Wastewater can be broken down into five key categories, which pose individual risks to both human health and downstream processing methods.
\\n\\n
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{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"}]},book:{item:{type:"book",id:"7707",leadTitle:null,fullTitle:"A Guide to Small-Scale Energy Harvesting Techniques",title:"A Guide to Small-Scale Energy Harvesting Techniques",subtitle:null,reviewType:"peer-reviewed",abstract:"The use of energy it is argued started about two million years ago when humans started cooking their food using firewood. As humans developed new skills with increased activities, energy interaction and usage emerged. Energy was used not only for domestic functions but also for space applications. With industrialization, humans realized that energy was needed to move machines and do other things as well. In this quest, and without understanding the consequences of using fossil fuels extensively, many problems arose. Researchers in energy embarked on a journey to study different forms of energy. To understand different needs, researchers have tried to come up with ways in which small-scale energy harvesting can be adapted to different needs that do not require heavy-duty energy production.This book attempts to present a number of ideas regarding a few selected small-scale energy harvesting methods and techniques as well as theories and products that may be helpful in improving the quality of life. Some of the new products are still in the prototype stage, while others are already being utilized. Many researchers in small-scale energy harvesting and those aspiring to follow this path of research will find this book not only motivating but also a useful guide in their endeavors.",isbn:"978-1-78923-910-2",printIsbn:"978-1-78923-909-6",pdfIsbn:"978-1-83968-506-4",doi:"10.5772/intechopen.77520",price:119,priceEur:129,priceUsd:155,slug:"a-guide-to-small-scale-energy-harvesting-techniques",numberOfPages:148,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"47d7741e30a569a74a8aa981a7b7a902",bookSignature:"Reccab Manyala",publishedDate:"January 22nd 2020",coverURL:"https://cdn.intechopen.com/books/images_new/7707.jpg",numberOfDownloads:8612,numberOfWosCitations:3,numberOfCrossrefCitations:7,numberOfCrossrefCitationsByBook:1,numberOfDimensionsCitations:12,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:22,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 5th 2018",dateEndSecondStepPublish:"September 26th 2018",dateEndThirdStepPublish:"November 25th 2018",dateEndFourthStepPublish:"February 13th 2019",dateEndFifthStepPublish:"April 14th 2019",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"12002",title:"Associate Prof.",name:"Reccab",middleName:"Ochieng",surname:"Manyala",slug:"reccab-manyala",fullName:"Reccab Manyala",profilePictureURL:"https://mts.intechopen.com/storage/users/12002/images/system/12002.jpg",biography:"Reccab Manyala is currently an Associate Professor of Physics at the University of Zambia where he lectures in Physics and carries out research and consultancy in New and Renewable Energy and Renewable Energy Technologies. He obtained his PhD. in Renewable Energy and Renewable Energy Technologies from Maseno University (Kenya) in 2009. Prof. Manyala holds a Master degree in Theoretical Physics (Plasma Physics and Mathematical Physics) from University of Nairobi (Kenya) as well as a Master degree in Experimental Physics (condensed Matter Physics) from University of Arkansas (USA). He is editor of 2 InTechOpen books and has published extensively in several refereed journals. He has research and teaching experience in many areas of Physics spanning over thirty years in Kenya and abroad.",institutionString:"University of Zambia",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"University of Zambia",institutionURL:null,country:{name:"Zambia"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"117",title:"Energy Engineering",slug:"engineering-energy-engineering"}],chapters:[{id:"65008",title:"Quest for Lead-Free Perovskite-Based Solar Cells",doi:"10.5772/intechopen.83360",slug:"quest-for-lead-free-perovskite-based-solar-cells",totalDownloads:1260,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Today, the perovskite solar cells (PSCs) are showing excellent potentials in terms of simple processing, abundance of materials, and architectural integration, as well as very promising device’s power conversion efficiencies (PCEs), rocketed from 3.8% in 2009 to 23.3% in 2018. However, the toxic lead (Pb) element containing the chemical composition of typically used organic-inorganic halide perovskites hinders the practical applications of PSCs. This chapter starts with a general discussion on the perovskite crystal structure along with the serious efforts focused on Pb replacement in these devices. Section 2 will elaborate the fundamental features of tin (Sn)-based perovskites together with their performance in the PSCs. Other alternative elements, such as copper (Cu), germanium (Ge), bismuth (Bi), and antimony (Sb), will be discussed in Section 3. The end will summarize the challenges and opportunities based on the chapter contents.",signatures:"Sajid Sajid, Jun Ji, Haoran Jiang, Xin Liu, Mingjun Duan, Dong Wei, Peng Cui, Hao Huang, Shangyi Dou, Lihua Chu, Yingfeng Li, Bing Jiang and Meicheng Li",downloadPdfUrl:"/chapter/pdf-download/65008",previewPdfUrl:"/chapter/pdf-preview/65008",authors:[null],corrections:null},{id:"66888",title:"Thermoelectric Energy Harvesting",doi:"10.5772/intechopen.85670",slug:"thermoelectric-energy-harvesting-1",totalDownloads:1170,totalCrossrefCites:3,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Thermoelectricity can be used to generate electrical power from temperature gradients or differences in naturally occurring geothermal heat and rocks, or from waste heat in man-made equipment and industrial processes. Thermoelectric energy harvesting systems are finding commercial applications to replace or recharge batteries in low power electronic systems. This chapter provides the fundamental thermoelectric theory related to power generation, including the theoretical analysis and numerical calculations required to calculate the thermoelectric efficiency and electrical power generated when a single thermoelectric couple, and a 127 couple thermoelectric module, are subject to different temperature gradients. A thermoelectric energy harvesting system, incorporating a low power boost converter and DC to DC converter, coupled with electrical energy storage in supercapacitors, is presented and enables a thermoelectric energy harvesting system to provide sufficient electrical power to operate low power electronic components and systems. The short-term challenge for thermoelectric energy harvesting is to become a cost effective and practical solution to replace batteries, and to be scaled to provide sufficient power to operate electrical rotating machines such as low power motors and pumps. The long-term challenge is to improve the efficiency, power output, and cost of thermoelectric modules and energy harvesting systems, and to develop from low power to low-to-medium power applications.",signatures:"Chris Gould",downloadPdfUrl:"/chapter/pdf-download/66888",previewPdfUrl:"/chapter/pdf-preview/66888",authors:[{id:"3552",title:"Dr.",name:"Chris",surname:"Gould",slug:"chris-gould",fullName:"Chris Gould"}],corrections:null},{id:"67097",title:"Energy Harvester Based on Magnetomechanical Effect as a Power Source for Multi-node Wireless Network",doi:"10.5772/intechopen.85987",slug:"energy-harvester-based-on-magnetomechanical-effect-as-a-power-source-for-multi-node-wireless-network",totalDownloads:1066,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"This work is focused on the development of new kind of energy harvesters that could be used in various applications including industrial, aerospace, or customer markets. The main aspect to consider is transformation of different sources of energy (that in normal conditions is wasted such as temperature, vibration, shock, etc.) into the usable electric power. The goal was to prepare wireless subsystem based on energy-harvesting technology which will aid different areas. The energy-harvesting devices are shown as small harvesting devices with power output from 10 mW up to 5 W. Proposed solutions might be used in applications such as low-power microprocessor systems, ultrasonic continuous power supply for low-power wireless network systems, and multi-node harvester systems that allow to collect more electrical power for critical structural health monitoring (SHM) applications. The main purpose was to obtain from harvesters the sufficient values for supplying the chosen 32-bit microcontroller systems. Additionally possible application in mechanic for the other than magneto-based solid harvesters is described.",signatures:"Jerzy Kaleta, Rafał Mech and Przemysław Wiewiórski",downloadPdfUrl:"/chapter/pdf-download/67097",previewPdfUrl:"/chapter/pdf-preview/67097",authors:[{id:"220028",title:"MSc.",name:"Przemysław",surname:"Wiewiórski",slug:"przemyslaw-wiewiorski",fullName:"Przemysław Wiewiórski"},{id:"233089",title:"Prof.",name:"Jerzy",surname:"Kaleta",slug:"jerzy-kaleta",fullName:"Jerzy Kaleta"},{id:"233090",title:"Dr.",name:"Rafał",surname:"Mech",slug:"rafal-mech",fullName:"Rafał Mech"}],corrections:null},{id:"65412",title:"Small-Scale Energy Harvesting from Environment by Triboelectric Nanogenerators",doi:"10.5772/intechopen.83703",slug:"small-scale-energy-harvesting-from-environment-by-triboelectric-nanogenerators",totalDownloads:2585,totalCrossrefCites:3,totalDimensionsCites:6,hasAltmetrics:0,abstract:"The increasing needs to power trillions of sensors and devices for the Internet of Things require effective technology to harvest small-scale energy from renewable natural resources. As a new energy technology, triboelectric nanogenerators (TENGs) can harvest ambient mechanical energy and convert it into electricity for powering small electronic devices continuously. In this chapter, the fundamental working mechanism and fundamental modes of a TENG will be presented. It can harvest all kinds of mechanical energy, especially at low frequencies, such as human motion, walking, vibration, mechanical triggering, rotating tire, wind, moving automobile, flowing water, rain drops, ocean waves, and so on. Such variety of energy harvesting methods promises TENG as a new approach for small-scale energy harvesting.",signatures:"Jie Wang, Linglin Zhou, Chunlei Zhang and Zhong Lin Wang",downloadPdfUrl:"/chapter/pdf-download/65412",previewPdfUrl:"/chapter/pdf-preview/65412",authors:[null],corrections:null},{id:"65618",title:"RF Energy Harvesting System and Circuits for Charging of Wireless Devices Using Spectrum Sensing",doi:"10.5772/intechopen.84526",slug:"rf-energy-harvesting-system-and-circuits-for-charging-of-wireless-devices-using-spectrum-sensing",totalDownloads:1598,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:0,abstract:"Recently, lots of works have been done on the optimal power management of wireless devices. This leads to the main idea of ambient energy harvesting. Among various energy harvesting approaches, one is to use radio waves existing in the ambient environment for battery charging, called RF energy harvesting. In this chapter, in order to improve the RF energy harvesting performance, we utilize spectrum sensing to allow the wireless devices to select the frequency band with maximum power that exceeds a predefined threshold to charge the device (this power threshold can be determined according to battery type and its required charging power) and the device can use this power for battery charging. Also, a novel voltage multiplier circuit is proposed. By means of simulations and experimental tests, it can be seen that after detection of our desired 1 mW RF signal, system output power is about 532μ W and 450μ W in simulation and practical situations respectively.",signatures:"Naser Ahmadi Moghaddam and Alireza Maleki",downloadPdfUrl:"/chapter/pdf-download/65618",previewPdfUrl:"/chapter/pdf-preview/65618",authors:[null],corrections:null},{id:"67336",title:"Thousand kW High-Temperature Solar Furnace in Parkent (Uzbekistan) – Energetical Characteristics",doi:"10.5772/intechopen.83411",slug:"thousand-kw-high-temperature-solar-furnace-in-parkent-uzbekistan-energetical-characteristics",totalDownloads:933,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:1,abstract:"This chapter presents a method of calculation of the energetical characteristics of the large solar furnace with a capacity of 1000 kW (LSF) taking into account its real optical parameters. The technical characteristics of the LSF are presented. The possible energy characteristics of the LSF based on numerical calculations are analyzed. The energy characteristics of the total system with different inaccuracies of the reflecting surfaces, energy contributions of certain shelves and groups of heliostats, and the contributions of certain heliostats and shapes of their focal spot are determined. Empirical formulas are proposed to describe the obtained numerical results. The problem of implementing the possible energy modes of the LSF with and/or without the inclusion of certain shelves and groups of heliostats is analyzed. The problem of a day changes in the energy density distribution in the focal spot of the LSF is considered.",signatures:"Akbarov Rasul",downloadPdfUrl:"/chapter/pdf-download/67336",previewPdfUrl:"/chapter/pdf-preview/67336",authors:[null],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"3676",title:"Solar Collectors and Panels",subtitle:"Theory and Applications",isOpenForSubmission:!1,hash:null,slug:"solar-collectors-and-panels--theory-and-applications",bookSignature:"Reccab Manyala",coverURL:"https://cdn.intechopen.com/books/images_new/3676.jpg",editedByType:"Edited by",editors:[{id:"12002",title:"Associate Prof.",name:"Reccab",surname:"Manyala",slug:"reccab-manyala",fullName:"Reccab Manyala"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited 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Water covers 70% of the surface of the planet, and yet the world currently faces a water crisis. Of this hugely abundant resource, less than 1% is available for human consumption. Two-thirds of all fresh water is locked up in glaciers and ice caps where it is typically physically separated from humans and is, therefore, not widely available for use. The remaining 97% of the global water is saline, present within the seas and oceans. This is inappropriate for agricultural uses, industrial cleansing or human consumption without significant energy inputs and desalination efforts, although it can be employed for some limited applications, such as certain types of cooling in industrial processes. These water sources have not changed in the last 100 years, but in that time the population has undergone rapid expansion. The majority of water used by humans is either as an energy carrier in thermo-electrical power generation; where it is used for both cooling and steam production to generate the driving force for the turbines or in agricultural irrigation and cleaning [1]. The United Nations Food and Agriculture Organisation (UNFAO) estimate that 11.8% of the 3918 km3 yr−1 fresh water withdrawn annually is used for municipal purposes, where it makes its way to households for drinking, washing and recreational purposes [2].
