.
Feedback is regularly sought from participants—both informally during the program and at follow-up reviews as well as written. More formal feedback has been obtained intermittently. While patients describe learning about pacing, thought challenging and educational tips as being helpful, they overwhelmingly describe meeting other young people in a similar position and feeling like they belong and are supported, as being the most valued part of the program. This often results in participants forming close bonds with each other and many friendships have continued over the years.
As the program is resource intense, and many young people are successfully managed in outpatients, it has been important to attempt to identify which ones need the more concentrated input and access to the multidisciplinary team and when the ideal time is to refer. Approximately 25 complete the program each year. It has been noted that the proportion of males (26%) to females referred to the program reflects the proportion noted over many years of close to 1:3 [10, 15]. However, there was a higher proportion than expected from rural areas. In Victoria, 23% of the population live in the non-metropolitan area, but 42% of participants came from non-metropolitan areas (chi-square 9.19, p < 0.005). Rural regions have less access to local paediatricians, additional educational services such as visiting teachers and specialised allied health support is scarce. There were higher proportions of young people participating in the program during year 9 (28%) and year 11 (24%) compared with the other years between grade 6 and year 12. The year 11 students are in their penultimate year of school prior to university entrance exams and year 9 is recognised as a turbulent year in adolescent social development, and the year after which some decisions on subject choices for future careers need to be made. Hence educational issues were a significant stimulus for the referral.
Of note, 44% admitted to >4 h of screen time (phone, computer, television) per day. This would generally be considered excessive but did reflect those who had been unable to increase their school attendance and who had become more socially isolated. It did also become an increasing problem when gaming was involved as this tended to occur late at night and contribute to day/night reversal of sleep cycle and increasing loss of time from school. A higher proportion of males than females saw this as their only social outlet.
POTS was diagnosed in 78% [1, 15] either coinciding with the onset of CFS following an infection, occurring associated with hyperflexibility and having associated CFS symptoms, or apparently developing after the prolonged bed rest or limited activity associated with their CFS. During recent years this has become better recognised, documented and managed but its management has occupied an increasing proportion of referrals. It has generally been poorly recognised by paediatricians and many allied health providers are unfamiliar with how to help especially in the context of the limited stamina of CFS.
From outpatients, it was noted that early referrals to the program were often not appropriate. Young people and their families needed time to understand the illness, develop some confidence that they could plan an appropriate schedule and sustain it, and have an opportunity to improve some of the more troublesome symptoms, such as sleep disturbance and headache. Frequently simple measures for managing POTS or if these were not sufficient, referral to an appropriate cardiologist was important to improve control. Crucially, having a sustainable school program with understanding from school staff and their peers was central to management. Families also needed time to adjust their schedules to a more balanced and sustainable form to assist the young person.
Hence, those who, although they were attending school, struggled with their weekly schedule and balancing their daily activities such as exercise, sleep, school work and social activities needed additional help. Occasionally the family social circumstances made it difficult to attend school regularly. Teachers who were unsympathetic or peers who did not understand contributed to difficulties at school.
Those who were not attending or managing school work, were often very anxious and increasing screen time contributed to further reduction in school attendance. Many found adjusting to avoiding a boom/bust cycle where they would do too much and then take a long time to recover and be very despondent or angry at these restrictions was a significant problem. They felt they needed more support in planning and adapting.
Only a small proportion of the patients seen in the outpatient clinic are referred to the program. As per the feedback over many years, ability to construct a self-management program and guidance to adapt and sustain progress was highly valued. In addition, assistance with planning sustainable education with school liaison was cited as helpful in allowing them to remain socially engaged and hope that their aspirations were achievable. In essence those referred and reporting benefit from the program where those who needed more support in planning their self-management, more intensive assistance for their POTS but most importantly assistance with their education.
It is clear that as the staff have become more familiar with the illness, and have received feedback that they have incorporated into the program, that the key features that are valued are identical to the feedback the outpatient program has received over the years [10, 28]. Access to physiotherapy especially for the specific management of POTS would make outpatient management easier. An education consultant to liaise with schools is often more acceptable for the school than being approached by a paediatrician, although usually medical documentation and recommendations are required by educational authorities. In addition, the input from a psychologist who has an understanding of the illness and the feelings of anxiety that occurs with POTS as well as the impact chronic illness and disrupted education has on the social and emotional development of a young person can be very helpful. Crucially it is the feeling that they are understood and believed and that they are not the only ones with the illness. Regaining some control over their lives by how they can manage the illness is highly valued.
The majority of young people can be managed in an outpatient setting and availability of some of the expertise such as physiotherapy and an educational consultant would greatly assist in management in that setting. This would then free the more intensive self-management program for young people who could not access allied health, needed more guidance for planning or who needed help for family understanding, cooperation with school or help to understand the mental health issues that may accompany chronic illness and social isolation. The acceptance and linking with other young people with an illness that is poorly understood and accepted, has been invaluable.
The program at RCH will continue in its current form of individualised patient plans within a group setting. Involvement of families in key sessions alongside participants has shown to be the most effective way to encourage carryover of improved engagement in life post-program.
Ongoing feedback from young people and their families as well as research findings continue to inform both the outpatient management and the intensive VPRS program. Increasing interest and understanding from paediatricians and allied health staff can only help by reducing the frustration, delay, misunderstanding and access to services for these young people. Assisting them with symptom management, guidance in devising and implementing a self-management plan and assistance in navigating the education system has reportedly been highly valued. Having the added assistance of a multidisciplinary team and intensive program when aspects of this management were not sufficient has been highly valued.
The frank feedback from the young people regarding their management has been greatly appreciated. The input and support from the team members in the VPRS and the support of A/Prof Adam Scheinberg in setting up and maintaining the program is gratefully acknowledged. There was no external funding for this report.
The authors declare no conflict of interest.
Considered the second most commonly performed operation after cesarean section worldwide, hysterectomy may be classified as abdominal (laparotomy, laparoscopy, or robotic assistance) and vaginal (via an incision through the superior part of the vagina).
The most common indications for hysterectomy are benign conditions such as uterine fibroids, endometriosis, genital prolapse, pelvic pain, heavy menstrual bleeding, but the technique is also used for gynecological malignancy (usually ovarian, uterine, or cervical) and risk-reducing surgery (in cases of BRCA 1 or 2 mutations or Lynch syndrome) [1, 2, 3, 4].
Actually, there are three types of hysterectomy—total hysterectomy (the uterus and cervix are removed), subtotal or partial hysterectomy (the uterus is removed, but the cervix is left in place), and total hysterectomy with bilateral salpingo-oophorectomy (uterus, fallopian tubes, ovaries, and cervix are removed) [1, 2, 3, 4]. The term radical hysterectomy (removal of the uterus, cervix, parametrium, vaginal cuff, and fallopian tubes) is used to describe a wide range of procedures universally applicable to cervical cancer. However, the degree of radicality clearly depends on preoperative estimation of tumor location, surgical margins and the risk of occult lymphatic spread. Moreover, the ovaries may or may not be removed according to the patient age [1, 2, 3, 4]. In addition, supracervical hysterectomy is sometimes preferred to diminish the intraoperative complications and surgical times, as well as to limit the possibility of lower urinary tract issues and maintain normal sexual function [1, 2, 3, 4].
The best route for hysterectomy is multifactorial, depending not only on the surgeon’s skills and patient safety (minimally invasive procedures as vaginal, laparoscopic, laparoscopic-assisted, and robotic-assisted hysterectomies) but also on economic reasons [1, 2, 3, 4].
Hemorrhage after hysterectomy is recognized as an occasional life-threatening complication in modern gynecological surgery, assuming appropriate medical and surgical management [2, 3, 4, 5, 6, 7, 8, 9].
Classified as “reactionary” (postoperative bleeding within the first 24 hours following surgery) and secondary (bleeding occurring in the interval 3–22 days after surgery), unexpected hemorrhage may arise regardless of the route or subtype of hysterectomy [5, 6, 9]. Early recognition and prompt intervention (reoperation or arterial embolization) to arrest bleeding are essential strategies for the suitable outcome of the patient [2, 3, 4, 5, 6, 7, 8, 9, 10].
While the role of risk factors for “reactionary” hemorrhage is emerging and critical for a correct assessment of the patient, operative laparoscopy is still ideal to treat hemorrhage after vaginal hysterectomy, laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparotomy being necessary only in selected cases [2, 3, 4, 6, 9].
Secondary hemorrhage presents with varying degrees of severity and tends to be more common after laparoscopic hysterectomy, especially total laparoscopic hysterectomy than after the other hysterectomy approaches [5, 9]. Factors potentially responsible are vaginal vault infection, vault hematoma, a poor surgical technique including excessive thermal injury by electrocoagulation, and early resumption of physical activity, large uterus size, excessive use of an energy source for the uterine artery, and culdotomy [2, 3, 4, 5, 7, 9, 10].
Ultimately, the management of secondary hemorrhage is challenging and involves diverse approaches based on the exact cause of bleeding, comprising vaginal packing with or without vault suturing, laparoscopic coagulation of the uterine artery if the source of bleeding could not be identified vaginally or arterial embolization [6, 9, 10].
