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\r\n\tThere are generally two types of masonry: brick and stone masonry. Brick masonry: a type of masonry that uses bricks. However, masonry is further divided into "clay work," which uses clay to fill various joints with bricks to build walls, and "cement masonry," the cheapest type of masonry. Masonry: this is the art of building with bricks or stone. The ability of masonry to support the load imposed by the structural elements above it is called strength. The application of loads to masonry creates internal stresses and deformations. The brand of mortar and brick, the shape and size of masonry materials, and the thickness and density of mortar joints affect the strength of masonry. The ability of masonry to maintain its position under horizontal load is called stability. This property limits the height of masonry depending on its thickness and the magnitude of wind loads. The thermal conductivity of bricks of different types (silicate, ceramic, facing, refractory) is considered. A comparison of bricks in terms of their thermal conductivity is made; the thermal conductivity coefficients of refractory bricks are presented at different temperatures - from 20 to 1700°C. The thermal conductivity depends mainly on the density and the configuration of the voids. Architecture and construction consist of various elements for building works, and masonry is the main element with which these constructions are realized. Masonry is a piece of fired clay with a rectangular shape and is used to build walls and structures. Nowadays, eco-masonry can be made of different materials that offer a variety of advantages, but all of them offer benefits at the level of the environment and sustainability; some of these utensils are plastic bottles, clay, etc. The book addresses the holistic issue of using modern masonry in construction. This book interprets masonry as an essential theme of contemporary architecture and sustainable construction. It is one of the most valuable materials in the history of mankind.
",isbn:"978-1-83768-126-6",printIsbn:"978-1-83768-125-9",pdfIsbn:"978-1-83768-127-3",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"85ef86d046d15e7d4b1988f1ec5dd750",bookSignature:"Prof. Amjad Almusaed and Prof. Asaad Almssad",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/12061.jpg",keywords:"Unreinforced Masonry Buildings, Masonry in Sustainable Building, Energy Saving and Masonry, Eco-Friendly Masonry, Modern Architecture and Masonry, Masonry and Human Behavior, Esthetic and Masonry, History of Advanced Masonry, Structural Masonry, Modeling of Masonry Structures, Modern Masonry Manufacturing, Masonry Walls",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 20th 2022",dateEndSecondStepPublish:"July 21st 2022",dateEndThirdStepPublish:"September 19th 2022",dateEndFourthStepPublish:"December 8th 2022",dateEndFifthStepPublish:"February 6th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"a month",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Prof. Amjad Almusaed, affiliated with Jönköping University has carried out a great deal of research and technical survey work and has performed several studies in these areas. 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As a group, anxiety disorders are frequent and persistent in childhood and adolescence. The prevalence of anxiety disorders in nonrefered children 4-6 years old has been estimated in 6.1% (Briggs-Gowan et al., 2000), and studies on older children and adolescents have reported lifetime prevalence ranging from 8.3% to 27.0% (Costello et al., 2005). Separation anxiety disorder (SA), specific phobias (SP) and generalized anxiety disorder (GA) are the most common. Left untreated, anxiety disorders tend to have a chronic and unremitting course (Yonkers et al., 2003; Ramsawh et al, 2009) and also increase the risk for adult psychiatric disorders (Pine et al., 1998; Costello et al., 2011).
In primary care settings studies have shown that approximately 9% to 15% (Benjamin et al., 1990; Costello, 1989) of 7- to 11-year-olds meet the criteria for an anxiety disorder, and at least 17% in pediatric patients (Chavira et al., 2004). Most contact with GPs is for physical health problems; only 2–5% of child and adolescent consultations involve presentations with emotional or behavioural problems (Giel et al., 1981). Pediatric anxiety disorders often feature somatic complaints such as abdominal pain, chest pain or discomfort, headaches, nausea, or vomiting, and are often comorbid with medical conditions such as asthma and other atopic disorders (Ramsawh et al., 2010). However, children and adolescents with mood and anxiety disorders in primary care and pediatric settings are underrecognized, not commonly treated onsite, and less likely than youths with behavioral disorders to be referred to specialized mental health settings (Wren et al., 2003, 2005).