\nGlobal water volumes remain constant in a system referred to as the water cycle, and so with the exception of deserts or very densely populated areas, physical limitations of water are not usually an issue. A more significant problem, however, is the limited supply of water that is either potable (suitable for human consumption) or at a sufficient quality for other municipal and industrial applications. After water has been used in an anthropogenic process, it is referred to as wastewater. Wastewater is classified as containing output of some combination of the sources given in Table 1. According to the UNFAO, in 2012, the world had access to 52,600 km3 yr−1 fresh water resources, which is just over thirteen times higher than the amount drawn annually; however, this resource is not evenly distributed. Asia, for example, has access to around a quarter of available world water resources, but has almost 60% of the world population [2]. The majority of people are based in global urban centres, 80% of which are located on the coast or major waterways. Many cities around the world—even in Countries which have both high annual rainfall, and are members of the Organisation for Economic Cooperation and Development (OECD countries), such as London—are considered ‘water stressed’. Being ‘water stressed’ occurs when an area requires access to more clean water than is available, or produces more wastewater than can be treated effectively. This results in a direct release of wastewater into waterways causing a reduction in water quality. This in turn has economic costs, through both work lost due to human illness and damage to the surrounding environmental resources—such as fishing stocks [3].
Name | Example contents | Risk factors |
---|---|---|
Blackwater | Excreta, urine and faecal sludge | |
Greywater | Bathing and washing water | |
Bluewater | Urban run-off and storm water | |
Greenwater | Agricultural effluent* | |
Redwater | Industrial effluent |
Wastewater can be broken down into five key categories, which pose individual risks to both human health and downstream processing methods.
Each category has been assigned a colour to simplify reference within the text. For each, a brief summary of the category is given, and some associated risks with the wastewater are highlighted. Risks of untreated release to human health or the environment are in boldface, whilst risks that affect downstream processing are italicised.
*Agricultural effluent includes effluent from aquaculture and horticulture.
The core role of wastewater treatment is to remove waste additives from a water stream until it is at a level suitable for environmental release. These levels are set by governments in each country, for example, the Environmental Protection Agency sets recommendations for the USA that are considered safe for aquatic life [4]. Depending on the source of the wastewater, different treatment methods are required—for example, bluewater (urban run-off and storm water) can contain grit and large debris and so needs to be put through Stage 1 processing or ‘screening’; as unless removed, this debris can cause blockages and serious wear/damage to downstream machinery. This is the stage where most centrifugal type separators are employed in wastewater treatment, as swirl flow is generally not employed for transport, separation or waste processing beyond the initial latrine and grit removal stages. A general outline of the stages of centralised wastewater treatment is presented in Figure 1, and a brief explanation of the workflow is given below (Figure 1). As mentioned in the example above, Stage 1 processing is the removal of grit and debris. This is usually done using a combination of grids and baffles, however, hydrocyclones have been employed for grit removal in some cases. Stage 2 processing is an important precursor to Stage 3 water treatment, as it removes the majority of the activated sludge from suspension, typically through natural settling or through the addition of a flocculating agent such as iron chloride. This sludge can then be collected and dried, or run through anaerobic digestion to generate useful products such as methane, which can be used to power other parts of the wastewater treatment or sold to mitigate operational costs. Stage 3 processing is used to reduce phosphate and nitrate levels in the final effluent, preventing harmful downstream effects like eutrophication. The residual bacteria remaining in solution after flocculation are aerated and encouraged to grow, and in the process, the nutrients in the liquid are depleted and more sludge is produced. This sludge is then flocculated and processed as in Stage 2. Finally, the nutrient and sludge-depleted liquid will still contain some organisms that did not flocculate, so needs to be sterilised before leaving the treatment plant. This is typically done with UV sterilisation, but can also be done with chlorine or ozone dosing where the clarity of the effluent is an issue. The vortex bioreactor has applications for Stages 2–4 (clarification/flocculation of suspended solids through centrifugal-type separation, removal of nutrients by acting as a bioreactor and sterilisation/pathogen removal) of the water treatment processes. For further reading on the stages of wastewater treatment process, see Ref. [1], and for a comprehensive compendium of sanitation systems, see Ref. [5].
The different streams of wastewater described in
Large urban treatment plants are economic and highly effective at treatment of municipal wastewater, however, they are not always suitable [1]. This is particularly true in areas that lack established sewerage systems—sewerage systems have relatively high initial capital expenditure requirements and in rural environments the population density is simply too low to justify the cost. Centralised water treatment is also not a good solution for an area that suffers from intermittent power loss, as power is required for pumping the water to and from the central station and certain treatment processes. The power requirements for running wastewater treatment in the US in 1996 came to approximately 75 billion kilowatt hours (kWh), around 3% of the US annual electricity consumption that year [6]. Aside from the power costs, interruption of the electricity supply, such as from brownouts or blackouts, pose a significant risk to the fidelity of the wastewater treatment process. The large capital expenditure and operating costs involved in centralised water treatment results in public ownership or subsidies, which can be a major issue in countries experiencing political instability [3]. Finally, the water treatment industry in the developed world is incredibly resistant to innovation [7]. New large-scale technologies that could produce a step-change in processing techniques are slow to be implemented, a stance that is reinforced by effluent regulation requirements and possible fines resulting from a failure to meet water treatment standards.
\nUrban populations are rising faster than the average population growth rate, as more people move away from rural areas to cities [3]. Due to space limitations, growth of urban centres tends to occur in the outskirts of urban areas. These peri-urban areas, between the urban and rural zones, have a higher population density than the rural areas but, due to rapid growth, lack the key infrastructure of developed urban areas. As a result, wastewater management is a major issue for peri-urban areas; particularly municipal wastewater, which consists of grey (washing water), black (faecal contaminated) and blue (urban run-off) wastewaters. Due to the dynamic nature of these spaces, designing a suitable water treatment plan that is future-proofed, suitable and cost-effective is challenging. In these cases, decentralised treatment options are an ideal solution.
Decentralised water treatment systems (DeWaTS) are small-scale water treatment systems ideally suited to operating in the urban, peri-urban and rural environments in developing countries—particularly in cases where pre-existing water infrastructure is either insufficient for requirements or unavailable [8]. A DeWaTS can be an individual unit, or a complete water treatment system, and can be utilised in either domestic or industrial water treatment. The amount of wastewater produced by an individual varies depending on environment, but typically an average person produces around 60 L of wastewater per day, with blackwater making up around 2 L on average and the remaining coming from greywater [5]. This implies that the average person requires access to 60 L clean water each day, and so any household level water purification system should be able to accommodate this requirement for all members of an individual home.
\nTypically, a DeWaTS will operate in the range of 1 m3 day−1 (1000 L day⁻¹) for a household unit, to 1000 m3 day−1 for a community treatment system. There are a number of defining characteristics that differentiate a DeWaTS from a model or an experimental water treatment system. The system should be reliable, built to last, tolerant to fluctuating inputs, cost-effective and above all have low control and maintenance requirements [9]. A DeWaTS designed to produce a profit should aim to return the initial cost of investment through sales of cleaned water or products produced from waste within the first 1–2 years of operation, to ensure uptake of the technology [3]. The vortex bioreactor was, therefore, designed with these vital features in mind.
The vortex bioreactor system (VBR) is a highly versatile, modular DeWaTS, which utilises suspended activated beads within a recirculating swirling flow system to facilitate downstream liquid processing and multiphase reactions. The swirl flow and accompanying vortex, for which the device is named, are induced by an impeller, which can be driven by a variety of devices such as an electric drill motor or a 3D printable hand crank. Under certain operating conditions, the device can perform liquid-liquid separation and acts as a type of centrifugal separator, where a lighter liquid phase is entrained by the precessing vortex and is siphoned into a separate flow channel. Increasing the impeller speed increases turbulence in the system, resulting in better mixing, more interaction between the contents and as a result acceleration of chemical reaction rates. Notably, this effect is also modulated by the activated beads, which can enhance, but in some cases dampen, the turbulence effect. Altering the impeller design has been shown to change the vortex characteristics, although investigations into this with the VBR system are still ongoing. To date a hydrofoil type design, a rounded blade design and a lily design have been utilised for the impeller, but so far the effects of impeller geometry have not been systematically investigated. Finally, by altering the properties of the suspended activated beads, it is possible to run a variety of different reactions or separations. For example, reducing the density of the beads by introducing sealed air microbubbles during their creation causes them to move to the core region of the VBR for easy separation and recycling, whilst sponge-like porous beads with a high surface area can be used as both a heterogeneous catalyst for multi-phase reactions and an adsorbant surface for sequestration of toxic materials, such as heavy metals.
\nDue to the swirl generated by the impeller, the flow within the VBR is not uniform but rather characterised by low velocities in the core region due to the formed vortex and higher velocities outside. Fluid in the core moves far more slowly than outer part, and under some regimes, the suspended beads can be held almost completely stationary within the slow-moving core region [10]. A CAD image of a prototype variant of the VBR can be seen below (Figure 2). This prototype consists of a closed loop, built from widely available standard plumbing parts forming a rounded quadrilateral of recirculated flow. The design was constructed from 60.4 mm outside diameter and 57.4 mm inner diameter clear polycarbonate, joined with 2-acrylonitrile butadiene styrene (ABS) fittings. There is an inlet for filling the reactor at the top, and in the working prototype, a ball-valve controlled outlet was introduced at one corner for draining the VBR. Swirl flow is induced with an impeller on a shaft, which is driven by a 450 W variable speed drill motor (0–2400 RPM Bosch). This design is capable of generating a stable horizontal vortex, which entrains less dense materials, such as air or oil in water, and separates them from the carrier fluid [10].
This CAD image shows one possible setup of the VBR system. The flow runs through a rounded quadrilateral pipe system, driven by an impeller. There is an inflow located at the top of the reactor. The prototype design also has a ball-valve controlled outflow (not shown) for emptying the system.
The first prototype was designed and built by the Allen research group at Plymouth Marine Laboratory in 2010. It was intended for the separation of high-value oils produced by microalgae from an oil-water suspension, using centrifugal flow technology. A low-cost variant of this technique is widely employed by the oil industry in the form of hydrocyclones, but swirl flow is not generally utilised in biological applications. Successful oil-water separation tests were performed on the device (see below), and during testing, the question of completing the whole process ‘in one box’ arose, and so investigation into upstream processing was carried out to see if the VBR could also be used for cell growth, oil production, cell rupturing for extraction of the biochemical products and ultimately separation of the functional product from the liquid media.
\nMicroalgae are microscopic, photosynthetic organisms that are found in both marine and fresh water environments. They can be an environmental and health hazard when they bloom in waterways and are responsible for causing discolouration of standing water, but are a promising set of organisms for photosynthetic biotechnological production [11]. One of these high-value products is speciality oils, such as the omega 3 oils Eicosapentaenoic acid (EPA) and docosahexeanoic acid (DHA), which are valuable ‘nutraceuticals’ [12]. To extract these oils from microalgae, first the cells must be broken open, a process also referred to as cellular lysis. It has been documented previously that shear forces, when applied at high enough levels, can literally tear cells apart through an unevenly distributed pressure gradient against the cell membrane, or if cells are at a high enough density trigger cellular damage and death through violent collisions [13]. It is important to note that this threshold varies with different organisms and is dependent on the presence of air bubbles; when air is absent from the system, cells are much more tolerant to mechanical shear forces [13]. The large shear forces introduced into the flow system during turbulent flow were found to trigger cell death in
The activated beads were found to modify the VBR operation significantly. Not only did they improve the shear and mixing effects within the system, but they also opened it up to a variety of other modifications and applications far beyond the humble swirl-flow system origins. They appear to hold three key functions: they increase the reactor surface area, they appear to decrease the impeller speed needed to attain turbulent flow within the VBR in the conditions tested so far and they transform the device into a different class of reactor—from a chemical engineering point of view, it acts as a fluidised bed reactor and from a bioengineering point of view, it acts as a immobilised microcapsule perfusion bioreactor, where organisms can adhere to or be embedded within the activated beads. To estimate the increased surface area and determine how to control for it, a simple model was prepared, considering the beads as solid spheres in suspension.
\nwhere
The internal surface area of the VBR can be calculated by taking the pipe circumference and multiplying it by the length of the reactor. In the case of the 9 L VBR prototype system described above, the internal pipe circumference is 18 cm and the length is 318 cm, resulting in an internal surface area of 5.7 × 103 cm2. Using the model above, adding 1 L beads results in an addition of 2.22 × 104 cm2, raising the overall surface area to 2.79 × 104 cm2.
\nWhilst this model only accounts for the outer surface of the beads, which is a conservative estimate for increased surface area in the 9 L system, it shows that adding 1 L of 1 mm radius beads to the prototype reactor design increases the internal surface area by approximately five-fold.
To characterise the ability of the system to separate oil and water effectively, a series of experiments were conducted on a model system. It was not practical to directly test algal oils throughout the experiment due to the expense and the volumes needed, so a model oil consisting of vegetable oil dyed with Nile Red so it could be observed in water was used instead. Dyed vegetable oil is a good model for algal oil, as it is cheap, available in large quantities, and has a similar density and viscosity. Algal oil has a density of 0.864 kg L−1, whilst the model oil had a density of 0.93 kg L−1. The dynamic viscosities are shown in Table 2.