Because of elective gynecologic surgery, we encourage selective patients to donate their own blood before surgery [6, 11]. Several definitions are actually used:
autologous blood transfusion, when is done with the patient’s own blood; blood is stored and can be transfused during surgery;
homologous transfusion or transfusion from another woman;
parachute pack or umbrella pack is a useful tool for pelvic bleeding after pelvic exenteration;
peanut dissector; this tool is indicated for blunt pressure dissection of small places;
total blood volume; estimated blood volume of total body weight is 8% or 4.5–5.0 liters in the average women. When intraoperative blood loss exceeds 15% of the blood volume, blood transfusion must be taken into consideration in combating hypovolemic shock. About 15% of an adult blood volume can be calculated by amplification a patient’s weight in kg 10 times. The usual method of performing abdominal hysterectomy involved the use of clamps or forceps on vessels.
The present chapter will give an overview on different aspects of bleeding after hysterectomy such as incidence rate, risk factors, mechanisms, and management techniques aiming to expand our knowledge and skills in recognizing and treating this unexpected potentially serious complication. Furthermore, we intend to offer a guide toward standardizing treatment practice across bleeding issues following hysterectomy considering clear recommendations and algorithms.
Postoperative hemorrhage represents a significant potential complication of contemporary gynecological surgery. Despite normal hemostasis, appropriate/suitable surgical technique and close monitoring, postoperative bleeding may occur, leading to the different clinical and operative scenarios and challenging even the most experienced operative team [2, 3, 4, 9, 11, 12].
Based on their timing to surgery, two main subtypes of postoperative hemorrhage are actually recognized [5, 6, 7, 8, 9]:
Although the incidence of postoperative hemorrhage basically varies according to surgery, the difference between abdominal, laparoscopic, and vaginal hysterectomy remains statistically insignificant [5, 6, 7]. Indeed, some authors postulate that postoperative bleeding occurs more frequently after abdominal and laparoscopic than after vaginal hysterectomy, but overall, the incidence of hemorrhagic events after a hysterectomy varies from 0.2 to 3.1%, irrespective of surgical route [5, 6, 7, 8, 10, 13, 14].
On the other hand, the true frequency of delayed bleeding complications is still unknown, although the consequences can be particularly significant in women undergoing outpatient surgery [5, 6, 7, 8, 10, 13, 14]. Paul et al. reported an overall cumulative incidence of secondary hemorrhage after a total laparoscopic hysterectomy of 1.3% [5]. Although secondary hemorrhage is rare, it is more often reported after total laparoscopic hysterectomy than after other hysterectomy approaches [5, 6, 7, 8, 10, 13, 14].
Table 1 summarizes data on the incidence of postoperative hemorrhage reported by several authors.
Authors | Type of study, no of cases | Incidence postoperative hemorrhage |
---|---|---|
Makinen et al. [15] |
|
|
Wilke et al. [13] |
|
|
Holub and Jabor [7] |
|
|
Erian et al. [6] | 719 patients between November 1990 and March 2007: 476 VH, 243 LH |
|
Paul et al. [5] |
|
|
Incidence of postoperative hemorrhage in gynecological surgery.*
AH, abdominal hysterectomy; LH, laparoscopic hysterectomy; VH, vaginal hysterectomy; L-AVH, laparoscopic-assisted vaginal hysterectomy.
Hemorrhage is responsible for about half of the postoperative complications following gynecological surgery, ranging from persistent venous oozing to massive blood loss from injury to retroperitoneal vessels [5, 6, 7, 12, 13].
Main bleeding sites comprise the anterior abdominal wall (both the suprapubic and the umbilical incision), the vaginal cuff (after laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy), and intraabdominal bleeding. Abdominal wall vessel injury occurs with increasing frequency, as the practice of laparoscopic surgery becomes wider and trocars become sharper [2, 3, 4, 7, 9].
The source of bleeding in secondary hemorrhage can be the uterine vessels or descending cervical/vaginal vessels; occasionally, uterine artery pseudoaneurysm can cause delayed heavy vaginal bleeding after laparoscopic hysterectomy [2, 3, 4, 7, 9]; additionally, the technique of vaginal vault closure may also contribute to the occurrence of secondary hemorrhage [5, 9].
Postoperative hemorrhage can result from failure to control vascular injury during surgery. Accurate clamp placement, gentle handling of tissues, and the accuracy of dissection are all important and contribute to maximum efficiency with minimum blood loss and minimum tissue damage when abdominal hysterectomy is performed [9].
The electrosurgical instrument can be used for a precise incision of the abdominal wall with minimal tissue injury. By holding the electrode close to the tissue or touching the metal clamp and pressing the coagulation button, superficial coagulation can be achieved [2, 3, 4, 9].
Intra- and post-operative bleeding generally develops in younger women or those with a more vascular pelvis who underwent a hysterectomy, especially laparoscopic hysterectomy in the presence of fibroids [6, 16].
Possible rationales for secondary hemorrhage comprise a bleeding vessel missed at the end of the procedure, effects of pneumoperitoneum, Trendelenburg position, low intraoperative pressure, wearing off the effect of vasopressin, subacute infection, postoperative analgesia, as well as bleeding disorders [2, 3, 4, 5, 7, 9].
Other potential factors accounting for delayed postsurgical bleeding are vaginal vault infection, vault hematoma, poor surgical technique with excessive thermal injury by electrocoagulation, and early resumption of physical activity [5, 7, 9]. A large-sized uterus, high vascularity, large-sized vessels, excessive use of an energy source for the uterine artery, and culdotomy also play a role in this hemorrhagic event [5, 7, 9].
Most of the complications during or after hysterectomy are preventable or treatable. Other complications may exist as medical conditions before hysterectomy but are worsened during surgery, especially if not managed as part of holistic woman’s care.
Complications after surgery include [2, 3, 4, 9, 12]:
In Romania, the mortality rate following a hysterectomy is very low.
Contemporary management of surgical interventions includes postoperative bleeding and the possibility of blood transfusion with risks of HIV transmission (in 1.9 million cases), the transmission of hepatitis B (one in every 180.000 cases), or a febrile reaction to transfusion (1% cases) [2]. Most experts recommend acute normovolemic hemodilution and cell salvage in women undergoing hysterectomy section who will not accept blood products.
Hypovolemic shock can occur after major bleeding as a direct result of uncontrolled hemorrhage. Depending on the total blood volume lost, hypovolemic shock may be divided into four classes: I (< 75 mL or 15%), II (750–1500 mL, or 15–30%), III (1500–2000 mL or 30–40%) and IV (>2000 mL or > 40%) [6].
The clinical manifestations of class I hypovolemia are not measurable and compensatory mechanisms restore plasma volume within a day. In class II hypovolemia, tachycardia is the most frequent clinical finding as a result of inadequate circulatory volume. The distinction between class I and II hypovolemic shock is made by recording blood pressure and pulse in the standing, sitting, or reclining position. Postural hypotension is observed as result of cardiac failure. Compensatory mechanisms begin to fail with the class III hypovolemic shock. This results in an increase in the arterial and venous oxygen difference with classic signs including worked tachycardia, tachypnea, oliguria, and cold skin. With the class IV hypovolemic shock, a patient’s survival depends on rapid transfusion of blood and immediate surgical intervention before cardiovascular collapse and death or organ system failure.
After initial resuscitative measures are instituted, it is highly recommended for patients to be carried out in a critical care unit. Use of sympathomimetic agents after sufficient hydration and vasodilator is normally preferred in the management of patients with hemorrhagic shock who have arterial pressure higher than 70 mm Hg.
Once restoration of the intravascular volume has been completed, it is important to reassess the patient’s response to blood transfusion when managing women with severe blood loss, especially in those patients who have pulmonary edema, myocardial infarction, or congestive heart failure [12].
Transfusion for patients with hemoglobin of 8–10 mg/dL is no longer recommended.
When major surgery is anticipated and transfusion is massive, platelets in addition to packed cell transfusion are required. It is recommended that cryoprecipitate be reserved for patients with deficiencies in von Willebrand factor, factor VIII, and fibrinogen factor XIII.
Recognized as an uncommon complication of hysterectomy, postoperative hemorrhage represents a true challenge in routine practice [8]; irrespective of the procedure, a close follow-up of the patient in a high-dependency unit is indicated in order to exclude recurrence of bleeding [6, 7].
The key to successful management is timely intervention meaning prompt diagnosis, urgent resuscitation if necessary and rapid decision for either arterial embolization or reoperation according to the severity of bleeding and the hemodynamic stability of the patient. Both techniques are highly effective to control bleeding; nevertheless, if the patient is hemodynamically unstable or of the interval since surgery is under 24 hours suggesting rapid hemorrhage, the emergency return to the operating theater to arrest the bleeding is preferred [6, 7, 9].
Current options for managing hemorrhage include [6, 7, 9]:
every patient should be carefully monitored postoperatively for signs of bleeding (hypotension, tachycardia, tachypnea, abdominal distension);
ultrasound can confirm intraperitoneal bleeding; more ways to determine intraabdominal hemorrhage include abdominal and pelvic CT scan; a routine coagulation profile should be done immediately for the patient with a rapid pulse, low blood pressure, and/or low urine output. The surgeon must take charge of the problem and execute the technical steps necessary to treat hemorrhagic shock in the operating room. Intraperitoneal bleeding can be hidden by incisional pain and analgesic medications. Despite adequate dissection, a small vessel may bleed or the suture may cut through tissue. Skeletonized vessels and small sutures should be used for significantly reducing the incidence of postoperative hemorrhage. Venous bleeding can be more life-threatening than arterial hemorrhage which can be clearly seen and controlled with fast small sutures or clamps.
the presence of unexpected drop in hematocrit or hemoglobin postoperatively.