Mental health presentations may also relate to educational or social issues and other risk factors for functioning and development rather than to diagnosable disorders per se. In children, anxiety disorders can be associated with school absenteeism or school refusal, poor academic performance, or grades that are lower than would be expected based on the child’s abilities (Mazzone et al, 2007). It is the concerns of parents that typically alert the primary care clinician to psychosocial issues (Dulcan et al., 1990), but parents are often either unaware of their child’s internalizing symptoms or do not see a need for services (Wu et al., 1999; Caraveo et al., 2002).
\n\t\tHaving identified that children’s and adolescent’s mental health problems are frequent and unrecognized conditions in Mexico City (Caraveo et al, 2002) and that an epidemiological study on the general population showed evidence about the familial risk for developing psychopathology acoss three generations (Caraveo et. al., 2005), a pilot study aimed on the surveillance of children’s and adolescent’s mental health at primary care level was launched. The initiative was conceived as a potential action-research oriented project for the enhancement of the role of primary care in the preventive actions that are needed for mental health care. Primary care has great potential as a source of education, triage, and frontline intervention. However, this role requires simple and efficient methods and tools to accurately identify, in collaboration with the family, the child’s core areas of difficulty (Wren et al., 2005).
Eventually, the information to be gathered by this program may contribute to a better understanding of the natural history of different psychiatric syndromes and disorders such as attention deficit and hyperactivity disorder, affective disorders, anxiety disorders and other neuro-psychiatric conditions. All of these produce varying degrees of handicap and may create a risk for other disorders such as alcohol and drug abuse (Merikangas et al., 1998; Hofstra et al. 2000), hence the importance of their surveillance, early detection and care.
As a first step in the development of this pilot study, the concurrent validity and efficiency of the Brief Screening and Diagnostic Questionnaire (CBTD for its initials in Spanish) was evaluated. The CBTD was built based on our previous experience using the Report Questionnaire for Children, RQC (Caraveo et al., 1995) adding 17 items to explore symptoms frequently reported as motives for seeking attention at the out-patient mental health services. The aim was to include cardinal symptoms that could lead to identify probable specific syndromes and disorders, based on the parent’s report. The instrument was tested and further developed using information gathered from a general population sample. Internal consistency showed a Cronbach’s alpha of 0.81 with a 0.75-0.85 range by age groups; cluster and factor analyses identified eight groups of symptoms that correlate with the most frequent syndromes seen in children and adolescents (Caraveo, 2006). Logistic regression analyses were then performed between cardinal symptoms for different diagnoses and the rest of the items from the questionnaire, and statistically significant associations were evaluated clinically and compared to psychiatric syndromes as defined by the DSM-IV (APA,1994) and the ICD-10 (WHO, 1993) classifications. Based on these results, algorithms for probable psychiatric syndromes, including subclinical forms, were created (Caraveo, 2007a) and the concurrent validity between some of them and the psychiatric diagnoses of children who received care at two out-patient mental health services showed a fair agreement (Yule’s Y: 0.43- 0.55; Caraveo, 2007b). However, as psychiatric diagnoses did not follow a structured clinical interview, there was the need to confirm these results using a standardized evaluation and on primary health attendants in order to evaluate the screening instrument adequacy for establishing a surveillance of mental health in childhood and adolescence.
Results showed an overall Sensitivity of 68%, Specificity of 82%, Positive Predictive Value (PPV) of 88% and a Negative Predictive Value (NPV) of 57%. When two or more CBTD syndromes are present the PPV is almost 100%. Concurrent validity showed a fair agreement for most of the CBTD syndromes as compared to DSM-IV diagnoses (Caraveo et al., 2011).
Once established the validity and efficiency of CBTD as the basic tool for screening purposes, an impairment measurement was considered as a priority for the surveillance pilot study, along with the obtention of psychiatric antecedents in both parents. Also, as besides genetic predisposition a variety of mechanisms have been postulated as being responsible for intergenerational continuity of psychopathology such as impairments in parenting and dysfunctional family relationships (Malcarne et al., 2010), and because along the field work of the surveillance study, these issues were frequently reported by the population, they were subsequently assessed during the two-year follow-up.
As this chapter is focused on anxiety disorders in clildren and adolescents, we will review research on these aspects as related to anxious children and adolescents.
\n\t\t\t\tFindings from family studies, either using a “top-down” design where the children of parents with anxiety disorders are evaluated or a “bottom-up” design which ascertain the parents of children with anxiety disorders, have clearly establish the cross-generation transmission of anxiety from parents to children (Klein & Pine, 2002). A detailed revision of the literature has been presented in a previous work (Caraveo-Anduaga, 2011).