Test liquid | Dynamic Viscosity at 25 °C |
---|---|
Test oil and dye | μ = 0.0562 Ns m−2 |
Test oil | μ = 0.0625 Ns m−2 |
Algal oil | μ = 0.0233 Ns m−2 |
The dynamic viscosities for the dyed vegetable oil was used as an affordable substitute for algal oil, the vegetable oil without the addition of the dye, and the algal oil that was being modelled.
An experimental series was run, beginning at an oil:water ratio of 1.58%. This ratio was modelled on a true extraction of algal oil from the growth media solution, based on the growth density of the algae and the relative quantities of oil they produce. The concentration of oil was gradually increased in the series, based on the assumption that the concentrated oil–water mix could be re-run through the system until a desired concentration had been attained or the volume limit was reached. This system was run at a number of impeller-tip speeds in order to optimise the vortex characteristics for maximum oil separation levels (Figure 3).
Variation in the oil concentration extracted from the VBR for a range of speeds and for a range of initial oil concentrations (a). The data in (b) is presented with respect to the initial oil concentration to show the efficiency of the extraction process.
A series of experiments were run, in which the ability of the VBR to extract oil from a mixture of oil and water was tested for a range of impeller speeds and oil:water volume ratios; beginning with the expected initial value of 1.58%. The concentration of oil was gradually increased in the series, based on the assumption that the concentrated oil-water mix could be re-run through the system until a desired concentration had been attained, or the volume limit was reached. This system was run at a number of impeller-tip speeds in order to optimise the vortex characteristics for maximum oil separation levels (Figure 3). Figure 3(a) shows the concentration of oil in the mixture extracted from the syphon (cex) for a range of impeller speeds (600–1800 RPM) and a number of different initial concentrations of oil in the system (c0 = 1.58–18.4%). The same data is presented in Figure 3(b), normalised with respect to the initial concentration to show the relative increase in the oil concentration at each step, i.e. the ‘efficiency’ of the system.
\nFor most initial concentrations, the maximum concentration of oil extracted tends to occur in the range of 800–1200 RPM. At low speeds (<800 RPM), the swirling motion was too weak to entrain the oil droplets into the vortex core, and the oil remained at the top of the pipe. In contrast, when the impeller speed was high (>1200 RPM), the flow became strongly turbulent and the oil broke into small droplets (a process known as ‘emulsification’) that tended to disperse throughout the fluid. This meant that fewer droplets remained in the vortex core, and the efficiency of the VBR was reduced. The data also suggest that the same efficiency may be achieved from a low initial concentration by sequential processing. For example, from an initial concentration of 1.5%, it is possible to increase the oil concentration to 4%; from 4% it is possible to increase to 12%, and so on. The maximum concentration extracted was close to 60%, although it is possible that the VBR could produce higher concentrations if the initial concentration of oil was greater.
\nA series of power consumption measurements were also made on the system, to determine the energy requirements and financial costs associated with operating the device at a range of rotational speeds. The measurements were initially performed when the device was filled with water, and subsequently, when it was filled with an oil-water mixture (Figure 4).
The variation in power consumption with increasing motor speed, measured when the SP-2 contained pure water (black circles) and a mixture of 14.7% oil (grey triangles).
The measured power consumption is shown in Figure 3. When the motor was not moving, the controller drew approximately 4 W from the mains. As the motor speed increased, the power consumption also increased in a linear fashion. The power consumption is approximately given by
\nwhere
The presence of the oil did not affect the total power consumption of the system. This indicates that to process 1000 L of oil-water mixture at optimal motor speeds (approximately 900 RPM), using a motor with a comparable efficiency, would require 6.5 kW. Over the course of an hour, this would cost £0.65, assuming an electricity cost of approximately £0.10 per kilowatt hour based on typical rates for domestic use in the UK [15]. This indicates that (i) the VBR represents a cost-efficient method of refining the concentration of oil in an oil-water mixture, and (ii) the use of multiple steps to achieve a given concentration is not associated with a significant increase in operating costs; however, these values may change, depending on the volume being processed and the efficiency of the motor being used.
Biological disease-causing agents, or pathogens, are a major concern in wastewater treatment. Human faecal effluent is a major health risk, as the organisms living within it are already attuned to living within humans. A number of diseases have been linked to human-derived pathogens, including dysentery, typhoid and gastroenteritis [16]. In wastewater treatment, the biological quality of the water is determined by quantifying ‘coliforms’. Coliforms are a subset of bacteria that are easy to culture and are present in large numbers in warm-blooded animal faeces—making them a good test for faecal contamination in wastewater [17]. The organisms are quantified by colony forming units (CFUs), referring to the number of living cells within a fixed volume. Guidelines state that to minimise risks to human health, wastewater containing blackwater should contain no measurable CFUs per 100 ml, and waste water from a known non-faecal source, such as redwater (industrial effluent), should contain no more than 10 CFUs per 100 [18].
\nCopper has long been known as an antimicrobial substance, given its employment in hospital door handles and work surfaces [19]. To trigger this effect within the reactor, dendritic copper micro particles were added to the system as a powder. A copper pipe was also considered; however, due to the comparably limited surface area and relatively high cost of copper within the otherwise cheap final design and the risk of corrosion over time under continuous exposure to water, it was deemed to be unsuitable [14]. The copper powder was found to be effective at triggering cell lysis; however, separating the copper from the system afterwards was considered too complicated for the design, a vital step in this case, as copper is toxic to aquatic ecosystems—and humans [20]. To aid in terminal removal from the system after processing, the copper powder was embedded within spherical, alginate matrix, hydrogel particles—referred to as the activated beads herein. A test was carried out to see if embedding copper within alginate would still trigger cell lysis; intriguingly, not only did the cells still lyse, but they did so at a more rapid rate than a comparable study with the powdered copper [20].
\nWhen the activated beads were run in the VBR system, they were found to be more effective at triggering cell lysis than the equivalent amount of free copper microparticles. Death of all the cells in the sample (initially at a concentration of 1 × 108 CFU ml−1) occurred within 15 min, a rate approximately 6× faster than had previously been reported in flask experiments. In addition, this effect was observed repeatedly when additional organisms were added into the system after all the previous cells were dead. Whilst the structural integrity had been affected by the turbulent flow at particularly high speeds, the activated bead fragments could still be extracted from the system safely with minimal copper leached into the system [10]. Development of the device subsequently received financial support from the Bill and Melinda Gates Foundation, for development as a low powered, affordable alternative to UV light sterilisation of water. This resulted in testing the device on wastewater streams in a number of facilities located around the world [21]. The device demonstrated clear bactericidal effects on coliforms within seconds of exposure to the VBR—activated bead combination, and even destroyed the radiation hardy
Embedding the copper within an alginate matrix proved extremely effective as an immobilisation technique. The low levels of measurable copper in solution—despite fragmentation of the beads during operation of the reactor—and the greater than expected rate of bactericidal action within the VBR doped with copper-alginate beads, instigated an investigation on the metal adsorption qualities of alginate in the VBR. The theory behind this application is based on alginate being a polyionic polymer that forms a hydrogel stabilised by calcium ions; it was thought that copper—or some other metal ion—could displace these calcium ions and become sequestered in the material [22]. The advantage of using alginate beads for this application is that because the bulk of the beads are composed of liquid, and as a result can be dried after use to concentrate any extracted materials for recycling and reduce volume. This is a particularly useful application when considering the VBR as a device for redwater treatment, as many industrial processes involve the use of metals and metal salts that need to be extracted from the final product due to their value, toxicity and environmental impact.
\nTo generate hand drawn alginate beads, sodium alginate solution was added in a drop-wise fashion by hand from a syringe to cold calcium carbonate solution. The beads created by this process were approximately 2 mm diameter on average, although beads created in this fashion did show some size variation. An automated variant of this process was conducted with a syringe pump to generate a more repeatable size distribution. Features of alginate beads can be altered by changing the reagents used in their generation—for example, increasing sodium alginate concentration will create more rigid beads; whilst mixing copper-powder into the solution will create beads embedded with copper and air entrainment can create lighter beads for simpler separation from liquids such as water, as such beads are relatively more buoyant than the liquid.
\nThe metal-absorbing properties of alginate beads were tested with metal salt solutions containing copper sulphate, nickel sulphate and chromium chloride at a high (100 mM) and low (30 μM) concentration. The alginate beads were added to make up 50% by volume of the total volume and were tested in shaking flasks containing each of the metal salt solutions. The beads were found to have metal-absorbing properties in shake flasks, with 30–40% of the metal by concentration being extracted from solution over a period of 30 min. The samples were left for a further 60 min, although a negligible amount of additional absorption was observed. The volumes of metal being extracted were consistent with partial volume removal of a fully diffused solution. This suggests that the liquid initially sequestered in the hydrogel gradually dilutes the sample as the metals permeate the beads. The experiment was repeated with stationary flasks, producing largely similar results, suggesting that fluid motion had a limited effect on diffusion within the beads. To verify this observation, beads that had already absorbed metals were extracted and recycled into fresh metal salt solution at the initial concentration. Each additional round of extraction resulted in a diminishing rate of return, as the beads became saturated with metal approaching the initial concentration.
\nWhen the beads were tested in the VBR, the same final rate of absorption was observed, however, an interesting phenomenon was observed repeatedly through all experiments. Within the first minute of extraction, the rate at which metal salt was extracted was far more rapid in the VBR than in either shaken flasks or static flasks. The rate of absorption equalised with other experimental set ups after around 8 min; however, these data suggested that the swirl flow within the VBR has a beneficial effect on the rate of metal absorbance, at least with the outer part of the beads. This observation needs experimental verification by running the system for 1 min with a coloured metal salt and then extracting and dissecting the beads to see if the effect is limited to the outer shell or actually uniform through the bead; however, the data suggests that this is the case as all three systems eventually reach the same point. Understanding this effect has broader-reaching consequences, as alginate is a major constituent of certain medically relevant biofilms. Biofilms are a biologically derived fouling effect that utilise polymeric substances and act as a protective layer to organisms within them, conferring resistance to antibiotics [23]. If this effect could be isolated, replicated and controlled, it could provide beneficial techniques for the removal of biofilms in industrial settings—where a cleaning agent, or a medical antibiotic, could be delivered directly into the biofilm, rather than just relying on diffusion. Whilst the metal capturing hypothesis was not found to be valid with alginate, making the beads from a polymeric substance that has specific metal-binding ability—such as polyacrylamide—could provide a more effective metal absorption process, although this has not yet been tested. The alginate was tested in this case as it followed on from previous work being conducted at the time and had demonstrated a good ability to hold metallic copper in situ. It is likely that the initially observed effects are a result of the metal particles being unable to escape from the bead due to steric hindrance, rather than through a specific affinity to the alginate.
As a relatively new and highly versatile piece of technology, there are a number of features of the VBR that remain to be optimised and tailored to the application to more fully understand the range of future applications it could be implemented with. The two main aspects that affect operation are the swirl-flow regime—which is controlled by speed and impeller design, and the active beads. These are discussed in the context of remaining issues for the device as a DeWaTS and the potential applications the device has as a bioreactor. There are several other potential avenues for investigation with this technology; however, they are beyond the scope of this chapter.
\nThere are three main potential issues with the VBR as a widespread functional DeWaTS device for water purification. The first, as mentioned earlier in this chapter, is the stability of the beads. During the process, shearing from the impeller results in the beads becoming fragmented. This is an issue, as whilst the dendritic copper powder used in the beads is relatively cheap, and can be recycled in the system, it is still the most expensive part of the fully operational system. One possible avenue for solving this is through modification of the beads. They could be modified in a number of ways, such as using the minimal amount of copper that still produces a lytic effect on pathogens to reduce the cost or by increasing the resistance of the beads to impeller shear by modifying the type or concentration of polymer. It is also possible that a different flow regime and less dense beads could be used in tandem, holding the beads static within the reactor whilst the wastewater passed around them. This would protect the beads from the impeller shear; however, it may reduce pathogen destruction efficacy, as the beads would no longer be present at the interface between the core and the turbulent outer part of the flow, and as a result may not encounter denser material or particulates within the reactor [10]. In addition, the location within the reactor where the beads have the strongest pathogen neutralising effect is not known and is also difficult to measure—if the strongest effect occurs at the site of the impeller, then this solution of keeping the beads separated from the impeller would likely be infeasible due to diminished antimicrobial activity.
\nThe second major issue is power consumption; as highlighted earlier in this chapter, interruption of power poses a major risk to wastewater processing. The prototype VBR operating at 956 RPM has been shown to take 15 min to sterilise 10 L volume, and so needs to run for 90 min to clean 60 L pathogen-laden waste water—the average amount of waste water from all sources produced per person per day. With the energy consumption figures shown above (Figure 4), this equates to approximately 65 W. It can, therefore, be considered to have an annual power footprint of around 36 kW·h−1 yr−1 per person, which at standard UK prices [15] comes to an average cost of £3.60 ($4.70) per person annually. An alternative impeller design could reduce power requirements here by as much as 30% [24], and the device could be made even more efficient by selecting a motor of the minimum power required to remove pathogens. Both of these are efficiency measures, however, and do not preclude the requirement of electricity to keep the device operational.