A simplified algorithm to describe steps after gynecological surgery and potential post-surgery bleeding is provided in Figure 1.
A simplified algorithm of post-surgery bleeding approach.
A closer look at the holistic management of postoperative blood should also underpin the following [9]:
to assess blood value and coagulation mechanisms;
to identify changes in the coagulation components, and to initiate replacement therapy in order to achieve adequate hemostasis. In assessing the patient’s coagulation status, it is very important to avoid such a situation known as the trauma triad of death consisting of—hypothermia, metabolic acidosis, and coagulopathy. In some patients with benign disease, blood transfusion is rarely indicated. Experience has shown that blood transfusion may be significant in women with malignant disease;
to establish the therapeutic strategy by measuring the level of prothrombin time < 14 sec, activated partial thromboplastin time (aptt) < 40 sec, fibrinogen >100 mg/dL, platelets >80 × 103 mL.
In hemodynamically unstable women (rapid pulse, falling blood pressure, with or without renal impairment) or if the bleeding occurs shortly in post-surgery (the so-called reactionary hemorrhage), it is desirable to return to the operating room [5, 6, 7, 8, 9].
A preoperative abdominal and pelvic ultrasound or CT scan is routinely required to visualize the source of bleeding as being intra- or retro-peritoneal, as well as adequate local examination without or under anesthesia. Moreover, the operative procedure should be mentally revised to identify any potential bleeding issue [9].
Surgical revision for postoperative bleeding may be performed transvaginally, laparoscopically, or both [5, 6, 7, 8, 9, 13, 14].
Postoperative hemorrhage from the vaginal vault recurrently originates from the vaginal artery in the lateral vaginal fornix or from one of its branches, since the lateral vaginal angle which includes the vaginal artery may not be accurately protected or turn into disligated [9, 13, 14]. Excessive vaginal bleeding needs to be objectively measured; since the vagina is a distensible organ, clots obstructing the vaginal introitus may lead to a large amount of blood accumulating and distending the vagina, subsequently covering the true significance of hemorrhage [9, 13, 14]. Vaginal bleeding can be controlled by clamping and ligating the bleeding point as well as by delayed-absorbable transfixion suturing of the vaginal mucosa and paravaginal tissue [9, 13, 14]. If such techniques are not enough or bleeding vessels have retracted, other tactics should be intended [8].
When no noticeable vaginal source, bleeding after abdominal or vaginal hysterectomy is traditionally treated by laparotomy or laparoscopy [7, 9]. While laparotomy is recommended in cases of intraperitoneal bleeding or unsuccessful conservative transvaginal treatment, operative laparoscopy is clearly indicated if the source of bleeding cannot be identified by the means of vaginal examination and/or if an intraabdominal bleeding source is suspected [7, 9, 13].
Post-surgery bleeding requires laparotomy in two situations.
Firstly, if the surgical hemostasis cannot be achieved transvaginally, laparotomy may be necessary [9].
Secondly, if the patient underwent an abdominal hysterectomy, the incision should be reopened, succeeding the following steps (i) clots and blood evacuation from the abdomen and pelvic area; (ii) searching of the potential bleeding sites, commencing with the most expected places; (iii) ligating, suturing, or clipping of the identified bleeding sites; (iv) verifying the ureteral integrity as high risk of ureteral damage during reoperation; and (v) closing second time after a completely dry abdomen and pelvis [9].
The laparoscopic approach to postoperative bleeding following laparoscopic hysterectomy, vaginal hysterectomy, or laparoscopic-assisted vaginal hysterectomy is an attractive alternative to the abdominal surgical approach in the majority of patients [6, 7, 9, 13]. The procedure can be used to adequately evaluate the pelvis and the abdominal wall, which is occasionally the source of hemorrhage after laparoscopic hysterectomy. Moreover, whether the bleeding is from the abdominal wall, the surgical pedicles, or the vaginal cuff, it can be managed laparoscopically [8, 9]. Evidently, hemostasis can be more easily obtained in laparoscopic surgery because of magnification, close inspection, routine use of suction irrigation, and bipolar coagulation [7, 9]. Besides, bipolar coagulation, a Foley catheter introduced in the port-site bleeding, or a collagen-fibrin agent can be used to achieve local hemostasis during laparoscopy [7, 9].
Following laparoscopic irrigation/suction using Ringer’s solution to clear the operative field, a combination of laparoscopic suturing using absorbable suture material and laparoscopic bipolar coagulation is commonly recommended [6, 8, 9]. Also, electrosurgery is effective in controlling bleeding during laparoscopic surgery. Furthermore, different forms of fibrin adhesive are tested in gynecologic open surgery in order to stop oozing hemorrhages after primary hemostatic treatment with a high efficacy rate (98%) [6]. Holub and Kliment reported successful treatment of hemorrhage from damaged tissue near important pelvic structures using the laparoscope to apply collagen fleece combined with fibrin glue [7, 17].
To avoid further risk of injury to the abdominal wall and to improve the recovery time from surgery,
Conversely, if the patient is reasonably stable and there is not abrupt early bleeding (based on the volume of blood in the abdomen or retroperitoneal space as estimated by ultrasound and the time from surgery), it seems realistic to try to identify the bleeding artery and embolize it by transcatheter interventional radiological techniques [2, 3, 4, 9, 10].
Arterial embolization remains an important minimally invasive option for the management of delayed postoperative hemorrhage [2, 3, 4, 8, 9, 18]. Transcatheter arterial embolization has been shown to be an effective tool for the management of postoperative hemorrhage after gynecologic laparoscopy, but also after abdominal and vaginal hysterectomy [8, 9]. Selective angiographic arterial embolization is a quite simple and safe procedure with a clinical success rate up to 90% in routine practice and usually a low complication rate less than 10%, including a mild postembolization syndrome with pain, fever, high leucocyte count related to vascular thrombosis and tissue necrosis [8, 9]. Bladder necrosis, vesicovaginal fistula, neuropathies as well as renal toxicity are uncommon, isolated side effects [9].
Arterial embolization technique comprises the following main steps—(i) identification of the site of bleeding by angiofluoroscopy if more than 2–3 mL/min bleeding rate; (ii) percutaneous catheterization of the femoral artery or, uncommonly, brachial artery under local anesthesia with retrograde direct access to the hypogastric artery; (iii) canulation of the hypogastric artery or specific collateral vessel if appropriate; (iv) injection of the embolization material under angiographic observation (metal coins, autologous clot, small pieces of gelfoam, small silastic spheres, subcutaneous tissue, or other hemostatic materials; (v) repeat angiography to demonstrate the occlusion of the bleeding vessel; (vi) remove of the catheter followed by careful monitoring for further bleeding [8, 9, 10].
Although second surgery is often the initial choice for postoperative hemorrhage, for a patient who is hemodynamically stable but is experiencing postoperative hemorrhage, transcatheter arterial embolization is a welcome alternative to a second surgery [8, 9]. However, if rapid access to interventional radiology is not available or if transcatheter arterial embolization is unsuccessful, laparoscopy can still be considered [8, 9]. Besides, a potential advantage of surgical management of postoperative hemorrhage over transcatheter arterial embolization is the ability to evacuate the hemoperitoneum, which may decrease postoperative pain, the risk of infection, and the risk of ileus [8, 9].
It is typical to expect some bleeding after hysterectomy in the 6–8 weeks following the procedure; the discharge may be red, brown, or pink. Bleeding should steadily decrease in the days and weeks following the surgery and should never be excessive at any point of recovery [18]. The exception is menstruation in women who have undergone a subtotal hysterectomy [18, 19]. In case of bleeding after hysterectomy, it is more likely to be of some pathologic cause instead of menstruation which needs to be ruled out [19].
However, a sudden and significant increase in bleeding during recovery should be considered abnormal. Points of concern comprise but are not limited to—bright red vaginal bleeding (indicating active bleed), temperature over 100.4°F, severe nausea or vomiting, increasing pelvic pain, a local complication such as redness, swelling, or drainage at the incision site as well as difficulty in urinating or pain with urination suggesting either an infection or a neurogenic bladder [18].
Delayed vaginal hemorrhage after laparoscopic supracervical hysterectomy usually requires emergent reoperation. Several studies have described continued cyclical bleeding from the cervical stump after supracervical hysterectomy in 0–25% of cases [20].
Effective interventions addressing hemorrhage after hysterectomy are needed to reduce women’s mortality worldwide.
Prior to hysterectomy, these women should be offered specific counseling and have a prospective plan for the management of their disease, developed by gynecologists of how their condition and hysterectomy interact. Prehysterectomy counseling services starting for all women planning this surgical intervention are a key part of hospital services and should be an integral part of the local health services network. They could be provided by general practitioners or specialist clinicians or surgeons, all of whom should be suitably trained or may require different management or specialized services before hysterectomy. There are special circumstances as congenital or acquired coagulation disorders that should be considered to evaluate by a thorough history and lab tests.
Professional interpretation services for women who do not speak English.