An epidemiological study on the general population of Mexico City investigated the presencce of psychopathology across three generations (Caraveo et al., 2005). Anxiety syndromes, as defined in the Brief Screening and Diagnostic Questionnaire (CBTD) showed a familial transmission pathway that is consistent with results from studies on Caucasian populations in developed countries (Klein & Pine, 2002), suggesting that familial risk for developing anxiety disorders is a fact, thus not limited by ethnicity or culture, but mediated by socio-economic conditions (Caraveo-Anduaga, 2011).
Results showed that comorbid anxiety disorders in grandparents seem to interact with anxiety-only as well as with anxiety comorbid disorders in parents, determining a robust morbid risk for the generalized anxiety screening syndrome in descendants, while the familial anxiety risk across generations for the anxiety with inhibition syndrome is less pronounced.
Results considering only the adult proband’s information showed that parent’s history of anxiety-only as well as comorbid anxiety-depression were significantly associated with both screening anxiety syndromes in their offspring. Male children developed more generalized anxiety as compared to females, and the relationship with spouse was inversely associated with the presence of the syndrome of anxiety with inhibition in the descendant. Additionally, household higher income showed a significant association with the presence of the generalized anxiety syndrome in the children, and poor adult proband’s own health perception was associated with both anxiety syndromes in their offspring (Caraveo-Anduaga, 2011).
A limitation of the study was that as the principal objective of the survey was focused on adult population, only one adult was selected at each household, and so familial risk across generations, was based on information about only one parent.
\n\t\t\t\tFunctional impairment describes the impact of psychopathology on the life of the child with respect to daily life activities (Üstun & Chatterji, 1997); it refers to ways in which symptoms interfere with and reduce adequate performance of important and desired aspects of the child’s life (Rapee et al., 2012). Most common conceptualisations indicate three areas of impairment within family, school and social domains. Ezpeleta et al. (2001) identified three dimensions: interference with parents, peers and education.
Different authors have shown the importance of including impairment indicators in the diagnostic definitions in order to reduce the prevalence rates of the disorders in epidemiological studies (Bird et al., 1988; Roberts, et al., 1997; Shaffer, et al, 1996; Simonoff et al., 1997). The knowledge of the degree of impairment is also necessary for the proper identification of those persons affected by a psychological disorder or in need of psychological help.
Measures of functional impairment besides being an aid in case definitions in epidemiological studies and in nosology are useful for studies of treatment effectiveness, planning services, service eligibility determination, evaluating and planning of programs, but, mainly, they are used as outcome indicators (Ezpeleta et al., 2006).
Available instruments of level of functioning could be classified either as one-dimensional or multidimensional. For the definition of impairment three primary measurement strategies have been identified (Bird et al., 2000): a) measures that incorporate the symptoms and their correlates into the definition of disorder, b) specific impairment measures associated with each diagnosis, and c) global omnibus impairment measures.
Goals for assessment of functional impairment should help to decide what the best strategy is. If the goal is to decide if a child needs intervention or not, a global strategy could be used, but if the objective is to plan the areas of intervention, then a decomposed instrument could be more appropriate.
Anxiety disorders are especially susceptible to impairment thresholds; however, the importance of impairment is uncertain in early diagnoses. Moreover, anxiety symptoms that are not impairing in early childhood may become so as development and life-experiences continues (Malcarne et al., 2010). Thus, knowledge of the degree of impairment is a necessary component for the surveillance of anxiety and other children’s mental health disorders at the primary care level.
\n\t\t\t\t\t\tKashani & Orvaschel (1990) in a community sample of 210 children and adolescents found that children diagnosed with anxiety disorder demonstrated greater impairment on both the physical and cognitive measures on self-competence, temperamental flexibility, and levels of self-esteem than non-clinic controls. Research on the psychosocial implications of anxiety indicates the disabling consequences affecting schooling and academic functioning, peer relationships, autonomous activities, self-esteem, family functioning and overall psychosocial impairment (Strauss et al, 1988; Bell-Dolan & Brazeal, 1993; Kendall et al., 1992; Wittchen, Nelson & Lachner, 1998; Essau et al., 2000).