\nA hand-crank was designed and 3D printed for the prototype, as a fail-safe option for this when access to electricity was limited or cut off. Whilst this option could be useful in an emergency it has a few issues. First, the obvious sociological issue—the 90 min per person per day time requirement for sterilisation is not an issue for a motor; however, an individual operating the hand-crank may have serious reservations about the technology, particularly if they are providing water for more than one individual. In addition, whilst a motor can be run at a fixed speed for a fixed amount of time, this same regularity is not ensured with a human operator. The effects of modulating the rate of impeller rotation on the pathogen removal will need to be thoroughly investigated if this avenue is to be considered in more depth. Designs that control the rate of rotation could be implemented, but they also increase the complexity of the device, which may cause problems for operation and repair. An advantage of the mechanism of pathogen destruction using the copper-laden beads within the swirl-flow system is that due to the mechanism of action, it practically only has a minimum threshold for pathogen removal—although high speeds will cause premature degradation of the beads. The antimicrobial effect occurs as a result of extensive cell membrane damage, where the shear forces, presence of oxygen and copper all contribute towards this effect. The device will still remove pathogens passively, however, the rate at which this happens is around six-fold slower.
\nThere is a strong argument that having a powered device, even a hand-powered device, is a less suitable solution than designing a passive swirl-flow system, such as a hydrocyclone. A gravity-driven device may be able to achieve similar effects without the need for an external power source. Whilst such a design would be favourable, it is important to keep in mind the key principals of a DeWaTS during its design. It is also important to ensure that not only is the operation of the device simple, which a passive device should be, but also that any repairs should be possible with locally available parts. If the device is too complicated for the end user to repair themselves, or if the repairs are infeasible due to the expense or scarcity of the materials used, then when an issue occurs and the device fails, it will simply no longer be used. This sociological angle needs to be considered when designing global challenge-type technologies, particularly those that will be maintained by individuals rather than by a dedicated authority.
\nThe final key issue that needs to be considered for the VBR as a DeWaTS is a simple efficacy or a failure test. As this device is intended for use by individuals, it should also come with some form of simple, reliable and cheap test to verify that the device has performed its function. Growth assays commonly used to determine the presence of CFUs are accurate and the materials needed are cheap, but the test requires sterile conditions, as well as specific training in aseptic technique. Without these, the test will produce false positive results. Some form of this test is essential for an operator, especially in cases where the design has been modified or repaired by an individual. An attempted but failed repair could result in a seemingly operational device, which is outputting harmful pathogen-laden water that is presumed to be clean. The test would need to follow the same principals as the rest of the DeWaTS design, and be free of expensive or difficult to obtain reagents. The field of synthetic biology may be particularly useful for this. Synthetic biology is a branch of genetic engineering that differentiates itself from the rest of the field by being founded in core engineering principals, namely, those of characterised standard parts and rational design. Initiatives such as the international genetically engineered machines (iGEM) foundation have created a repository of standard parts, most of which are freely available [25]. The repository is boosted by an annual iGEM competition, where numerous teams have created parts based around wastewater treatment. The advantage of a genetically engineered ‘biomarker’ for this task is that once designed it can be propagated indefinitely for very low costs. Furthermore, a design like this could be utilised in ensuring functional operation in a variety of different water treatment devices beyond the VBR.
The VBR was named for the cell growth aspects that were observed during operation [14]. When microalgae grow photo-autotrophically—with light as their sole source of energy—the ensuing photosynthesis results in toxic levels of oxygen being produced. One of the main advantages with the swirl flow in the VBR design is the high levels of gas exchange which occurs between the liquid and any gas present in the system. This high level of exchange results in the dissolved oxygen levels being kept at a level closer to that of ambient air, providing a free air exchange that is enabled with the outside environment. Oxygen toxicity resulting from limited gas exchange is a significant issue for impeller-driven photo-bioreactor systems, hence the widespread use of energy intensive gas-mixed systems, such as air lift reactors or bubble columns. Typically, if a gas is not used for mixing the liquid, then a dedicated degasser compartment will need to be added to the design of any photobioreactor. A vortex degasser could have wide-ranging functionality in this field, as vortex flow is both an effective gas exchange method and a scalable technology, however, tuning the shear forces to avoid killing organisms from each individual species whilst maintaining maximum oxygen exchange, likely precludes a ‘one size fits all’ passive design.
\nModulating the shear forces on the VBR can provide a user controlled growth-lysis switch; however, it is also possible to grow the microalgae embedded within the beads, which provides protection during recirculation. This is already done with alginate beads in industrial bioreactors with Chinese Hamster Ovary (CHO) cells for high-value pharmaceutical production, as these mammalian cells are highly susceptible to shear-derived lysis and grow much more readily when affixed to a surface; however, it is important to note that recent research suggests that alginate is not the most suitable encapsulation polymer [26].
\nWithin the VBR, there are three key benefits to using this growth regime. First, the mixing rate could be increased to a level that encourages maximum gas exchange but does not damage the cells, reduce growth rates or negatively impact the final product. Second, introducing a hostile, high-shear environment within the reactor reduces the movement of biological organisms between the environment and the bioreactor system. This is true in both the inward (contaminant) and outward (containment) directions. It is accepted that during microbial scale-up a certain amount of external contamination will occur, however, under a high-shear regime in the VBR, contaminating organisms will either be destroyed outright, or will have their growth diminished so that the chances of them outcompeting the encapsulated species in the reactor is lower. When working with genetically modified (GM) organisms, there is extensive concern about a GM release. The same principles mentioned above that keep the culture axenic (free from contamination) will also limit GM release. Finally, the process could be run completely continuously rather than in batch like the majority of other systems. This removes the need for expensive turnaround between cultures. With the culture confined to the beads, it also becomes trivial to separate them from the media and to recycle the media by replenishing only the nutrients that have become depleted rather than needing to replace the entire liquid volume.
This work was supported by grants awarded to MJA from the Bill & Melinda Gates Foundation (OPP1044451, OPP1095464), Innovate UK (previously Technology Strategy Board, TSB100985) and Biotechnology and Biological Sciences Research Council (BB/N010396/1). The findings and conclusions contained within are those of the author(s) and do not necessarily reflect positions or policies of the BMGF, I-UK or BBSRC. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
Stroke is an insult to the brain tissue caused by a sudden interruption to the blood supply to the brain [1]. Sacco et al. gave an elaborate definition of stroke as a neurological deficit attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intra-cerebral haemorrhage (ICH), and subarachnoid haemorrhage (SAH) [2]. Stroke is highly prevalent and a second major cause of death and disability worldwide [2, 3, 4]. Stroke is a leading cause of dementia and depression. It can be classified on the basis of its aetiology as either ischaemic (87%) or haemorrhagic (13%) [5]. Ischaemic stroke results from occlusion of a cerebral artery which can be thrombotic or atherosclerotic (50%), embolic (25%) and micro-artery occlusion (lacunar stroke or infarcts) (25%) [5]. Haemorrhagic stroke is caused mainly by spontaneous rupture of blood vessels or aneurysms or secondary to trauma [5]. Early definitions of stroke and transient ischemic attack (TIA) focused on the duration of symptoms and signs. However, Sacco et al. [2], noted that use of clinical observations and modern brain imaging showed that the duration and reversibility of brain ischemia is variable. Brain tissue that is deprived of needed nutrients can, in some patients, survive without permanent injury for a considerable period of time, that is, several hours or even, rarely, days, while in most other individuals, irreversible damage (infarction) occurs quickly [2].
There has been a rise in the prevalence of stroke related disability in many countries [6]. A rise in the incidence of stroke in Zimbabwe from 31/100,000 to 57/100,000 in a decade was reported with fatality rates ranging from 22 to 58% at one month following stroke reported in Zimbabwe and other African studies [7].
The risk factors for stroke are generally similar to those for coronary heart diseases and other vascular diseases [4]. High blood pressure is one of the leading primary and secondary modifiable risk factors [5]. The other risk factors for stroke include smoking, low physical activity levels, unhealthy diet, abdominal obesity, diabetes and excessive consumption of alcohol [4]. Effective prevention strategies should include targeting the key modifiable risk factors such as hypertension, elevated lipids and diabetes.
Clinical manifestations of each stroke differ based on the part and side of the brain affected, extent of the lesion and the person’s general health. Some of the effects of stroke include numbness, weakness or paralysis on one side of the body opposite the side of the brain affected, slurred speech, difficulty thinking of words or understanding other people, confusion, sudden blurred vision or sight loss, being unsteady on your feet and severe headache [8]. Concerning the stroke warning signs, numbness on one side was surprisingly identified as the commonest warning (44%) while unspecified pain was the least cited (11%) in one of the studies [9]. Stroke can also result in psychological problems such as depression, anxiety, feeling helpless and thoughts of death or suicide, trouble sleeping and feelings of worthlessness [10]. In general, a right cerebrovascular accident may result in left hemiplegia or hemiparesis, difficulties with visuo-spatial memory, neglect of the left side of the body, poor judgement, and impulsivity, while a left cerebrovascular accident may cause right hemiplegia or hemiparesis, apraxia, and aphasia due to the location of the Broccas’ and Wernicke’s areas [11].
Stroke was associated with 43.7 million disability-adjusted life years annually around the world [5]. It is one of the most common neurological diseases in the black African and the leading cause of adult neurological admissions in West African sub-region, constituting up to 65% of such admissions [9]. Globally, 70% of strokes and 87% of both stroke-related deaths and disability-adjusted life years occur in low- and middle-income countries [4]. Approximately 60% of stroke patients acquire permanent disabilities and experience limitations in terms of mobility, vision, voice, speech, swallowing (dysphagia) and sexual function globally [4]. Stroke can cause multiple impairments which might need a variety of rehabilitation interventions [12]. Motor impairment is the most common deficit after stroke and the motor deficits increase fall risks and fall-related injuries. This in turn significantly affects the patients’ mobility, participation in their activities of daily living, social events and other occupational performance areas [13].
Stroke is a leading cause of functional impairments; with 20% of survivors requiring institutional care after three months and 15–30% being permanently disabled [14]. Many stroke patients experience activity limitation, restricted social participation, and psychological issues such as anxiety and depression some years after having stroke [15]. Approximately 65% of stroke patients are dependent on others to help them with everyday activities and the quality of life 2–5 years after stroke has been reported by many stroke survivors as poor [15].
Several researchers have studied the stroke survivor’s physical, social, psychological and emotional needs [16, 17, 18, 19]. Although most stroke patients receive rehabilitation, the lifelong need for care of stroke patients with disabilities has not been fully explored [17]. Despite calls for comprehensive stroke services to address long-term needs of patients, there had been little investigation of the perceived needs of stroke survivors in the long term or what determines such needs [20]. This area lacked a systematic approach to problem identification, had a poor evidence base, and was not underpinned by sound theoretical concepts hence there was need for further research in the area [15]. Similarly, needs of caregivers for stroke patients need further exploration.
Stroke Rehabilitation is a progressive, dynamic and goal-orientated process aimed at enabling a person with impairment as a result of stroke to reach their optimal physical, cognitive, emotional, communicative, social and functional activity level [21]. Stroke rehabilitation begins in the acute care hospital after the person’s overall condition has been stabilised, often within 24–48 hours after the stroke [22]. Stroke rehabilitation plays a vital role in lessening the effects of impairments and activity limitations, and in facilitating the return to active participation in community life and economic self-sufficiency after the stroke [12]. Internationally recognised best practice in the early management and rehabilitation of individuals following stroke includes collaborative and multidisciplinary assessment and treatment by a coordinated team of health care professionals [23]. A collaborative approach improves quality of life in stroke patients [12].
In the first weeks and months of recovery, the goals of rehabilitation are to help survivors become as independent as possible and to attain the best possible quality of life [21]. Although rehabilitation may not reverse the brain damage, it can substantially help people achieve the best possible long-term outcomes [22] through various ways that include facilitation of neuroplasticity of the brain. Rehabilitation is especially crucial during the early stages of recovery to regain independence when patients have little or no control over their affected muscles [22].
As part of stroke rehabilitation, occupational therapy (OT) involves the use of activities or training to improve or maintain the ability to live independently and cope with daily life for people with stroke [16]. The philosophy of occupational therapy is based on the concept that all humans have a need to become engaged in occupations [24], and that need is present even after stroke. Therefore, the role of the occupational therapist is to facilitate the patient’s continued participation in meaningful and purposeful daily activities and adaptation to the patient’s changed status. These occupations (all goal-directed engagement in self-care, work or leisure activities) can be termed as activities and participation areas in the International Classification of Functioning, Disability and Health (ICF) terminology [25]. According to the ICF framework, stroke results in activity limitation and participation restriction [26]. The ICF is a globally agreed framework and classification to define the spectrum of problems in the functioning of patients [27]. The ICF was also shown to be an essential tool for identifying and measuring efficacy and effectiveness of rehabilitation services [28]. Using the ICF takes a biopsychosocial approach which addresses the quality of life gap which is often left in favour of quantity of life.
Occupational Therapy in general, focuses on the assessment and treatment of individuals who are limited by physical injury or illness, psychosocial dysfunction, developmental or learning disabilities, or the ageing process through the use of purposeful activity and adaptive equipment and technology in order to maximise independence, prevent disability and maintain health [29]. Occupational therapists play a crucial role in the rehabilitation of stroke patients as they are experts at training patients to relearn complex bodily movements and avoid complications that could derail their progress later [30]. Occupational therapy is concerned with promoting health and wellbeing through participation in activities of everyday life and this is done by modifying the occupations and the environment in a therapeutic way to better support participation [23]. Occupational therapists also employ neurophysiologically based handling techniques meant to facilitate neuroplasticity of the brain. In some instances, occupational therapists can teach compensatory strategies when the old ways of functioning are no longer possible [30]. Therefore, occupational therapy for stroke includes interventions for physical, social, psychological and cognitive impairments [30]. The role of occupational therapists in stroke rehabilitation is particularly important because they focus on functional outcomes and getting clients back to doing everyday activities [11] which is usually unique to the profession. It is important that the interventions suit a patient’s needs [30].