It is not clear how much the specific medical terminology is conveyed to the patient. Healthcare providers have to invest in technology, security, specialists, and translators to ensure healthcare becomes world-class. Medical tourism is growing each year. Romania provides the highest quality healthcare at the lowest price. Also, the cost of hysterectomy in Romania is lower than the same treatment in UK or UE. In developed countries as the USA, UE countries or Canada patients have to wait a long time for major surgeries. The cost involved in treating a patient depends upon factors like—type of hysterectomy needed, hospital and physician selected for it, and duration of staying.
Communication and referrals among professionals.
Good communication among professionals is essential. Referral between specialties involved should be rapid. They can use a variety of communication methods including—mobile phone, email, fax, Whatsapp, Instagram, Tik Tok, Facebook, etc. In many cases, junior trainees in the front line did not have proper support and need to have clear guidelines about when to seek senior help.
Women with serious medical conditions
They require immediate and appropriate multidisciplinary specialist care; women will require referral to tertiary or specialist medical centers for their preexisting medical or mental conditions before hysterectomy. Conditions that require prehysterectomy counseling and advice include—epilepsy, diabetes, asthma, congenital or known acquired cardiac disease, autoimmune disorders, renal and liver disease, obesity (BMI > 30), severe mental illness, or psychiatric conditions that require a change of medication, HIV infection. Women with potential serious underlying preexisting medical on mental health conditions should be immediately referred to appropriate specialist centers of expertise as soon as their symptoms develop.
Clinical training
All clinical staff must undertake regular training for the identification and management of serious disease conditions or potential emergencies or signs and symptoms of potentially life-threatening conditions, circulatory failure, severe hypertension or major hemorrhage, pyrexia >38°C, tachycardia >100 bpm, breathlessness. The local clinicians may be excellent at the management of severely ill women but must also accept written, documented, and audited courses. There should be a well-trained team of doctors for recording and charting investigations performed, obtaining quick results, ensuring that abnormal results are followed up promptly and have resulted in a better outcome.
Identifying and managing very sick women with critical illness before, during or after hysterectomy
In very acute situations, a team approach can be very healthful. The management of patients with an acute severe illness with circulatory failure, arterial hypertension, and major hemorrhage requires a team approach and help from the anesthetic and critical care services. There are some healthcare professionals who failed to manage crisis situations outside their immediate area of expertise; therefore, it is crucial to recognize their limitations and to know when and whom to call for another opinion once the patient was admitted to the hospital.
Coagulation factors, hematocrit, serum calcium, glucose, and electrolytes could be assessed every 120 minutes or after 10 U of transfusion; these lab tests are very helpful for the diagnosis of postoperative bleeding.
RCOG guidelines of the responsibilities of the consultant on call should be followed.
Bilateral hypogastric artery ligation can reduce blood loss to a minimum during hysterectomy [9].
Hypotensive anesthesia is also a safe and effective technique in reducing the circulation to the operative field [9].
Serious incident and women death reporting
Health professionals, senior or junior, must recognize an act on the signs and symptoms of potentially life-threatening conditions.
The evaluation of such a report must include clinicians from relevant disciplines (including anesthetics) who were not involved with the deaths. This report is recommended to be a requirement in the future.
The identification and act on women’s death should be reviewed as a serious incident and disseminated to all health professionals, junior or senior. Women’s deaths are generally underreported because of incorrect classification of cause.
Fatal hemorrhage can result from laceration of the external iliac vein or the hypogastric vein where they join together which are at risk of injury when the surgeon dissects between the distal common iliac artery, the psoas muscle, and the area of lumbosacral nerve trunks [9]. These vessels cannot be clamped and ligated with clips or sutures [9].
Dissection around the aorta and vena cava done with inadequate exposure performed in order to remove lymph nodes around them can result in serious hemorrhage. Bleeding usually can be avoided by placing a finger over the laceration and a vascular needle is used to close the laceration from side to side. The same technique may be used for common and external iliac veins [9].
Also, bleeding can occur by dissecting pararectal space and presacral space as well as obturator fossa [9].
Pathology
Patient death autopsy must be improved and require more expertise.
In Romania, the number of women death after hysterectomy (death rate) is very small and many of the autopsies reviewed were considered adequate. When an autopsy is needed, the body can be taken to another area for more expert examination. Despite evaluation by many examiners in the different specialties, the final diagnosis could not be resolved because of inadequate clinical data, poor autopsy quality, or the unmanageable nature of some death.
The lack of routine observation in the postoperative period or a failure to appreciate blood loss or recognition of abnormal vital signs such as oxygen saturation and respiratory rate can lead to death after hysterectomy. The patient should be evaluated before hysterectomy for risk factors and the medical conditions of the women should be diagnosed by a careful history and lab tests in order to decrease the possibility of hemorrhage.
The risks of blood transfusion, the transmission of HIV or hepatitis B should be discussed before surgical procedure.
The peace of surgical intervention should be governed by good exposure of the tissue, accuracy of dissection, and clamping or suturing the vessels in a precise manner. The skills and experiences of the surgeon without wasting time with unnecessary hesitation or indecision will reduce the risk of uncontrolled hemorrhage after a hysterectomy.
The surgeon should control the life-threatening hemorrhage by judgment, knowledge, and technical skills. The patient’s medical history for vital signs, blood loss volume, and levels of coagulation factors will determine how quickly blood transfusion is initiated. Careful postoperative clinical evaluation of the patient by the surgeon and surgical team with abdominal or pelvic ultrasound or CT scanning will help to prevent or minimize significant blood loss after hysterectomy and localize the site of bleeding.
No funding was received for this chapter.
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The possible interferences of atomic or molecular species are used to specify organic, inorganic or biological materials which allows critical applications in defense (landmines, explosive, forensic (trace of explosive or organic materials), public health (toxic substances pharmaceutical products), or environment (organic wastes). Laser induced plasma for organic material potentially provide fast sensor systems for explosive trace and pathogen biological agent detection and analysis. The laser ablation process starts with electronic energy absorption (~fs) and ends at particle recondensation (~ms). Then, the ablation process can be governed by thermal, non-thermal processes or a combination of both. There are several types of models, i.e., thermal, mechanical, photophysical, photochemical and defect models, which describe the ablation process by one dominant mechanism only. Plasma ignition process includes bond breaking and plasma shielding during the laser pulse. 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During first microsecond after the laser pulse, plume expansion is adiabatic afterwards line radiation becomes the dominant mechanism of energy loss.",book:{id:"5093",slug:"plasma-science-and-technology-progress-in-physical-states-and-chemical-reactions",title:"Plasma Science and Technology",fullTitle:"Plasma Science and Technology - Progress in Physical States and Chemical Reactions"},signatures:"Kashif Chaudhary, Syed Zuhaib Haider Rizvi and Jalil Ali",authors:[{id:"176684",title:"Dr.",name:"Kashif Tufail",middleName:null,surname:"Chaudhary",slug:"kashif-tufail-chaudhary",fullName:"Kashif Tufail Chaudhary"},{id:"176867",title:"Dr.",name:"Syed Zuhaib",middleName:null,surname:"Haider Rizivi",slug:"syed-zuhaib-haider-rizivi",fullName:"Syed Zuhaib Haider Rizivi"},{id:"176868",title:"Prof.",name:"Jalil",middleName:null,surname:"Ali",slug:"jalil-ali",fullName:"Jalil Ali"}]},{id:"52164",title:"An Overview on Quantum Cascade Lasers: Origins and Development",slug:"an-overview-on-quantum-cascade-lasers-origins-and-development",totalDownloads:3232,totalCrossrefCites:2,totalDimensionsCites:11,abstract:"This chapter presents an introductory review on quantum cascade lasers (QCLs). 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Furthermore, a number of state-of-the-art applications are described in different fields, and finally a brief assessment of the possibilities of volume production and the overall state of the art in QCLs research are elaborated.",book:{id:"5389",slug:"quantum-cascade-lasers",title:"Quantum Cascade Lasers",fullTitle:"Quantum Cascade Lasers"},signatures:"Raúl Pecharromán-Gallego",authors:[{id:"188866",title:"Dr.",name:"Raúl",middleName:null,surname:"Pecharromán-Gallego",slug:"raul-pecharroman-gallego",fullName:"Raúl Pecharromán-Gallego"}]},{id:"49526",title:"Focused Ion Beams (FIB) — Novel Methodologies and Recent Applications for Multidisciplinary Sciences",slug:"focused-ion-beams-fib-novel-methodologies-and-recent-applications-for-multidisciplinary-sciences",totalDownloads:4299,totalCrossrefCites:5,totalDimensionsCites:11,abstract:"Considered as the newest field of electron microscopy, focused ion beam (FIB) technologies are used in many fields of science for site-specific analysis, imaging, milling, deposition, micromachining, and manipulation. Dual-beam platforms, combining a high-resolution scanning electron microscope (HR-SEM) and an FIB column, additionally equipped with precursor-based gas injection systems (GIS), micromanipulators, and chemical analysis tools (such as energy-dispersive spectra (EDS) or wavelength-dispersive spectra (WDS)), serve as multifunctional tools for direct lithography in terms of nano-machining and nano-prototyping, while advanced specimen preparation for transmission electron microscopy (TEM) can practically be carried out with ultrahigh precision. Especially, when hard materials and material systems with hard substrates are concerned, FIB is the only technique for site-specific micro- and nanostructuring. 