\n\t\t\t\t\t\tManassis and Hood (1998) determined the correlates of anxiety disorders that were predictive of impairment. They concluded that predictors were different depending on disorder. The impairment for generalized anxiety disorder was mainly determined by psychosocial adversity, but in the case of phobia, it was determined by mothers\' ratings of conduct problems of the child, the depressive symptoms reported by the child, the maternal phobic anxiety, and the development difficulties suffered by the child.
\n\t\t\t\t\t\tWhiteside (2009) found that the greatest impairment report from both the child and parents was associated with obssessive compulsive disorder and social anxiety disorder, followed by separation anxiety disorder, and then generalized anxiety disorder. Thus, level of impairment seems to be associated with the type of anxiety disorder. However, literature suggests that there are many shared risk or associated factors for psychiatric morbidity and functional impairment in children (Wille N, et al, 2008).
\n\t\t\t\t\n\t\t\t\t\t\tDarling and Steinberg (1993) defined child-rearing style as ‘a constellation of attitudes toward the child that are communicated to the child and create an emotional climate in which the parent’s behaviours are expressed’; it describes the quality of the parent-child relationship, whereas parenting practices describes the content and frequency of specific parenting behaviour (Stevenson-Hinde, 1998).
In the literature on child-rearing style, the term ‘care’ is interchangeably used with warmth, acceptance, nurturance, affection, responsiveness or supportiveness on the one end of the dimension and rejection, hostility or criticism on the other.
Ever since the seminal paper of Bell and Chapman (1986) about the child’s influence on parental behaviour, parenting is no longer considered to be a purely parental characteristic affecting the child, but rather an interactional phenomenon in which parent and child participate and reciprocally influence one another.
Relationship may be reciprocal, that is, anxious child influences the parental style exhibited and vice versa (Samerof & Emde, 1989; Thomasgard & Metz, 1993; Bögels and Brechman-Toussaint, 2006).
Behavioural genetic research (Rowe & Plomin, 1981; Plomin & Daniels, 1987) has shown that environmental factors that all children in a family share may have a different influence than those that are unique. Child-rearing style is often considered to belong to the shared environment, but when the contribution of the child to parenting style is taken into consideration, it should rather be regarded as part of the nonshared environment. When differences in parenting behaviour regarding different children within the same family are very outspoken, this is called parental differential treatment (Lindhout, 2008).
Anxiety disorders could be conceptualized, considering the multi factorial aetiological view of the phenomenom, as a self-perpetuating cycle of elevated biological responses to stress, debilitated cognition and avoidance of stressful circumstances reinforced by environmental factor including a parenting style, which interferes with children’s attempts at solving their own problems, and instead emphasizes threat in situations, and encourages children’s avoidance behavior. The exposure to traumatic or aversive situations also increases the risk of children developing anxious responses (Webster, 2002).
Studies have shown that parents of anxious children behave in ways that increase the chance that their child behaves in an anxious manner. High levels of maternal control and anxiety, and maternal rejection and depression (Rapee, 1997) as well as less accepting, aversiveness, intrusiveness, overinvolved, over protective and more controlling parenting styles have been found associated with anxiety disorders in children (Siqueland et al., 1996; Hudson & Rapee, 2001; Wood et al., 2003; Moore et al., 2004; McLeod et al., 2007; Hudson et al., 2008).
\n\t\t\t\tFamily relationships are viewed as critical factors influencing a child\'s social and emotional development (Hannan & Luster, 1991; Levitt, 1991). A number of broad classes of dysfunction such as psychosocial stress, poverty, parental marital discord, parental psychopathology, maltreatment, and parental emotional unavailability, have been associated with both internalizing and externalizing problems (Gotlib & Avison, 1993).
Exposure to conflict has been shown to influence children directly. Witnessing adult anger is physiologically and affectively stressful for children, and exposure to conflict has been shown to influence children indirectly through its effect on parenting and parents’ psychological wellbeing. Some researchers have shown that the effects of parental conflict can be more harmful to children than parental absence through death or divorce (Emery, 1982; Jekielek, 1998; Mechanic & Hansell, 1989; Peterson & Zill, 1986). Marital fighting has been found to be more predictive of children’s functioning than divorce (Cummings, 1994; Jekielek, 1998). More specifically, the quality of the marital relationship in early life has been found to predict future anxiety in the child (Bögels & Brechman-Toussaint, 2006).