The period of receiving services in stroke rehabilitation depends on the severity of disability and specific needs of the stroke survivor, although it has been proved that a great deal of stroke recovery occur within the first six months to a year following the onset of the stroke [31]. Occupational therapists work collaboratively with the patient to establish the impact of stroke on their performance of daily tasks, including personal care, domestic tasks, work and leisure activities; and in formulating a goal-focused program to develop the required skills for participation in daily life [23]. Given the variability in stroke complications, occupational therapists need to have a wide repertoire of techniques to help each client [11]. The treatment techniques in occupational therapy may include using occupational tasks to help improve cognitive abilities, teaching adaptations to meaningful activities to keep the client involved, and using task-specific movement to help with range of motion and motor control [11]. The occupational therapist can provide a patient with an assistive device or adjustments and adaptations in the environment, for example, in a patient’s home. This enables the patient to perform his/her ADLs independently and also dealing with other emotional or social issues that may result from stroke [30].
The occupational therapy process for stroke patients begins with an assessment of the patient’s roles, tasks and activities that are important for the patient [30]. An assessment is conducted to understand the impact of changes in motor function, sensation, coordination, visual perception, and cognition on the stroke patients and on the capacity to manage daily life tasks [23]. Assessment is also used to identify areas of individual and environmental difficulties and to enable patient-centred goal setting with the participation of both the patient and the caregiver [23]. The occupational therapist will then assess the ability to perform the roles, tasks and activities and if a limitation or restriction in some area is found, the occupational therapist will identify the performance components and craft the solution or intervention meant to restore, improve or maintain patient’s maximum level of performance [30]. Some of the performance components may include neuromuscular, cognitive and perceptual, language and psychosocial problems.
The occupational therapy interventions should therefore be able to address the patient’s needs and be provided in both the acute and rehabilitation phases [30]. For some stroke survivors, rehabilitation will be an on-going process to maintain and refine skills and could involve working with occupational therapists and other specialists in that field for months or even years after the stroke [22].
In order to adequately address challenges stroke patients face, there is need to identify the activities and areas of participation they consider important. This section is therefore based on a study done in Zimbabwe which sought to find out the activities and areas of participation considered important by stroke patients, the level of difficulty experienced in carrying out these activities and the reasons for attaching importance to these areas [32]. The study was cross sectional descriptive in nature and was done with 40 stroke patients consecutively selected as they came for their reviews at an outpatient stroke clinic at a central hospital in Zimbabwe [33]. An interview questionnaire adapted from the ICF checklist version 2.1a clinician form was administered by the researchers with consent after ethical approval (JREC….). Excluded were patients with significant cognitive and language impairments as it would have been difficult to communicate with them. In the study, 25 were female and 15 were male. Participants’ ages ranged from 34 to 81 years with the 50–59 years age group being the mode. These demographic characteristics are consistent with a study done by Mlambo et al. [34], which was done in South Africa and the participants’ ages ranged from 32 to 81 with a mean age of 52 years. The activities and areas of participation assessed during the study were obtained from the domains in the ICF checklist as alluded to earlier.
Half of the patients reported severe difficulty in lifting and carrying objects, while 43 and 38% of participants experienced complete and severe difficulties in fine hand use respectively [32]. About 20% had flexion contractures of the elbow and wrist joints of the affected side. These difficulties were due to the condition (stroke) which causes disturbances in muscle tone and loss of selective and isolated movements in the hand and arm [35] and this hinders execution of functional movements [36]. Thirty three percent of the participants had moderate difficulty in walking and used mobility aids while 20% had complete difficulty [32]. Half of the participants reported experiencing complete difficulty in using transportation like cars or buses. On driving, only 18 participants were drivers and 78% of them reported complete difficulty in the area [32].
On importance attached to these domains, all participants considered fine hand use and walking important, while 98% considered being able to use transportation important [32]. However, it was noted that none of the participants who were drivers had driving addressed by their therapist. Driving rehabilitation is an area that has not been fully explored by OTs in Zimbabwe. Driving is an important ADL and many stroke patients who were driving prior to their stroke wished to resume driving as noted by Kneebone and Lincoln [37]. A study by Duncan et al. [38] found that hand function and mobility were some of the key areas considered important by stroke patients.
Half of the participants in the study reported severe difficulties in dressing, 33% had moderate to severe difficulties in grooming while 65% had severe difficulty in bathing themselves [32]. About 73% had no difficulty in feeding and this can be explained by the exclusion of patients with speech and cognitive problems in the study. Speech and cognitive problems are often associated with feeding problems. Thirty three percent did not experience any difficulties in toileting while the remainder had mild to severe difficulties and used sanitary wear or were catheterised [32].
All aspects of self-care were considered as very important by all participants as they viewed these activities crucial for human survival [32]. This was also noted in a study by Aberg et al. [39] where the participants valued their independence in self-care activities.
In Chimusoro’s study [32], 78 and 75% of participants had complete difficulties in acquisition of goods and services, and preparing meals respectively. About half of the participants considered being able to prepare meals important, while 32% consisting mainly of male participants and elderly female participants did not view it as important since they had their meals prepared for them by caregivers. On doing housework, all male participants considered it as not applicable to them. This is common in the Zimbabwean and most African cultures where most if not all men, do not consider household chores as part of their ADLs. Therefore it would be irrelevant to engage a male patient in therapy sessions focusing on retraining household chores unless found necessary during the assessment process. The same notion applied to the elderly female patients who had long stopped doing those chores before suffering a stroke. These duties were done for them by children, grandchildren and/or caregivers [32]. This is where the aspect of interdependence is seen in the African culture. The elderly in Africa usually end up living with their children and grandchildren as compared to the Western culture where the elderly can be living alone and independence in home maintenance tasks becomes an important aspect of their lives.
All the participants did not have any difficulties in basic interpersonal interactions, formal and informal interactions [32]. Participants considered these areas important. However, 10 and 4% had mild and moderate difficulties in intimate relationships respectively. They attributed their problems in sexual function to their condition and felt it hindered maximum enjoyment of intimate relationships. They viewed their intimate relationships as important but were reluctant to share this with their therapist since they were not aware that the issue could be addressed in occupational therapy. Resumption of sexual activity for stroke patients is very important as cited by Edmans, although they may fail to articulate this to the therapist [40].
In this domain remunerative employment was not applicable to half of the participants as some were retired and some did not work prior to suffering the stroke. For the remaining half they reported complete difficulty and had not yet returned to their previous jobs. This is consistent with the findings by D’Alisa et al. [41] in which 40% had severe restrictions in employment issues. About 95% of patients to whom employment was applicable considered it as very important [41].
About 33% had moderate difficulties in economic self-sufficiency as they had financial problems due to their unemployment status. All the participants considered being self-sufficient important. In D’Alisa et al. [41], 15% had moderate to severe restrictions in economic self-sufficiency. This difference may be due to lack of a national social security system that cushions persons with disabilities in Zimbabwe as compared to more developed countries.
All participants considered it important to be reintegrated into the community. About 85% did not report any difficulty in participating in religious and spiritual activities and 95% considered them very important [32].
Fifty eight percent considered recreational activities as important. These recreational activities were mainly visiting friends and relatives, watching television, reading or listening to the radio [32]. There is a stark contrast in the type of recreational activities cited by the Zimbabwean sample as compared to other studies where participants reported restrictions in activities like golf, bowling, tennis and attending social clubs. The differences in the recreational activities can be explained by the differences in the socio-economic statuses of the samples. The culture of participating in recreational activities for leisure purposes need to be reinforced and further explored especially in low income groups where people mostly engage in productive activities whether paid or unpaid than they do in recreational activities.
Out of the 40 participants, 53% wanted to return to their work. They considered it very important because some were breadwinners and wanted to be able to look after their families [32]. In a study in Singapore by Kong and Yang [42], 14 out of 54 participants continued to be gainfully employed [42]. Of these 14, 11 were able to go back to previous jobs while 3 had to change jobs due to their physical limitations [42].
Thirty four percent wanted to be able to do their instrumental ADLs again [32]. These were mainly female participants who valued being able to look after their children and homes. Only 10% did not wish to return to any activity in particular and these were mainly elderly patients who had not been engaging in any activities that they considered important enough to return to [32]. In such cases, it would be necessary for the therapist to try to look for areas of interest for the patient so as to build a passion for doing activities that are meaningful to them and can also be used during therapy.
In summary, these findings give insight into the areas stroke patients consider important in the Zimbabwean context. They are consistent with other studies, for example, one study by Sumathipala [20], where stroke patients considered ADLs, social participation, mobility aids, home adaptations, housing and financial support as important [20].
The ICF is an important framework in guiding management of stroke patients as it can be used to assess and address all aspects of a person’s life without just focusing on his/her diagnosis [43]. Occupational therapy has an important role of facilitating a patient’s optimal functioning and independence through participation in meaningful and purposeful daily activities. The strength of occupational therapy lies in the ability to analyse activities/occupations. The occupations in which a person engages and the amount of time one spends doing the occupations is very specific to the circumstances and the culture in which a person lives [44]. Therefore, the effectiveness of occupational therapy and the quality of care can improve when culturally relevant occupations are selected and interventions are important to a person with stroke.
This section is based on a cross sectional pilot study done in Harare, Zimbabwe in 2020 with 35 stroke patients attending rehabilitation [45]. Mean age of participants was 58 years (S.D 8.8) and the greater proportion were female (
About 49% were employed [45], consistent with another study done on stroke survivors in Zimbabwe where less than half were working and the rest had no source of income [46]. Left cerebral Vascular Accidents accounted for 74.3% of the strokes. Study participants had a median duration with stroke diagnosis of 104 days (inter-quartile range 44–270). This is mainly the situation in Zimbabwe where most of the patients who come for rehabilitation have stroke duration of less than two years. Those who had stroke for more than two years will have inadequate funds to continue treatment, hence will not come for rehabilitation services.
The needs of participants were grouped into physical, instrumental, social, informational and emotional needs. Highlighted in Table 1 are the needs according to the groupings and it consists of 28 statements to which participants were expected to answer “yes” or “no” on whether they consider it a need.
Item | Need | Considered as a need by stroke patients | |
---|---|---|---|
Yes | No | ||
1 | To ease my pain, since nothing seems to ease it. | 35 (100%) | 0 |
2 | Help on walking and general moving | 35 (100%) | 0 |
3 | Help on how to get job done in my home (ADLs) such as cleaning, cooking, ironing and laundry | 35 (100%) | 0 |
4 | Help on how to do things like cutting my toenails, washing myself | 35 (100%) | 0 |
5 | Help on how to deal with fatigue | 35 (100%) | 0 |
6 | Learning about exercise | 35 (100%) | 0 |
7 | Help on how to bath independently | 35 (100%) | 0 |
8 | Help on dealing with bladder/ bowel problems (accidents, constipation, diarrhoea) | 32 (91.43%) | 3 (8.57%) |
9 | Help on how to prevent pressure sores | 30 (85.71) | 5 (14.29%) |
10 | Help on sight problems. | 29 (82.86%) | 6 (17.14%) |
11 | Help on getting back to driving | 19 (54.29%) | 16 (45.71%) |
12 | Help on swallowing problems. | 14 (40%) | 21 (60%) |
13 | Help on speech and communication problems | 12 (34.29%) | 23 (65.71%) |
14 | Help on hearing problems. | 4 (11.43%) | 31 (88.57%) |
15 | Additional aids or adaptations (kitchen appliances, stair lift, grab rails) if other please specify | 35 (100%) | 0 |
16 | Adaptations outside the home (e.g., ramps, rail) if other please specify | 33 (94.29%) | 2 (5.71%) |
17 | Help on how to occupy my day better (e.g., social outings, hobbies, leisure activities) | 35 (100%) | 0 |
18 | Help and advocacy in accessing social services | 34 (97.14%) | 1 (2.86%) |
19 | Help on how to travel using public transport such as buses and commuter omnibuses | 32 (91.43%) | 3 (8.57%) |
20 | More information about my stroke (e.g., what is stroke, why has it happened to me, how to avoid having another one) | 35 (100%) | 0 |
21 | Advice on how to improve my diet | 35 (100%) | 0 |
22 | Advice on how to manage my money better. | 33 (94.29%) | (5.71%) |
23 | Help on how to do shopping. | 32 (91.43%) | 3 (8.57%) |
24 | Advice on employment after stroke | 25 (71.43%) | 10 (28.57%) |
25 | Help and information on how to manage my physical relationship with my partner | 13 (37.14%) | 22 (62.86%) |
26 | Help on improving self-esteem, anger issues and other emotional issues If other please specify | 35 (100%) | 0 |
27 | Help on improving my memory and concentration. | 33 (94.29%) | 2 (5.71%) |
28 | Help on how to deal with emotional and behavioural changes | 34 (97.06%) | 1 (2.94%) |
Distribution of participants according to need (
Fourteen statements related to physical needs. All the participants in the study considered pain management, walking and general mobility, performing basic and instrumental activities of daily living (ADLs), engaging in recreational activities, dealing with fatigue and exercising as their physical needs post stroke [45]. Specific self-care needs cited were independent bathing and cutting toenails. Only 40% and about 11% cited swallowing and hearing problems respectively. Thus physical needs were the most common needs of stroke patients. This is because stroke mainly affects the physical components resulting in pain, reduced mobility, poor muscle strength, reduced speech and communication, problems with swallowing and incontinence and many other deficits which might results in decreased functioning and inability to cope [12]. In a similar study done in Australia, patients mostly over the age of 65 years needed assistance with performing ADLs, such as self-care [15], and this shows that this is a major need among all stroke patients regardless of location.