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In addition, recent studies concerning the active use of dual-beam platforms are mentioned",book:{id:"5075",slug:"modern-electron-microscopy-in-physical-and-life-sciences",title:"Modern Electron Microscopy in Physical and Life Sciences",fullTitle:"Modern Electron Microscopy in Physical and Life Sciences"},signatures:"Meltem Sezen",authors:[{id:"176338",title:"Associate Prof.",name:"Meltem",middleName:null,surname:"Sezen",slug:"meltem-sezen",fullName:"Meltem Sezen"}]},{id:"50866",title:"Effects of Different Laser Pulse Regimes (Nanosecond, Picosecond and Femtosecond) on the Ablation of Materials for Production of Nanoparticles in Liquid Solution",slug:"effects-of-different-laser-pulse-regimes-nanosecond-picosecond-and-femtosecond-on-the-ablation-of-ma",totalDownloads:6073,totalCrossrefCites:10,totalDimensionsCites:34,abstract:"Ultra-short laser pulse interaction with materials has received much attention from researchers in micro- and nanomachining, especially for the generation of nanoparticles in liquid environments, because of the straightforward method and direct application for organic solvents. In addition, the colloidal nanoparticles produced by laser ablation have very high purity—they are free from surfactants and reaction products or by-products. In this chapter, nanosecond, picosecond and femtosecond laser pulse durations are compared in laser material processing. Due to the unique properties of the short and ultra-short laser pulse durations in material processing, they are more apparent in the production of precision material processing and generation of nanoparticles in liquid environments.",book:{id:"5236",slug:"high-energy-and-short-pulse-lasers",title:"High Energy and Short Pulse Lasers",fullTitle:"High Energy and Short Pulse Lasers"},signatures:"Abubaker Hassan Hamad",authors:[{id:"183494",title:"Dr.",name:"Abubaker",middleName:"Hassan",surname:"Hamad",slug:"abubaker-hamad",fullName:"Abubaker Hamad"}]},{id:"49537",title:"Electron Diffraction",slug:"electron-diffraction",totalDownloads:10111,totalCrossrefCites:10,totalDimensionsCites:31,abstract:"Electron microscopes are usually supplied with equipment for obtaining diffraction patterns and micrographs from the same area of a specimen and the best results are attained if the complete use is to be made of these combined facilities. Electron diffraction patterns are used to obtain quantitative data including phase identification, orientation relationship and crystal defects in materials, etc. At first, a general introduction including a geometrical and quantitative approach to electron diffraction from a crystalline specimen, the reciprocal lattice and electron diffraction in the electron microscope are presented. The scattering process by an individual atom as well as a crystal, the Bragg law, Laue conditions and structure factor are also discussed. Types of diffraction patterns such as ring pattern, spot pattern and Kikuchi pattern, and general and unique indexing diffraction patterns are explained. The procedure for indexing simple, complicated and imperfect patterns as well as Kikuchi lines and a combination of Kikuchi lines and spots is outlined. The known and unknown materials are identified by indexing patterns. Practical comparisons between various methods of analysing diffraction patterns are also described. The basic diffraction patterns and the fine structure in the patterns including specimen tilting experiments, orientation relationship determination, phase identification, twinning, second phases, crystallographic information, dislocation, preferred orientation and texture, extra spots and streaks are described in detail. Finally, electron diffraction patterns of new materials are investigated.",book:{id:"5075",slug:"modern-electron-microscopy-in-physical-and-life-sciences",title:"Modern Electron Microscopy in Physical and Life Sciences",fullTitle:"Modern Electron Microscopy in Physical and Life Sciences"},signatures:"Mohsen Asadi Asadabad and Mohammad Jafari Eskandari",authors:[{id:"176352",title:"Dr.",name:"Mohsen",middleName:null,surname:"Asadi Asadabad",slug:"mohsen-asadi-asadabad",fullName:"Mohsen Asadi Asadabad"},{id:"177600",title:"Dr.",name:"Mohammad",middleName:null,surname:"Jafari Eskandari",slug:"mohammad-jafari-eskandari",fullName:"Mohammad Jafari Eskandari"}]}],onlineFirstChaptersFilter:{topicId:"20",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82228",title:"Nonlinear Intelligent Predictive Control for the Yaw System of Large-Scale Wind Turbines",slug:"nonlinear-intelligent-predictive-control-for-the-yaw-system-of-large-scale-wind-turbines",totalDownloads:6,totalDimensionsCites:0,doi:"10.5772/intechopen.105484",abstract:"This chapter presents a nonlinear intelligent predictive control using multi-step prediction model for the electrical motor-based yaw system of an industrial wind turbine. The proposed method introduces a finite control set under constraints for the demanded yaw rate, predicts the multi-step yaw error using the control set element and the prediction wind directions, and employs an exhaustive search method to search the control output candidate giving the minimal value of the objective function. As the objective function is designed for a joint power and actuator usage optimization, the weighting factor in the objective function is optimally determined by the fuzzy regulator that is optimized by an intelligent algorithm. Finally, the proposed method is demonstrated by simulation tests using real wind direction data.",book:{id:"11499",title:"Nonlinear Systems - Recent Developments and Advances",coverURL:"https://cdn.intechopen.com/books/images_new/11499.jpg"},signatures:"Dongran Song, Ziqun Li, Jian Yang, Mi Dong, Xiaojiao Chen and Liansheng Huang"},{id:"82102",title:"Vortex Analysis and Fluid Transport in Time-Dependent Flows",slug:"vortex-analysis-and-fluid-transport-in-time-dependent-flows",totalDownloads:10,totalDimensionsCites:0,doi:"10.5772/intechopen.105196",abstract:"In this contribution, we present a set of procedures developed to identify fluid flow structures and characterize their space-time evolution in time-dependent flows. In particular, we consider two different contests of importance in applied fluid mechanics: 1) large-scale almost 2D atmospheric and oceanic flows and 2) flow inside the left ventricle in the human blood circulation. For both cases, we designed an ad hoc experimental model to reproduce and deeply investigate the considered phenomena. We will focus on the post-processing of high-resolution velocity data sets obtained via laboratory experiments by measuring the flow field using a technique based on image analysis. We show how the proposed methodologies represent a valid tool suitable for extracting the main patterns and quantify fluid transport in complex flows from both Eulerian and Lagrangian perspectives.",book:{id:"10958",title:"Vortex Dynamics - From Physical to Mathematical Aspects",coverURL:"https://cdn.intechopen.com/books/images_new/10958.jpg"},signatures:"Stefania Espa, Maria Grazia Badas and Simon Cabanes"},{id:"82222",title:"High-Lying Confined Subbands in Terahertz Quantum Cascade Lasers",slug:"high-lying-confined-subbands-in-terahertz-quantum-cascade-lasers",totalDownloads:5,totalDimensionsCites:0,doi:"10.5772/intechopen.105479",abstract:"In designing the terahertz quantum cascade lasers, electron injection manner indeed plays a significant role to achieve the population inversion. The resonant tunneling process is commonly employed for this injection process but waste more than 50% fraction of populations out of the active region owing to resonance alignment, and the injection efficiency is obviously degraded due to thermal incoherence. An alternative approach is to consider the phonon-assisted injection process that basically contributes to most of the populations to the upper lasing level. However, this manner is still not realized in experiments if a short-period design only containing two quantum wells is used. In this work, it is found in this design that the population inversion is indeed well improved; however, the optical gain is inherently low even at a low temperature. Those two opposite trends are ascribed to a strong parasitic absorption overlapping the gain. The magnitude of this overlap is closely related to the lasing frequency, where frequencies below 3 THz suffer from fewer effects.",book:{id:"11495",title:"Fundamentals and Application of Femtosecond Optics",coverURL:"https://cdn.intechopen.com/books/images_new/11495.jpg"},signatures:"Li Wang"},{id:"81917",title:"Fluidics for Reconfigurable Microwave Components",slug:"fluidics-for-reconfigurable-microwave-components",totalDownloads:11,totalDimensionsCites:0,doi:"10.5772/intechopen.104857",abstract:"Dielectric and conducting liquids with varying electromagnetic properties can offer novel alternatives for building tunable microwave passive components as well as antennas. Injecting these fluidics in or around microwave substrates alters their overall electrical characteristics, enabling circuit reconfigurability. Alternatively, changing the shapes and dimensions of conductors by using liquid metals can achieve similar reconfigurability. An overview of different liquids and their electromagnetic properties is first given. The principles behind the reconfigurability of the electrical characteristics of typical guiding structures based on mode shape variation in the presence of fluids are discussed. The realization of an N-bit programmable impedance tuner in 3D LTCC technology based on these principles is presented.",book:{id:"11145",title:"Recent Microwave Technologies",coverURL:"https://cdn.intechopen.com/books/images_new/11145.jpg"},signatures:"Dorra Bahloul, Ines Amor and Ammar Kouki"},{id:"82149",title:"Colorimetric Evaluations and Characterization of Natural and Synthetic Dyes/Pigments and Dyed Textiles and Related Products",slug:"colorimetric-evaluations-and-characterization-of-natural-and-synthetic-dyes-pigments-and-dyed-textil",totalDownloads:7,totalDimensionsCites:0,doi:"10.5772/intechopen.104774",abstract:"This