Sight problems, prevention of pressure sores and dealing with bladder and bowel problems were cited by more than 80% of participants as needs indicating that they are also common needs in this group.
These two aspects had a combined five needs (Table 1). There were two items on instrumental needs, and all participants indicated the need for additional aids or adaptations in the house while 94% cited need for adaptations outside the home. Under social needs, there were three items and about 97 and 91% respectively indicated the need for help and advocacy in accessing social services and using public transport. All participants needed help on how to engage in social outings, hobbies and leisure activities. Stroke survivors in this study faced societal barriers that can affect engagement in activities of daily living namely problems in using public transportation, lack of adaptations inside and outside the home environment as well as lack of aids and appliances to facilitate independence. Due to the economic situation in Zimbabwe, most places are not specifically adapted for people with disabilities to engage fully in social and daily activities, for example, inadequate provision of rails and ramps in public buildings for those who have problems with mobility [47]. Assistive devices like wheelchairs and modifications to the home environment are not available to the survivor soon after discharge to promote maximum participation [48], hence participants citing them as needs they require occupational therapists to meet. In Zimbabwe, wheelchair service provision and services are fragmented and poorly integrated [49]. The use of mobility devices such as wheelchairs, crutches and canes improves mobility, health and quality of life, and it enables those with mobility issues to mobilise without any restrictions [48]. Another study showed that stroke survivors had more participation restrictions as a result of environmental barriers [50]. Physical/structural and services/assistance were considered the dominant barriers to participation in activities of daily life for stroke survivors in China, hence there were considered to be among the most common needs presented by stroke survivors [51]. In another study on “Identification of rehabilitation needs after a stroke”, some of the most expressed needs of the participants were needs relating to adapted means of transportation and home visits from healthcare personnel [52]. Home visits might also help in noting any home adaptations that need to be done [53]. Social support should be provided to stroke survivors, including barrier-free facilities and occupational therapists should advocate for those services in the community.
Six items related to informational needs. All the participants needed information on their condition (stroke) and advice on diet. Over 90% needed advice on or help on better money management and shopping. Twenty-five participants needed advice on employment after stroke. The least cited as informational need had to do with managing physical relationships with partner/spouse (about 37%) (Table 1). The need to give more information about the condition is consistent with findings by Williams et al., where only 38% professed to know stroke warning signs and only 25% correctly interpreted their symptoms [54]. Similarly, Mckevitt, et al., reported more than half of their participants wanting more information about their stroke (cause, prevention of recurrence) [55]. This shows that this is a major concern among most stroke patients regardless of the part of the world they live, hence the need for occupational therapy intervention. Knowledge about the condition will also help them to adhere to the home programs they will be given and to seek for early treatment before any complications or permanent disability arises. With more knowledge about stroke, they could identify the disease immediately, resulting in a decrease in the time from symptom onset to hospital arrival, and a subsequent increase in the number of patients who may receive appropriate interventions [56]. It might also help them to know how to prevent any future recurrence of the condition and the services that might be beneficial to them in order to minimise any complications that may arise as a result of the condition.
Three items related to emotional needs. All items were cited as needs by more than 94% (improving memory and concentration (94.29%), self-esteem, anger and other emotional issues (100%) plus dealing with the emotional and behavioural changes (97.06%) (Table 1). This high proportion of more than 90% of the participants having emotional needs after stroke is probably because stroke affects the person’s ability to engage in daily living activities, communicate well with others and that can lead to increased dependence, feelings of low self-worth, (e.g., if the patient is incontinent) resulting in many psychological and emotional issues like depression [57]. The findings in this Zimbabwean study are consistent with a study on “Self-Reported Long-Term Needs After Stroke” where over one third of respondents reported experiencing emotional problems (including depression, crying) after the stroke [55]. Since emotional and psychological needs are liable to be neglected, post-stroke depression is a common complication which seriously impairs quality of life [18]. Therefore, psychological expertise and psychological support is needed by stoke survivors [18].
The majority of the participants in the Zimbabwean study perceived most of the needs in all categories as important and requiring intervention [45]. Physical needs rated as very important in this study were independent mobility and dealing with bladder and bowel incontinence. These aspects enable participants to be independent and to perform daily activities without restrictions. Participants also perceived informational needs as important [45]. Information on dietary issues is important among stroke patients as this might enhance recovery and help in minimising the intake of unhealthy foods such as saturated fats and too much sodium chloride which might even increase the risk of having a recurrent stroke [58]. Knowledge about one’s condition will conscientise them on the importance of receiving rehabilitation and adhering to one’s treatment and medications. The knowledge can also minimise complications and prevent future recurrence of the condition, hence this information is important among stroke patients [59]. Furthermore, knowledge and information about the condition is important since there is often confusion and a lack of information about surviving after a stroke, prevention of subsequent strokes, treatment, services, benefits and adaptions to property [60, 61]. Stroke survivors had to adapt to changes in their bodies as a result of stroke and adjust their expectations, including roles within the home and community [60]. This was particularly so for those of working age and hence the importance of knowledge on the condition.
In one study, stroke survivors experienced a lack of information about what had happened to them and did not realise they had had a stroke [62]. Relevant information is required at different times after a stroke, for example, information about benefits and services most needed after discharge from hospital [61]. Some survivors and carers are unsure which profession offers which service, and there can be role confusion related to an Occupational Therapist, a Physiotherapist, a Home Carer and a social worker, hence this information is also important among stroke patients who should know which services can address their specific needs [60].
The majority of the patients in the Zimbabwean study indicated that adaptations in the home environment were important [45]. Without these, stroke survivors are restricted in performing their daily activities and social roles resulting in increased dependency [63]. Without assistive technology, stroke survivors and other people with disabilities are often excluded, isolated and locked into poverty, resulting in increased burden of morbidity and disability [63]. This is similar to a study done to identify the long-term needs of stroke survivors using the ICF where the participants reported that home adaptations (such as stair or grab rails) provided after discharge from hospital enabled them to adapt to their physical disabilities by facilitating independence in walking, climbing stairs and ADLs [20]. Stroke patients saw this as important since these factors might create a significant barrier to their physical functioning and independence.
Pfavai [45] also revealed that emotional issues such as dealing with depression and behavioural changes were rated as important by more than 80% of the participants. Most of these are not easily seen unlike physical needs hence their importance might be overlooked by occupational therapists. These issues might affect recovery and engagement in daily occupations hence they were perceived as important by the participants. Emotional problems such as depression might also be fatal, in worst cases leading to suicide and general increased mortality, hence their importance must not be overlooked [64]. A sudden attack and poor prognosis had an appreciable effect on the psychological and emotional wellbeing of stroke survivors [18], hence they are important and should be addressed. Interventions usually focus on treating the disease, rather than the emotional needs of the patients. These emotional and psychological needs are liable to be neglected and post-stroke depression is a common complication which seriously impairs quality of life [18, 63].
Participants in Zimbabwe also perceived the need to engage in recreational pursuits as important in their lives [45]. This is one of the areas which are mostly neglected during intervention by occupational therapists. However, engaging in leisure and recreational activities is of importance since it improves physical health, enhances mental wellness, social interaction with others and it enables the stroke survivors to engage in activities which are meaningful in their lives [65]. In a study done on coping with the challenges of recovering from stroke, participants reported the importance of recreational activities and the great distress which was associated with the loss of hobbies and activities that had previously been a source of pleasure and achievement [62]. This is also in line with Rhoda et al., [66] where the participants highlighted the importance of engaging in recreational activities. Participants experienced social isolation, restriction to their homes which they felt could result in sadness and depression due to inability to engage in those activities which were normally found interesting before [66]. However, these activities should be client centred so that their benefits to each individual can be realised.
Access to public transport which is conducive and specifically adapted for people with disabilities was perceived as important by participants in Pfavai study [45]. This is important since lack of suitable transport results in participation restriction in activities such as religious activities, shopping and other social gatherings participants might want to engage in [47]. In a study done in China, physical/structural and services/assistance which include inaccessible public transport for those with disabilities were considered the dominant barriers to participation in activities of daily life for stroke survivors in China hence these needs are important and should be addressed [18]. Social support should be provided to stroke survivors, including barrier-free facilities [47]. Furthermore, the social security system for stroke survivors and other disabling conditions needs to be improved in low-income and middle-income countries.
Findings from Pfavai study [45] indicated that most of the needs of stroke patients were not being fully met including those needs participants rated as very important. Perceived unmet needs may reflect expectations and knowledge but may also indicate where service provision should be developed [55]. The needs which were mostly being fulfilled were physical needs such as pain management, exercises to facilitate walking and mobility in general, and self-care including independent bathing [45]. This is because these needs can be easily identified and their physical limitations can be easily noted compared to other needs such as emotional, informational and societal. The later ones are therefore less likely to be addressed. These findings are consistent with McKevitt
The emotional needs highlighted included how to deal with depression, anger issues, low self-esteem and behavioural changes as a result of stroke [45]. Emotional needs might be overlooked during the assessment process especially if the patient does not mention any emotional issues they might be experiencing. This is in line with a study done on the unmet needs of stroke patients where cognitive and emotional health needs such as concentration, memory, cognition, fatigue, and emotions were less likely to be fully met than physical needs despite physical needs being more common [15]. This affirms the requirement to implement strategies to help stroke survivors address the range of emotional problems they may experience [55]. Stroke rehabilitation usually focuses on physical impairments and assisting stroke survivors to develop functional independence. This may mean that services aimed at addressing the cognitive and emotional needs of stroke survivors are not adequately resourced [15]. This supports the results obtained in Pfavai [45] study where emotional needs were not being fully met compared to most of the physical needs [45]. Therapists need to be intentional in ensuring that emotional problems experienced by stroke survivors are adequately addressed.
Instrumental needs which were perceived as being unmet by more than 70% of the participants included adaptations outside the home environment and aids and adaptions inside the home environment [45]. Without these aids, stroke survivors are less able to perform their daily activities without restrictions [49]. However, due to the economic situation in Zimbabwe there is lack of resources in hospitals and assistive devices are scarce for those with performance limitations [45, 47]. There is also lack of transport and financial resources for the occupational therapists to do home adaptations for the patients soon after discharge [53]. This need might also be more than the 70% which was obtained in Pfavai study [45] since the study was partly done at a rehabilitation centre where the patients are given assistive devices such as wheelchairs for them to use before discharge and at a nominal fee after discharge. Stroke survivors have also reported that health systems are not responsive to their changing needs and that there is a lack of long-term re-assessment of their needs, [15]; hence some of the needs which might arise later during intervention may not be met.
Training on getting back to driving and information on how to do shopping were rated by more than 90% of participants as unmet [45]. These are some of the needs which are over looked during intervention. This might be due to lack of expertise among the concerned occupational therapists on driving rehabilitation. At the time of writing this chapter, there was no comprehensive module on driving in the University of Zimbabwe curriculum on occupational therapy undergraduate training. This might result in lack of expertise and confidence in addressing that need. This is also in line with a study done on coping with the challenges of recovering from stroke where loss of ability to drive a car was seen as a major challenge which required intervention and the ability to resume driving was spoken with deep emotion [62]. Driving was seen as representative of independence, a way to regain self-esteem, a means to access social support and to facilitate participation in valued activities [62]. This aspect however needs special training to avoid causing harm to patient and society.
Skills on shopping independently were also perceived as unmet in Pfavai study [45], and this might be due to lack of resources to simulate the shopping environment or lack of funds to teach the patients in the actual environment. In a study that looked at the combined perceptions of people with stroke and their carers regarding rehabilitation needs one year after stroke [67], patients reported having to give up a task in advance and had limitations in more physically demanding activities such as going to buy groceries among other tasks, supporting the need to address shopping needs among stroke patients [67]. The importance of this need might be overlooked during interventions. Information and knowledge needs of stroke survivors should not be underestimated and should be considered when developing strategies to meet the rehabilitation needs of stroke survivors [68].
Another unmet need in the Zimbabwean study [45] was financial/money management after a stroke. Most stroke survivors lose their jobs after the incident of stroke, and cognitive components might also be affected resulting in inability to adequately manage their money. However, this need seemed to have been overlooked. Li et al. also noted that few studies have looked at the financial impact of stroke on the survivors and their families, indicating that this area’s importance might be underrated [18].
Early discharge of patients due to unavailability of beds might also result in some of the stroke patients’ needs not being adequately met. Although many individuals still have rehabilitation needs one year after stroke, rehabilitation is often concluded within the first three months, and follow up is not usually done hence some of the needs might not be adequately fulfilled [67].
The occupational therapist is the health professional who specifically addresses patients’ involvement in daily life situations, and as such, she/he should be well conversant with that particular aspect of patients’ lives. This in turn addresses one’s quality of life which is often neglected. Stroke patients’ perceived needs highlighted above provide patients’ perspectives which is critical in the development of patient-centred services by service providers. The commonly used functional outcome measures (e.g., the Barthel Index) may underestimate dependence leading to rehabilitation professionals and patients prioritising different needs. Not using meaningful occupations in treatment; lack of discharge planning, using interventions not perceived as driven by patient’s occupational goals, and use of interventions chosen by therapists without considering what the patient needs thereby placing the patient in a passive role were noted as major challenges [69]. The stroke patients’ perceptions help the therapists to tailor interventions to meet patients’ specific needs.
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\\n\\nNo partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Author or any Co-Author, nor authorize any party to make or enter into any commitments for, or on behalf of, any other party.
\\n\\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
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\n\nNo partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Author or any Co-Author, nor authorize any party to make or enter into any commitments for, or on behalf of, any other party.
\n\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
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These physiological events occur smoothly in normal healthy individual and/or under normal conditions. However, in certain cases, these molecular events are retarded resulting in hard-to-heal or chronic wounds arising from several factors such as poor venous return, underlying physiological or metabolic conditions such as diabetes as well as external factors such as poor nutrition. In most cases, such wounds are infected and infection also presents as another complicating phenomenon which triggers inflammatory reactions, therefore delaying wound healing. There has therefore been recent interests and significant efforts in preventing and actively treating wound infections by directly targeting infection causative agents through direct application of antimicrobial agents either alone or loaded into dressings (medicated). These have the advantage of overcoming challenges such as poor circulation in diabetic and leg ulcers when administered systemically and also require lower amounts to be applied compared to that required via oral or iv administration. This chapter will review and evaluate various antimicrobial agents used to target infected wounds, the means of delivery, and current state of the art, including commercially available dressings. Data sources will include mainly peer-reviewed literature, clinical trials and reports, patents as well as government reports where available.",book:{id:"5290",slug:"wound-healing-new-insights-into-ancient-challenges",title:"Wound Healing",fullTitle:"Wound Healing - New insights into Ancient Challenges"},signatures:"Omar Sarheed, Asif Ahmed, Douha Shouqair and Joshua Boateng",authors:[{id:"183108",title:"Dr.",name:"Joshua",middleName:null,surname:"Boateng",slug:"joshua-boateng",fullName:"Joshua Boateng"},{id:"183399",title:"Dr.",name:"Omar",middleName:null,surname:"Sarheed",slug:"omar-sarheed",fullName:"Omar Sarheed"},{id:"188082",title:"Mr.",name:"Asif",middleName:null,surname:"Ahmed",slug:"asif-ahmed",fullName:"Asif Ahmed"},{id:"188083",title:"Ms.",name:"Douha",middleName:null,surname:"Shouqair",slug:"douha-shouqair",fullName:"Douha Shouqair"}]},{id:"51825",doi:"10.5772/64611",title:"Roles of Matrix Metalloproteinases in Cutaneous Wound Healing",slug:"roles-of-matrix-metalloproteinases-in-cutaneous-wound-healing",totalDownloads:3629,totalCrossrefCites:20,totalDimensionsCites:39,abstract:"Wound healing is a complex process that consists of hemostasis and inflammation, angiogenesis, re-epithelialization, and tissue remodeling. Matrix metalloproteinases (MMPs) play important roles in wound healing, and their dysregulation leads to prolonged inflammation and delayed wound healing. There are 24 MMPs in humans, and each MMP exists in three forms, of which only the active MMPs play a role in the pathology or repair of wounds. The current methodology does not distinguish between the three forms of MMPs, making it challenging to investigate the roles of MMPs in pathology and wound repair. We used a novel MMP-inhibitor-tethered affinity resin that binds only the active form of MMPs, from which we identified and quantified active MMP-8 and active MMP-9 in a murine diabetic model with delayed wound healing. We showed that up-regulation of active MMP-9 plays a detrimental role whereas active MMP-8 is involved in repairing the wound in diabetic mice. These studies identified MMP-9 as a novel target for therapeutic intervention in the treatment of chronic wounds. A selective inhibitor of MMP-9 that leaves MMP-8 unaffected would provide the most effective therapy and represents a promising strategy for therapeutic intervention in the treatment of diabetic foot ulcers.",book:{id:"5290",slug:"wound-healing-new-insights-into-ancient-challenges",title:"Wound Healing",fullTitle:"Wound Healing - New insights into Ancient Challenges"},signatures:"Trung T. Nguyen, Shahriar Mobashery and Mayland Chang",authors:[{id:"183405",title:"Prof.",name:"Mayland",middleName:null,surname:"Chang",slug:"mayland-chang",fullName:"Mayland Chang"},{id:"191152",title:"Mr.",name:"Trung",middleName:null,surname:"Nguyen",slug:"trung-nguyen",fullName:"Trung Nguyen"},{id:"191153",title:"Prof.",name:"Shahriar",middleName:null,surname:"Mobashery",slug:"shahriar-mobashery",fullName:"Shahriar Mobashery"}]},{id:"63675",doi:"10.5772/intechopen.81208",title:"Wound Healing: Contributions from Plant Secondary Metabolite Antioxidants",slug:"wound-healing-contributions-from-plant-secondary-metabolite-antioxidants",totalDownloads:1331,totalCrossrefCites:7,totalDimensionsCites:20,abstract:"Plants by their genetic makeup possess an innate ability to synthesize a wide variety of phytochemicals that help them to perform their normal physiological functions and/or to protect themselves from microbial pathogens and animal herbivores. The synthesis of these phytochemicals presents the plants their natural tendency to respond to environmental stress conditions. These phytochemicals are classified either as primary or secondary metabolites. The secondary metabolites have been identified in plants as alkaloids, terpenoids, phenolics, anthraquinones, and triterpenes. These plant-based compounds are believed to have diverse medicinal properties including antioxidant properties. Plants have therefore been a potential source of antioxidants which have received a great deal of attention since increased oxidative stress has been identified as a major causative factor in the development and progression of several life-threatening diseases, including neurodegenerative and cardiovascular diseases and wound infection. Consequently, many medicinal plants have been cited and known to effect wound healing and antioxidant properties. This chapter briefly reviews antioxidant properties of medicinal plants to highlight the important roles medicinal plants play in wound healing.",book:{id:"7046",slug:"wound-healing-current-perspectives",title:"Wound Healing",fullTitle:"Wound Healing - Current Perspectives"},signatures:"Victor Y.A. Barku",authors:[{id:"261027",title:"Prof.",name:"Victor Y. A.",middleName:null,surname:"Barku",slug:"victor-y.-a.-barku",fullName:"Victor Y. A. Barku"}]},{id:"66793",doi:"10.5772/intechopen.85020",title:"The Impact of Biofilm Formation on Wound Healing",slug:"the-impact-of-biofilm-formation-on-wound-healing",totalDownloads:1434,totalCrossrefCites:7,totalDimensionsCites:16,abstract:"Chronic wounds represent an important challenge for wound care and are universally colonized by bacteria. These bacteria can form biofilm as a survival mechanism that confers the ability to resist environmental stressors and antimicrobials due to a variety of reasons, including low metabolic activity. Additionally, the exopolymeric substance (EPS) contained in biofilm acts as a mechanical barrier to immune system cells, leading to collateral damage in the surrounding tissue as well as chronic inflammation, which eventually will delay healing of the wound. This chapter will discuss current knowledge on biofilm formation, its presence in acute and chronic wounds, how biofilm affects antibiotic resistance and tolerance, as well as the wound healing process. We will also discuss proposed methods to eliminate biofilm and improve wound healing despite its presence, including basic science and clinical studies regarding these matters.",book:{id:"7046",slug:"wound-healing-current-perspectives",title:"Wound Healing",fullTitle:"Wound Healing - Current Perspectives"},signatures:"Rafael A. Mendoza, Ji-Cheng Hsieh and Robert D. Galiano",authors:[{id:"253607",title:"M.D.",name:"Rafael",middleName:null,surname:"Mendoza",slug:"rafael-mendoza",fullName:"Rafael Mendoza"},{id:"254018",title:"Dr.",name:"Robert",middleName:null,surname:"Galiano",slug:"robert-galiano",fullName:"Robert Galiano"},{id:"271116",title:"Mr.",name:"Ji-Cheng",middleName:null,surname:"Hsieh",slug:"ji-cheng-hsieh",fullName:"Ji-Cheng Hsieh"}]},{id:"63086",doi:"10.5772/intechopen.80215",title:"Medicinal Plants in Wound Healing",slug:"medicinal-plants-in-wound-healing",totalDownloads:2901,totalCrossrefCites:7,totalDimensionsCites:15,abstract:"Wound healing process is known as interdependent cellular and biochemical stages which are in trying to improve the wound. Wound healing can be defined as stages which is done by body and delayed in wound healing increases chance of microbial infection. Improved wound healing process can be performed by shortening the time needed for healing or lowering the inappropriate happens. The drugs were locally or systemically administrated in order to help wound healing. Antibiotics, antiseptics, desloughing agents, extracts, etc. have been used in order to wound healing. Some synthetic drugs are faced with limitations because of their side effects. Plants or combinations derived from plants are needed to investigate identify and formulate for treatment and management of wound healing. There is increasing interest to use the medicinal plants in wound healing because of lower side effects and management of wounds over the years. Studies have shown that medicinal plants improve wound healing in diabetic, infected and opened wounds. The different mechanisms have been reported to improve the wound healing by medicinal plants. In this chapter, some medicinal plants and the reported mechanisms will be discussed.",book:{id:"7046",slug:"wound-healing-current-perspectives",title:"Wound Healing",fullTitle:"Wound Healing - Current Perspectives"},signatures:"Mohammad Reza Farahpour",authors:[{id:"253340",title:"Prof.",name:"Mohammadreza",middleName:null,surname:"Farahpour",slug:"mohammadreza-farahpour",fullName:"Mohammadreza Farahpour"}]}],mostDownloadedChaptersLast30Days:[{id:"55736",title:"Haemodynamic Monitoring in the Intensive Care Unit",slug:"haemodynamic-monitoring-in-the-intensive-care-unit",totalDownloads:3369,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Monitoring is a cognitive aid that allows clinicians to detect the nature and extent of pathology and helps assessment of response to therapy. The cardiovascular system is the most commonly monitored organ system in the critical care setting. It helps identify the presence and nature of shock and guides response to resuscitation by detection of cardiac rate and rhythm, evaluation of volume state, cardiac contractility and systemic vascular resistance. Newer technologies allow greater assessment of oxygen delivery to vulnerable tissues. We discuss the nature, history, modalities and interpretation of the most commonly available haemodynamic monitoring methods in clinical use currently.",book:{id:"5756",slug:"intensive-care",title:"Intensive Care",fullTitle:"Intensive Care"},signatures:"Mainak Majumdar",authors:[{id:"86678",title:"Dr.",name:"Mainak",middleName:null,surname:"Majumdar",slug:"mainak-majumdar",fullName:"Mainak Majumdar"}]},{id:"51825",title:"Roles of Matrix Metalloproteinases in Cutaneous Wound Healing",slug:"roles-of-matrix-metalloproteinases-in-cutaneous-wound-healing",totalDownloads:3628,totalCrossrefCites:20,totalDimensionsCites:37,abstract:"Wound healing is a complex process that consists of hemostasis and inflammation, angiogenesis, re-epithelialization, and tissue remodeling. Matrix metalloproteinases (MMPs) play important roles in wound healing, and their dysregulation leads to prolonged inflammation and delayed wound healing. There are 24 MMPs in humans, and each MMP exists in three forms, of which only the active MMPs play a role in the pathology or repair of wounds. The current methodology does not distinguish between the three forms of MMPs, making it challenging to investigate the roles of MMPs in pathology and wound repair. We used a novel MMP-inhibitor-tethered affinity resin that binds only the active form of MMPs, from which we identified and quantified active MMP-8 and active MMP-9 in a murine diabetic model with delayed wound healing. We showed that up-regulation of active MMP-9 plays a detrimental role whereas active MMP-8 is involved in repairing the wound in diabetic mice. These studies identified MMP-9 as a novel target for therapeutic intervention in the treatment of chronic wounds. A selective inhibitor of MMP-9 that leaves MMP-8 unaffected would provide the most effective therapy and represents a promising strategy for therapeutic intervention in the treatment of diabetic foot ulcers.",book:{id:"5290",slug:"wound-healing-new-insights-into-ancient-challenges",title:"Wound Healing",fullTitle:"Wound Healing - New insights into Ancient Challenges"},signatures:"Trung T. Nguyen, Shahriar Mobashery and Mayland Chang",authors:[{id:"183405",title:"Prof.",name:"Mayland",middleName:null,surname:"Chang",slug:"mayland-chang",fullName:"Mayland Chang"},{id:"191152",title:"Mr.",name:"Trung",middleName:null,surname:"Nguyen",slug:"trung-nguyen",fullName:"Trung Nguyen"},{id:"191153",title:"Prof.",name:"Shahriar",middleName:null,surname:"Mobashery",slug:"shahriar-mobashery",fullName:"Shahriar Mobashery"}]},{id:"63086",title:"Medicinal Plants in Wound Healing",slug:"medicinal-plants-in-wound-healing",totalDownloads:2898,totalCrossrefCites:7,totalDimensionsCites:15,abstract:"Wound healing process is known as interdependent cellular and biochemical stages which are in trying to improve the wound. Wound healing can be defined as stages which is done by body and delayed in wound healing increases chance of microbial infection. Improved wound healing process can be performed by shortening the time needed for healing or lowering the inappropriate happens. The drugs were locally or systemically administrated in order to help wound healing. Antibiotics, antiseptics, desloughing agents, extracts, etc. have been used in order to wound healing. Some synthetic drugs are faced with limitations because of their