book chapter covers principles and few case studies on colorimetric Estimation of (i) determining purity/active ingredient % of selective dyes/pigments (ii) Identification of any colorants to distinguish from other similar compound, (iii) Measurement of surface colour strength of a dyed textile, (iv) Measurement of colour differences by estimating DE, DL*, Da*, Db*, DC and DH values, (v)Computer-aided colour match prediction for any standard shades, (vi) Estimation of compatibility of two dyes/colourants to use for compound shades, (vii) Determination of rate of dyeing, dyeing isotherm and dyeing kinetics to control dyeing, (viii) Optimization of dyeing process variables, (ix) Precession grading of Colour Fastness of dyed textiles on fading under different ways/agencies and (x) Estimation of Soil Removal efficacy of different detergent used for textiles. These colorimetric measurements are found to be very useful for effective process and product control of dyed textile materials. Selected Case studies on all the above colorimetric applications with specific example or experimented data are discussed for each of the method under reference. Finally, the other applications of colorimetric analysis besides textiles industry are also mentioned in concluding remarks.",book:{id:"11002",title:"Colorimetry",coverURL:"https://cdn.intechopen.com/books/images_new/11002.jpg"},signatures:"Ashis Kumar Samanta"},{id:"82116",title:"Thermo-Rheological Effect on Weak Nonlinear Rayleigh-Benard Convection under Rotation Speed Modulation",slug:"thermo-rheological-effect-on-weak-nonlinear-rayleigh-benard-convection-under-rotation-speed-modulati",totalDownloads:10,totalDimensionsCites:0,doi:"10.5772/intechopen.105097",abstract:"The effects of rotation speed modulation and temperature-dependent viscosity on Rayleigh-Benard convection were investigated using a non-autonomous Ginzburg-Landau equation. The rotating temperature-dependent viscous fluid layer has been considered. The momentum equation with the Coriolis term has been used to describe finite-amplitude convective flow. The system is considered to be rotating about its vertical axis with a non-uniform rotation speed. In particular, we assume that the rotation speed is varying sinusoidally with time. Nusselt number is obtained in terms of the system parameters and graphically evaluated their effects. The effect of the modulated system diminishes the heat transfer more than the un-modulated system. Further, thermo-rheological parameter VT is found to destabilize the system.",book:{id:"11498",title:"Boundary Layer Flows - Modelling, Computation, and Applications of Laminar, Turbulent Incompressible and Compressible Flows",coverURL:"https://cdn.intechopen.com/books/images_new/11498.jpg"},signatures:"S.H. Manjula and Palle Kiran"}],onlineFirstChaptersTotal:50},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:31,numberOfPublishedChapters:315,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:11,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:105,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:2,numberOfUpcomingTopics:1,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:14,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. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"7",title:"Biomedical Engineering",doi:"10.5772/intechopen.71985",issn:"2631-5343",scope:"Biomedical Engineering is one of the fastest-growing interdisciplinary branches of science and industry. The combination of electronics and computer science with biology and medicine has improved patient diagnosis, reduced rehabilitation time, and helped to facilitate a better quality of life. Nowadays, all medical imaging devices, medical instruments, or new laboratory techniques result from the cooperation of specialists in various fields. The series of Biomedical Engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine, and biology. This series is intended for doctors, engineers, and scientists involved in biomedical engineering or those wanting to start working in this field.",coverUrl:"https://cdn.intechopen.com/series/covers/7.jpg",latestPublicationDate:"June 25th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:12,editor:{id:"50150",title:"Prof.",name:"Robert",middleName:null,surname:"Koprowski",slug:"robert-koprowski",fullName:"Robert Koprowski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTYNQA4/Profile_Picture_1630478535317",biography:"Robert Koprowski, MD (1997), PhD (2003), Habilitation (2015), is an employee of the University of Silesia, Poland, Institute of Computer Science, Department of Biomedical Computer Systems. For 20 years, he has studied the analysis and processing of biomedical images, emphasizing the full automation of measurement for a large inter-individual variability of patients. Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:3,paginationItems:[{id:"7",title:"Bioinformatics and Medical Informatics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",isOpenForSubmission:!0,annualVolume:11403,editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",slug:"slawomir-wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",biography:"Professor Sławomir Wilczyński, Head of the Chair of Department of Basic Biomedical Sciences, Faculty of Pharmaceutical Sciences, Medical University of Silesia in Katowice, Poland. His research interests are focused on modern imaging methods used in medicine and pharmacy, including in particular hyperspectral imaging, dynamic thermovision analysis, high-resolution ultrasound, as well as other techniques such as EPR, NMR and hemispheric directional reflectance. Author of over 100 scientific works, patents and industrial designs. Expert of the Polish National Center for Research and Development, Member of the Investment Committee in the Bridge Alfa NCBiR program, expert of the Polish Ministry of Funds and Regional Policy, Polish Medical Research Agency. Editor-in-chief of the journal in the field of aesthetic medicine and dermatology - Aesthetica.",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},{id:"8",title:"Bioinspired Technology and Biomechanics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",isOpenForSubmission:!0,annualVolume:11404,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. His research interests include Biomedical Signal Processing and Modelling, Assistive Technology, Rehabilitation Engineering, Neuroengineering and Parkinson's Disease.",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",isOpenForSubmission:!0,annualVolume:11405,editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",slug:"luis-villarreal-gomez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",biography:"Dr. Luis Villarreal is a research professor from the Facultad de Ciencias de la Ingeniería y Tecnología, Universidad Autónoma de Baja California, Tijuana, Baja California, México. Dr. Villarreal is the editor in chief and founder of the Revista de Ciencias Tecnológicas (RECIT) (https://recit.uabc.mx/) and is a member of several editorial and reviewer boards for numerous international journals. He has published more than thirty international papers and reviewed more than ninety-two manuscripts. His research interests include biomaterials, nanomaterials, bioengineering, biosensors, drug delivery systems, and tissue engineering.",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:23,paginationItems:[{id:"82392",title:"Nanomaterials as Novel Biomarkers for Cancer Nanotheranostics: State of the Art",doi:"10.5772/intechopen.105700",signatures:"Hao Yu, Zhihai Han, Cunrong Chen and Leisheng Zhang",slug:"nanomaterials-as-novel-biomarkers-for-cancer-nanotheranostics-state-of-the-art",totalDownloads:1,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering - Annual Volume 2022",coverURL:"https://cdn.intechopen.com/books/images_new/11405.jpg",subseries:{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering"}}},{id:"82184",title:"Biological Sensing Using Infrared SPR Devices Based on ZnO",doi:"10.5772/intechopen.104562",signatures:"Hiroaki Matsui",slug:"biological-sensing-using-infrared-spr-devices-based-on-zno",totalDownloads:3,totalCrossrefCites:0,totalDimensionsCites:0,authors:[{name:"Hiroaki",surname:"Matsui"}],book:{title:"Biosignal Processing",coverURL:"https://cdn.intechopen.com/books/images_new/11153.jpg",subseries:{id:"7",title:"Bioinformatics and Medical Informatics"}}},{id:"82122",title:"Recent Advances in Biosensing in Tissue Engineering and Regenerative Medicine",doi:"10.5772/intechopen.104922",signatures:"Alma T. Banigo, Chigozie A. Nnadiekwe and Emmanuel M. Beasi",slug:"recent-advances-in-biosensing-in-tissue-engineering-and-regenerative-medicine",totalDownloads:13,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Biosignal Processing",coverURL:"https://cdn.intechopen.com/books/images_new/11153.jpg",subseries:{id:"7",title:"Bioinformatics and Medical Informatics"}}},{id:"82080",title:"The Clinical Usefulness of Prostate Cancer Biomarkers: Current and Future Directions",doi:"10.5772/intechopen.103172",signatures:"Donovan McGrowder, Lennox Anderson-Jackson, Lowell Dilworth, Shada Mohansingh, Melisa Anderson Cross, Sophia Bryan, Fabian Miller, Cameil Wilson-Clarke, Chukwuemeka Nwokocha, Ruby Alexander-Lindo and Shelly McFarlane",slug:"the-clinical-usefulness-of-prostate-cancer-biomarkers-current-and-future-directions",totalDownloads:14,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Cancer Bioinformatics",coverURL:"https://cdn.intechopen.com/books/images_new/10661.jpg",subseries:{id:"7",title:"Bioinformatics and Medical Informatics"}}}]},overviewPagePublishedBooks:{paginationCount:12,paginationItems:[{type:"book",id:"6692",title:"Medical and Biological Image Analysis",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6692.jpg",slug:"medical-and-biological-image-analysis",publishedDate:"July 4th 2018",editedByType:"Edited by",bookSignature:"Robert Koprowski",hash:"e75f234a0fc1988d9816a94e4c724deb",volumeInSeries:1,fullTitle:"Medical and Biological Image Analysis",editors:[{id:"50150",title:"Prof.",name:"Robert",middleName:null,surname:"Koprowski",slug:"robert-koprowski",fullName:"Robert Koprowski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTYNQA4/Profile_Picture_1630478535317",biography:"Robert Koprowski, MD (1997), PhD (2003), Habilitation (2015), is an employee of the University of Silesia, Poland, Institute of Computer Science, Department of Biomedical Computer Systems. For 20 years, he has studied the analysis and processing of biomedical images, emphasizing the full automation of measurement for a large inter-individual variability of patients. Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}}]},{type:"book",id:"7218",title:"OCT",subtitle:"Applications in Ophthalmology",coverURL:"https://cdn.intechopen.com/books/images_new/7218.jpg",slug:"oct-applications-in-ophthalmology",publishedDate:"September 19th 2018",editedByType:"Edited by",bookSignature:"Michele Lanza",hash:"e3a3430cdfd6999caccac933e4613885",volumeInSeries:2,fullTitle:"OCT - Applications in Ophthalmology",editors:[{id:"240088",title:"Prof.",name:"Michele",middleName:null,surname:"Lanza",slug:"michele-lanza",fullName:"Michele Lanza",profilePictureURL:"https://mts.intechopen.com/storage/users/240088/images/system/240088.png",biography:"Michele Lanza is Associate Professor of Ophthalmology at Università della Campania, Luigi Vanvitelli, Napoli, Italy. His fields of interest are anterior segment disease, keratoconus, glaucoma, corneal dystrophies, and cataracts. His research topics include\nintraocular lens power calculation, eye modification induced by refractive surgery, glaucoma progression, and validation of new diagnostic devices in ophthalmology. \nHe has published more than 100 papers in international and Italian scientific journals, more than 60 in journals with impact factors, and chapters in international and Italian books. 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His research focuses on biochemistry, biophysics, genetics, molecular biology, and molecular medicine with specialization in the fields of drug design, protein structure-function, protein folding, prions, microRNA, pseudogenes, molecular cancer, epigenetics, metabolites, proteomics, genomics, protein expression, and characterization by spectroscopic and calorimetric methods.",institutionString:"University of Health Sciences",institution:null},{id:"180528",title:"Dr.",name:"Hiroyuki",middleName:null,surname:"Kagechika",slug:"hiroyuki-kagechika",fullName:"Hiroyuki Kagechika",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180528/images/system/180528.jpg",biography:"Hiroyuki Kagechika received his bachelor’s degree and Ph.D. in Pharmaceutical Sciences from the University of Tokyo, Japan, where he served as an associate professor until 2004. 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Demonstrated record of scientific achievements through consistent publication record (H index = 13, with 874 citations) in high impact journals such as Nature Communications, Oncotarget, Annals of Oncology, PNAS, and AJRCCM, etc. Strong research professional with a post-doctorate from ACTREC where I gained experimental oncology experience in clinical settings and a doctorate from IGIB where I gained expertise in asthma pathophysiology. A well-trained biotechnologist with diverse experience on the bench across different research themes ranging from asthma to cancer and other infectious diseases. An individual with a strong commitment and innovative mindset. Have the ability to work on diverse projects such as regenerative and molecular medicine with an overall mindset of improving healthcare.",institutionString:"DY Patil Deemed to Be University",institution:null},{id:"349288",title:"Prof.",name:"Soumya",middleName:null,surname:"Basu",slug:"soumya-basu",fullName:"Soumya Basu",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035QxIDQA0/Profile_Picture_2022-04-15T07:47:01.jpg",biography:"Soumya Basu, Ph.D., is currently working as an Associate Professor at Dr. D. Y. Patil Biotechnology and Bioinformatics Institute, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India. With 16+ years of trans-disciplinary research experience in Drug Design, development, and pre-clinical validation; 20+ research article publications in journals of repute, 9+ years of teaching experience, trained with cross-disciplinary education, Dr. Basu is a life-long learner and always thrives for new challenges.\r\nHer research area is the design and synthesis of small molecule partial agonists of PPAR-γ in lung cancer. She is also using artificial intelligence and deep learning methods to understand the exosomal miRNA’s role in cancer metastasis. Dr. Basu is the recipient of many awards including the Early Career Research Award from the Department of Science and Technology, Govt. of India. She is a reviewer of many journals like Molecular Biology Reports, Frontiers in Oncology, RSC Advances, PLOS ONE, Journal of Biomolecular Structure & Dynamics, Journal of Molecular Graphics and Modelling, etc. She has edited and authored/co-authored 21 journal papers, 3 book chapters, and 15 abstracts. She is a Board of Studies member at her university. She is a life member of 'The Cytometry Society”-in India and 'All India Cell Biology Society”- in India.",institutionString:"Dr. D.Y. Patil Vidyapeeth, Pune",institution:{name:"Dr. D.Y. Patil Vidyapeeth, Pune",country:{name:"India"}}},{id:"354817",title:"Dr.",name:"Anubhab",middleName:null,surname:"Mukherjee",slug:"anubhab-mukherjee",fullName:"Anubhab Mukherjee",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y0000365PbRQAU/ProfilePicture%202022-04-15%2005%3A11%3A18.480",biography:"A former member of Laboratory of Nanomedicine, Brigham and Women’s Hospital, Harvard University, Boston, USA, Dr. Anubhab Mukherjee is an ardent votary of science who strives to make an impact in the lives of those afflicted with cancer and other chronic/acute ailments. He completed his Ph.D. from CSIR-Indian Institute of Chemical Technology, Hyderabad, India, having been skilled with RNAi, liposomal drug delivery, preclinical cell and animal studies. He pursued post-doctoral research at College of Pharmacy, Health Science Center, Texas A & M University and was involved in another postdoctoral research at Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Santa Monica, California. In 2015, he worked in Harvard-MIT Health Sciences & Technology as a visiting scientist. He has substantial experience in nanotechnology-based formulation development and successfully served various Indian organizations to develop pharmaceuticals and nutraceutical products. He is an inventor in many US patents and an author in many peer-reviewed articles, book chapters and books published in various media of international repute. Dr. Mukherjee is currently serving as Principal Scientist, R&D at Esperer Onco Nutrition (EON) Pvt. Ltd. and heads the Hyderabad R&D center of the organization.",institutionString:"Esperer Onco Nutrition Pvt Ltd.",institution:null},{id:"319365",title:"Assistant Prof.",name:"Manash K.",middleName:null,surname:"Paul",slug:"manash-k.-paul",fullName:"Manash K. Paul",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/319365/images/system/319365.png",biography:"Manash K. Paul is a Principal Investigator and Scientist at the University of California Los Angeles. He has contributed significantly to the fields of stem cell biology, regenerative medicine, and lung cancer. His research focuses on various signaling processes involved in maintaining stem cell homeostasis during the injury-repair process, deciphering lung stem cell niche, pulmonary disease modeling, immuno-oncology, and drug discovery. He is currently investigating the role of extracellular vesicles in premalignant lung cell migration and detecting the metastatic phenotype of lung cancer via machine-learning-based analyses of exosomal signatures. Dr. Paul has published in more than fifty peer-reviewed international journals and is highly cited. He is the recipient of many awards, including the UCLA Vice Chancellor’s award, a senior member of the Institute of Electrical and Electronics Engineers (IEEE), and an editorial board member for several international journals.",institutionString:"University of California Los Angeles",institution:{name:"University of California Los Angeles",country:{name:"United States of America"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/219081/images/system/219081.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Associate Prof.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. She has been a Professor since 1996. Currently, she is the Head of the Laboratory of Metabolism, a division of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation. N.V. Beloborodova has many years of clinical experience in the field of intensive care and surgery. She studies infectious complications and sepsis. She initiated a series of interdisciplinary clinical and experimental studies based on the concept of integrating human metabolism and its microbiota. Her scientific achievements are widely known: she is the recipient of the Marie E. Coates Award \\"Best lecturer-scientist\\" Gustafsson Fund, Karolinska Institutes, Stockholm, Sweden, and the International Sepsis Forum Award, Pasteur Institute, Paris, France (2014), etc. Professor N.V. Beloborodova wrote 210 papers, five books, 10 chapters and has edited four books.',institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"354260",title:"Ph.D.",name:"Tércio Elyan",middleName:"Azevedo",surname:"Azevedo Martins",slug:"tercio-elyan-azevedo-martins",fullName:"Tércio Elyan Azevedo Martins",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/354260/images/16241_n.jpg",biography:"Graduated in Pharmacy from the Federal University of Ceará with the modality in Industrial Pharmacy, Specialist in Production and Control of Medicines from the University of São Paulo (USP), Master in Pharmaceuticals and Medicines from the University of São Paulo (USP) and Doctor of Science in the program of Pharmaceuticals and Medicines by the University of São Paulo. Professor at Universidade Paulista (UNIP) in the areas of chemistry, cosmetology and trichology. Assistant Coordinator of the Higher Course in Aesthetic and Cosmetic Technology at Universidade Paulista Campus Chácara Santo Antônio. Experience in the Pharmacy area, with emphasis on Pharmacotechnics, Pharmaceutical Technology, Research and Development of Cosmetics, acting mainly on topics such as cosmetology, antioxidant activity, aesthetics, photoprotection, cyclodextrin and thermal analysis.",institutionString:null,institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"334285",title:"Ph.D. Student",name:"Sameer",middleName:"Kumar",surname:"Jagirdar",slug:"sameer-jagirdar",fullName:"Sameer Jagirdar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334285/images/14691_n.jpg",biography:"I\\'m a graduate student at the center for biosystems science and engineering at the Indian Institute of Science, Bangalore, India. I am interested in studying host-pathogen interactions at the biomaterial interface.",institutionString:null,institution:{name:"Indian Institute of Science Bangalore",country:{name:"India"}}},{id:"329248",title:"Dr.",name:"Md. Faheem",middleName:null,surname:"Haider",slug:"md.