side effects. Plants or combinations derived from plants are needed to investigate identify and formulate for treatment and management of wound healing. There is increasing interest to use the medicinal plants in wound healing because of lower side effects and management of wounds over the years. Studies have shown that medicinal plants improve wound healing in diabetic, infected and opened wounds. The different mechanisms have been reported to improve the wound healing by medicinal plants. In this chapter, some medicinal plants and the reported mechanisms will be discussed.",book:{id:"7046",slug:"wound-healing-current-perspectives",title:"Wound Healing",fullTitle:"Wound Healing - Current Perspectives"},signatures:"Mohammad Reza Farahpour",authors:[{id:"253340",title:"Prof.",name:"Mohammadreza",middleName:null,surname:"Farahpour",slug:"mohammadreza-farahpour",fullName:"Mohammadreza Farahpour"}]},{id:"67217",title:"Nursing Implications in the ECMO Patient",slug:"nursing-implications-in-the-ecmo-patient",totalDownloads:2528,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"Effective care and positive outcomes of the extracorporeal membrane oxygenation (ECMO) patient necessitate optimal interdisciplinary management from the healthcare team, including expert care from specially trained registered nurses (RNs). It is incumbent upon the RN caring for the ECMO patient to excel in both time management and assessment skills, as this population often demands care delivery at the pinnacle of intensive care unit (ICU) acuity. Astute and nuanced monitoring of neurological status, bleeding risk with potential (often massive) transfusions, poor hemodynamics, and integrity of the ECMO pump itself are only the few specialized areas of focus that must share priority with traditional nursing considerations involving the critically ill, such as prevention of pressure injuries and bloodstream infections. These high-intensity medical foci must be balanced with ethical considerations, as the ultimate goal of returning the patient to their normal life is not always possible. These demands highlight the dynamic proficiency of the RN caring for the ECMO patient. The following chapter will highlight the importance of specialized nursing care in the critically ill patient supported with ECMO.",book:{id:"7878",slug:"advances-in-extracorporeal-membrane-oxygenation-volume-3",title:"Advances in Extracorporeal Membrane Oxygenation",fullTitle:"Advances in Extracorporeal Membrane Oxygenation - Volume 3"},signatures:"Alex Botsch, Elizabeth Protain, Amanda R. Smith and Ryan Szilagyi",authors:[{id:"298623",title:"Mr.",name:"Alexander",middleName:null,surname:"Botsch",slug:"alexander-botsch",fullName:"Alexander Botsch"}]},{id:"66239",title:"Echocardiography Evaluation in ECMO Patients",slug:"echocardiography-evaluation-in-ecmo-patients",totalDownloads:2184,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Extracorporeal membrane oxygenation (ECMO) is a special form of organ support for selected cases of cardiovascular and severe respiratory failure. Echocardiography is a diagnostic and monitoring tool widely used in all aspects of ECMO support. The pathophysiology of ECMO, and its distinct effects on cardiorespiratory physiology, requires an echocardiographer with high skills to understand the interaction between the ECMO and the patient. In this chapter, we present the main application of echocardiography in ECMO patients and some general concepts on the ECMO working. ECMO, such as the standard cardiopulmonary bypass employed in cardiac surgery, V-V (veno-venous), can support the insufficient respiratory system by oxygenating and removing carbon dioxide from the blood. VA-ECMO (venous-arterial) can support haemodynamics by providing mechanical circulatory assistance. Today, ECMO can be used as bridge to decision, waiting for the development of the clinical conditions to support with other devices the evolution of cardiorespiratory failure or stop the assistance. Echocardiography (transthoracic (TTE) or transoesophageal (TOE)) can be used primarily to take decisions regarding appropriateness of ECMO support, therefore to control cannula insertion and confirm final position, to modify number and position of the cannulae in case of malfunctioning of these, and, finally, to assess clinical progress and suitability for weaning from ECMO.",book:{id:"7878",slug:"advances-in-extracorporeal-membrane-oxygenation-volume-3",title:"Advances in Extracorporeal Membrane Oxygenation",fullTitle:"Advances in Extracorporeal Membrane Oxygenation - Volume 3"},signatures:"Luigi Tritapepe, Ernesto Greco and Carlo Gaudio",authors:[{id:"284893",title:"Prof.",name:"Luigi",middleName:null,surname:"Tritapepe",slug:"luigi-tritapepe",fullName:"Luigi Tritapepe"},{id:"294005",title:"Prof.",name:"Ernesto",middleName:null,surname:"Greco",slug:"ernesto-greco",fullName:"Ernesto Greco"},{id:"294006",title:"Prof.",name:"Carlo",middleName:null,surname:"Gaudio",slug:"carlo-gaudio",fullName:"Carlo Gaudio"}]}],onlineFirstChaptersFilter:{topicId:"173",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:11,numberOfPublishedChapters:91,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:108,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:332,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:11,numberOfPublishedChapters:142,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:124,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:22,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:12,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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He previously worked as a post-doctoral fellow at the Ben-Gurion University of Negev, Israel; University of the Free State, South Africa; and Central University of Technology Bloemfontein, South Africa. He obtained his Ph.D. in Organic Chemistry from Nagaoka University of Technology, Japan. He has published more than seventy-four journal articles and attended several national and international conferences as speaker and chair. Dr. Kendrekar has received many international awards. He has several funded projects, namely, anti-malaria drug development, MRSA, and SARS-CoV-2 activity of curcumin and its formulations. He has filed four patents in collaboration with the University of Central Lancashire and Mayo Clinic Infectious Diseases. His present research includes organic synthesis, drug discovery and development, biochemistry, nanoscience, and nanotechnology.",institutionString:"Visiting Scientist at Lipid Nanostructures Laboratory, Centre for Smart Materials, School of Natural Sciences, University of Central Lancashire",institution:null},{id:"428125",title:"Dr.",name:"Vinayak",middleName:null,surname:"Adimule",slug:"vinayak-adimule",fullName:"Vinayak Adimule",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/428125/images/system/428125.jpg",biography:"Dr. Vinayak Adimule, MSc, Ph.D., is a professor and dean of R&D, Angadi Institute of Technology and Management, India. He has 15 years of research experience as a senior research scientist and associate research scientist in R&D organizations. He has published more than fifty research articles as well as several book chapters. He has two Indian patents and two international patents to his credit. Dr. Adimule has attended, chaired, and presented papers at national and international conferences. He is a guest editor for Topics in Catalysis and other journals. He is also an editorial board member, life member, and associate member for many international societies and research institutions. His research interests include nanoelectronics, material chemistry, artificial intelligence, sensors and actuators, bio-nanomaterials, and medicinal chemistry.",institutionString:"Angadi Institute of Technology and Management",institution:null},{id:"284317",title:"Prof.",name:"Kantharaju",middleName:null,surname:"Kamanna",slug:"kantharaju-kamanna",fullName:"Kantharaju Kamanna",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284317/images/21050_n.jpg",biography:"Prof. K. Kantharaju has received Bachelor of science (PCM), master of science (Organic Chemistry) and Doctor of Philosophy in Chemistry from Bangalore University. He worked as a Executive Research & Development @ Cadila Pharmaceuticals Ltd, Ahmedabad. He received DBT-postdoc fellow @ Molecular Biophysics Unit, Indian Institute of Science, Bangalore under the supervision of Prof. P. Balaram, later he moved to NIH-postdoc researcher at Drexel University College of Medicine, Philadelphia, USA, after his return from postdoc joined NITK-Surthakal as a Adhoc faculty at department of chemistry. Since from August 2013 working as a Associate Professor, and in 2016 promoted to Profeesor in the School of Basic Sciences: Department of Chemistry and having 20 years of teaching and research experiences.",institutionString:null,institution:{name:"Rani Channamma University, Belagavi",country:{name:"India"}}},{id:"158492",title:"Prof.",name:"Yusuf",middleName:null,surname:"Tutar",slug:"yusuf-tutar",fullName:"Yusuf Tutar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/158492/images/system/158492.jpeg",biography:"Prof. Dr. Yusuf Tutar conducts his research at the Hamidiye Faculty of Pharmacy, Department of Basic Pharmaceutical Sciences, Division of Biochemistry, University of Health Sciences, Turkey. He is also a faculty member in the Molecular Oncology Program. He obtained his MSc and Ph.D. at Oregon State University and Texas Tech University, respectively. He pursued his postdoctoral studies at Rutgers University Medical School and the National Institutes of Health (NIH/NIDDK), USA. 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. He is currently a professor at the Institute of Biomaterials and Bioengineering (IBB), Tokyo Medical and Dental University (TMDU). From 2010 to 2012, he was the dean of the Graduate School of Biomedical Science. Since 2012, he has served as the vice dean of the Graduate School of Medical and Dental Sciences. He has been the director of the IBB since 2020. Dr. Kagechika’s major research interests are the medicinal chemistry of retinoids, vitamins D/K, and nuclear receptors. He has developed various compounds including a drug for acute promyelocytic leukemia.",institutionString:"Tokyo Medical and Dental University",institution:{name:"Tokyo Medical and Dental University",country:{name:"Japan"}}},{id:"94311",title:"Prof.",name:"Martins",middleName:"Ochubiojo",surname:"Ochubiojo Emeje",slug:"martins-ochubiojo-emeje",fullName:"Martins Ochubiojo Emeje",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94311/images/system/94311.jpeg",biography:"Martins Emeje obtained a BPharm with distinction from Ahmadu Bello University, Nigeria, and an MPharm and Ph.D. from the University of Nigeria (UNN), where he received the best Ph.D. award and was enlisted as UNN’s “Face of Research.” He established the first nanomedicine center in Nigeria and was the pioneer head of the intellectual property and technology transfer as well as the technology innovation and support center. Prof. Emeje’s several international fellowships include the prestigious Raman fellowship. He has published more than 150 articles and patents. He is also the head of R&D at NIPRD and holds a visiting professor position at Nnamdi Azikiwe University, Nigeria. He has a postgraduate certificate in Project Management from Walden University, Minnesota, as well as a professional teaching certificate and a World Bank certification in Public Procurement. Prof. Emeje was a national chairman of academic pharmacists in Nigeria and the 2021 winner of the May & Baker Nigeria Plc–sponsored prize for professional service in research and innovation.",institutionString:"National Institute for Pharmaceutical Research and Development",institution:{name:"National Institute for Pharmaceutical Research and Development",country:{name:"Nigeria"}}},{id:"436430",title:"Associate Prof.",name:"Mesut",middleName:null,surname:"Işık",slug:"mesut-isik",fullName:"Mesut Işık",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/436430/images/19686_n.jpg",biography:null,institutionString:null,institution:{name:"Bilecik University",country:{name:"Turkey"}}},{id:"268659",title:"Ms.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/268659/images/8143_n.jpg",biography:"Dr. Zhan received his undergraduate and graduate training in the fields of preventive medicine and epidemiology and statistics at the West China University of Medical Sciences in China during 1989 to 1999. He received his post-doctoral training in oncology and cancer proteomics for two years at the Cancer Research Institute of Human Medical University in China. In 2001, he went to the University of Tennessee Health Science Center (UTHSC) in USA, where he was a post-doctoral researcher and focused on mass spectrometry and cancer proteomics. Then, he was appointed as an Assistant Professor of Neurology, UTHSC in 2005. He moved to the Cleveland Clinic in USA as a Project Scientist/Staff in 2006 where he focused on the studies of eye disease proteomics and biomarkers. He returned to UTHSC as an Assistant Professor of Neurology in the end of 2007, engaging in proteomics and biomarker studies of lung diseases and brain tumors, and initiating the studies of predictive, preventive, and personalized medicine (PPPM) in cancer. In 2010, he was promoted to Associate Professor of Neurology, UTHSC. Currently, he is a Professor at Xiangya Hospital of Central South University in China, Fellow of Royal Society of Medicine (FRSM), the European EPMA National Representative in China, Regular Member of American Association for the Advancement of Science (AAAS), European Cooperation of Science and Technology (e-COST) grant evaluator, Associate Editors of BMC Genomics, BMC Medical Genomics, EPMA Journal, and Frontiers in Endocrinology, Executive Editor-in-Chief of Med One. He has\npublished 116 peer-reviewed research articles, 16 book chapters, 2 books, and 2 US patents. His current main research interest focuses on the studies of cancer proteomics and biomarkers, and the use of modern omics techniques and systems biology for PPPM in cancer, and on the development and use of 2DE-LC/MS for the large-scale study of human proteoforms.",institutionString:null,institution:{name:"Xiangya Hospital Central South University",country:{name:"China"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"418340",title:"Dr.",name:"Jyotirmoi",middleName:null,surname:"Aich",slug:"jyotirmoi-aich",fullName:"Jyotirmoi Aich",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038Ugi5QAC/Profile_Picture_2022-04-15T07:48:28.png",biography:"Biotechnologist with 15 years of research including 6 years of teaching experience. 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. 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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. 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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. 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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/system/329795.png",biography:"Dr. Mohd Aftab Siddiqui is an assistant professor in the Faculty of Pharmacy, Integral University, Lucknow, India, where he obtained a Ph.D. in Pharmacology in 2020. He also obtained a BPharm and MPharm from the same university in 2013 and 2015, respectively. 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