-faheem-haider",fullName:"Md. Faheem Haider",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329248/images/system/329248.jpg",biography:"Dr. Md. Faheem Haider completed his BPharm in 2012 at Integral University, Lucknow, India. In 2014, he completed his MPharm with specialization in Pharmaceutics at Babasaheb Bhimrao Ambedkar University, Lucknow, India. He received his Ph.D. degree from Jamia Hamdard University, New Delhi, India, in 2018. He was selected for the GPAT six times and his best All India Rank was 34. Currently, he is an assistant professor at Integral University. Previously he was an assistant professor at IIMT University, Meerut, India. He has experience teaching DPharm, Pharm.D, BPharm, and MPharm students. He has more than five publications in reputed journals to his credit. Dr. Faheem’s research area is the development and characterization of nanoformulation for the delivery of drugs to various organs.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"329795",title:"Dr.",name:"Mohd Aftab",middleName:"Aftab",surname:"Siddiqui",slug:"mohd-aftab-siddiqui",fullName:"Mohd Aftab Siddiqui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329795/images/15648_n.jpg",biography:"Dr. Mohd Aftab Siddiqui is currently working as Assistant Professor in the Faculty of Pharmacy, Integral University, Lucknow for the last 6 years. He has completed his Doctor in Philosophy (Pharmacology) in 2020 from Integral University, Lucknow. He completed his Bachelor in Pharmacy in 2013 and Master in Pharmacy (Pharmacology) in 2015 from Integral University, Lucknow. He is the gold medalist in Bachelor and Master degree. He qualified GPAT -2013, GPAT -2014, and GPAT 2015. His area of research is Pharmacological screening of herbal drugs/ natural products in liver and cardiac diseases. He has guided many M. Pharm. research projects. He has many national and international publications.",institutionString:"Integral University",institution:null},{id:"333824",title:"Dr.",name:"Ahmad Farouk",middleName:null,surname:"Musa",slug:"ahmad-farouk-musa",fullName:"Ahmad Farouk Musa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333824/images/22684_n.jpg",biography:"Dato’ Dr Ahmad Farouk Musa\nMD, MMED (Surgery) (Mal), Fellowship in Cardiothoracic Surgery (Monash Health, Aust), Graduate Certificate in Higher Education (Aust), Academy of Medicine (Mal)\n\n\n\nDato’ Dr Ahmad Farouk Musa obtained his Doctor of Medicine from USM in 1992. He then obtained his Master of Medicine in Surgery from the same university in the year 2000 before subspecialising in Cardiothoracic Surgery at Institut Jantung Negara (IJN), Kuala Lumpur from 2002 until 2005. He then completed his Fellowship in Cardiothoracic Surgery at Monash Health, Melbourne, Australia in 2008. He has served in the Malaysian army as a Medical Officer with the rank of Captain upon completing his Internship before joining USM as a trainee lecturer. He is now serving as an academic and researcher at Monash University Malaysia. He is a life-member of the Malaysian Association of Thoracic & Cardiovascular Surgery (MATCVS) and a committee member of the MATCVS Database. He is also a life-member of the College of Surgeons, Academy of Medicine of Malaysia; a life-member of Malaysian Medical Association (MMA), and a life-member of Islamic Medical Association of Malaysia (IMAM). Recently he was appointed as an Interim Chairperson of Examination & Assessment Subcommittee of the UiTM-IJN Cardiothoracic Surgery Postgraduate Program. As an academic, he has published numerous research papers and book chapters. He has also been appointed to review many scientific manuscripts by established journals such as the British Medical Journal (BMJ). He has presented his research works at numerous local and international conferences such as the European Association for Cardiothoracic Surgery (EACTS) and the European Society of Cardiovascular Surgery (ESCVS), to name a few. He has also won many awards for his research presentations at meetings and conferences like the prestigious International Invention, Innovation & Technology Exhibition (ITEX); Design, Research and Innovation Exhibition, the National Conference on Medical Sciences and the Annual Scientific Meetings of the Malaysian Association for Thoracic and Cardiovascular Surgery. He was awarded the Darjah Setia Pangkuan Negeri (DSPN) by the Governor of Penang in July, 2015.",institutionString:null,institution:{name:"Monash University Malaysia",country:{name:"Malaysia"}}},{id:"30568",title:"Prof.",name:"Madhu",middleName:null,surname:"Khullar",slug:"madhu-khullar",fullName:"Madhu Khullar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/30568/images/system/30568.jpg",biography:"Dr. Madhu Khullar is a Professor of Experimental Medicine and Biotechnology at the Post Graduate Institute of Medical Education and Research, Chandigarh, India. She completed her Post Doctorate in hypertension research at the Henry Ford Hospital, Detroit, USA in 1985. She is an editor and reviewer of several international journals, and a fellow and member of several cardiovascular research societies. Dr. Khullar has a keen research interest in genetics of hypertension, and is currently studying pharmacogenetics of hypertension.",institutionString:"Post Graduate Institute of Medical Education and Research",institution:{name:"Post Graduate Institute of Medical Education and Research",country:{name:"India"}}},{id:"223233",title:"Prof.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/223233/images/system/223233.png",biography:"Xianquan Zhan received his MD and Ph.D. in Preventive Medicine at West China University of Medical Sciences. He received his post-doctoral training in oncology and cancer proteomics at the Central South University, China, and the University of Tennessee Health Science Center (UTHSC), USA. He worked at UTHSC and the Cleveland Clinic in 2001–2012 and achieved the rank of associate professor at UTHSC. Currently, he is a full professor at Central South University and Shandong First Medical University, and an advisor to MS/PhD students and postdoctoral fellows. He is also a fellow of the Royal Society of Medicine and European Association for Predictive Preventive Personalized Medicine (EPMA), a national representative of EPMA, and a member of the American Society of Clinical Oncology (ASCO) and the American Association for the Advancement of Sciences (AAAS). He is also the editor in chief of International Journal of Chronic Diseases & Therapy, an associate editor of EPMA Journal, Frontiers in Endocrinology, and BMC Medical Genomics, and a guest editor of Mass Spectrometry Reviews, Frontiers in Endocrinology, EPMA Journal, and Oxidative Medicine and Cellular Longevity. He has published more than 148 articles, 28 book chapters, 6 books, and 2 US patents in the field of clinical proteomics and biomarkers.",institutionString:"Shandong First Medical University",institution:{name:"Affiliated Hospital of Shandong Academy of Medical Sciences",country:{name:"China"}}},{id:"297507",title:"Dr.",name:"Charles",middleName:"Elias",surname:"Assmann",slug:"charles-assmann",fullName:"Charles Assmann",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/297507/images/system/297507.jpg",biography:"Charles Elias Assmann is a biologist from Federal University of Santa Maria (UFSM, Brazil), who spent some time abroad at the Ludwig-Maximilians-Universität München (LMU, Germany). He has Masters Degree in Biochemistry (UFSM), and is currently a PhD student at Biochemistry at the Department of Biochemistry and Molecular Biology of the UFSM. His areas of expertise include: Biochemistry, Molecular Biology, Enzymology, Genetics and Toxicology. He is currently working on the following subjects: Aluminium toxicity, Neuroinflammation, Oxidative stress and Purinergic system. Since 2011 he has presented more than 80 abstracts in scientific proceedings of national and international meetings. Since 2014, he has published more than 20 peer reviewed papers (including 4 reviews, 3 in Portuguese) and 2 book chapters. He has also been a reviewer of international journals and ad hoc reviewer of scientific committees from Brazilian Universities.",institutionString:"Universidade Federal de Santa Maria",institution:{name:"Universidade Federal de Santa Maria",country:{name:"Brazil"}}},{id:"217850",title:"Dr.",name:"Margarete Dulce",middleName:null,surname:"Bagatini",slug:"margarete-dulce-bagatini",fullName:"Margarete Dulce Bagatini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217850/images/system/217850.jpeg",biography:"Dr. Margarete Dulce Bagatini is an associate professor at the Federal University of Fronteira Sul/Brazil. She has a degree in Pharmacy and a PhD in Biological Sciences: Toxicological Biochemistry. She is a member of the UFFS Research Advisory Committee\nand a member of the Biovitta Research Institute. She is currently:\nthe leader of the research group: Biological and Clinical Studies\nin Human Pathologies, professor of postgraduate program in\nBiochemistry at UFSC and postgraduate program in Science and Food Technology at\nUFFS. She has experience in the area of pharmacy and clinical analysis, acting mainly\non the following topics: oxidative stress, the purinergic system and human pathologies, being a reviewer of several international journals and books.",institutionString:"Universidade Federal da Fronteira Sul",institution:{name:"Universidade Federal da Fronteira Sul",country:{name:"Brazil"}}}]}},subseries:{item:{id:"23",type:"subseries",title:"Computational Neuroscience",keywords:"Single-Neuron Modeling, Sensory Processing, Motor Control, Memory and Synaptic Pasticity, Attention, Identification, Categorization, Discrimination, Learning, Development, Axonal Patterning and Guidance, Neural Architecture, Behaviours and Dynamics of Networks, Cognition and the Neuroscientific Basis of Consciousness",scope:"Computational neuroscience focuses on biologically realistic abstractions and models validated and solved through computational simulations to understand principles for the development, structure, physiology, and ability of the nervous system. This topic is dedicated to biologically plausible descriptions and computational models - at various abstraction levels - of neurons and neural systems. This includes, but is not limited to: single-neuron modeling, sensory processing, motor control, memory, and synaptic plasticity, attention, identification, categorization, discrimination, learning, development, axonal patterning, guidance, neural architecture, behaviors, and dynamics of networks, cognition and the neuroscientific basis of consciousness. 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