In children exposed to chronic violence, increasing sensitization has been reported. Hennessy et al. (1994) found that children exposed to violence, in comparison to peers, were more fearful and emotionally reactive to videotaped scenes of anger between adults. Sensitization may be related to hypervigilance, the tendency to anxiously scan the environment for possible threat that is one of the hallmarks of posttraumatic stress.
Also, deficits in emotion regulation have been observed in children exposed to uncontrolled anger and distress in the very figures they would turn to for soothing and solace (Graham-Bermann & Levendosky, 1998).
Exposure to violence at home is recognized as a form of child maltreatment. Witnessing domestic abuse, especially when it is perpetrated against the mother, in itself is a traumatic experience. Although children growing up in violent homes do not consistently show cognitive deficits, they often display academic problems. Distractibility and inattention in school may occur as a result of the trauma that is associated with exposure ot violence. Research suggest that children exposed to domestic violence show a range of emotional and behavioral problems including insecure attachment in younger children and both externalizing and internalizing problems in the school years (Wenar & Kerig, 2006).
Some children experience negative effects in the short term, others have both short and longer term effects, and still others seem to experience no effects related to witnessing violence. Children’s age and sex, as well as severity, intensity and chronicity of the violence are variables that play a role in the outcome of the exposure. In a longitudinal study of a sample of 155 children followed from birth through adolescence, Yates et al. (2003) found that exposure to violence in the home was an independent predictor of externalizing problems in boys and internalizing problems in girls. A study in Canada reported that children aged 4 to 7 years old who witnessed violence at home showed more overt aggression two and four years later. For boys the experience was also linked to indirect aggression, and for girls, with anxiety (Moss, 2003).
\n\t\t\t\tThis chapter will focus on testing whether the basic issues included for the surveillance of mental health in childhood and adolescence are somehow significantly associated with the presence of anxiety syndromes in children an adolescents attended at a primary care setting and followed along a two-year period.
The specific goals for this report are:
\n\t\t\t\tConfirm familial associations between parental psychiatric history and anxiety CBTD screening syndromes in their offspring.
Determine if a higher score on the scale for the assessment of impairment is associated with anxiety CBTD screening syndromes in children and adolescents.
Determine if a higher score on the scales examining child-rearing and parental practices are associated with anxiety CBTD screening syndromes in children and adolescents.
Determine if a higher score on the scale for the assessment of a potential dysfunctional environment at home is associated with anxiety CBTD screening syndromes in children and adolescents.
Evaluate the morbid risk of these variables for the development of anxiety CBTD screening syndromes.
All consecutive children and adolescents aged 4 to 16 years attended during a six-month period at a primary care health center (PCHC) were included for this study. Children and adolescents already in treatment at the mental health service were excluded. Informed consent was obtained from the parents of the minors at the beginning of the study. At the initial interview, socio demographic data was obtained and parents responded the Brief Screening and Diagnostic Questionnaire (CBTD). Whenever a probable case was detected, parents were advised to seek help from the mental health service at the PCHC or at another facility. The cohort was followed for two years (2005-2007); at each consecutive evaluation a follow-up version of the CBTD was used and complementary information was gathered at different points of time as will be explained.
\n\t\t\t\tThe Brief Screening and Diagnostic Questionnaire (CBTD for its initials in Spanish) is a 27-item questionnaire answered by the parents of the child exploring symptoms frequently reported as motives for seeking attention at the outpatient mental health services. Presence of the symptom requires that each item has to be reported as “frequently” presented. The internal consistency of the questionnaire showed a Cronbach’s alpha of 0.81, range: 0.76 to 0.85 (Caraveo, 2006). Diagnostic algorithms in order to define probable DSM-IV disorders in children were created based on data from the general population epidemiological study (Caraveo, 2007a). The generalized anxiety screening syndrome was defined as follows: Key symptom: a positive response to the question: Does the child gets scared or nervous for no good reason?, and at least two of the following: can´t seat still, irritable, sleep problems, and frequent nightmares. The anxiety with inhibition screening syndrome was defined as follows: Key symptom: a positive response to the question: Is the child excessively dependent or attached to adults?; and at least two positive answers on the following: aloof, frequent headaches, afraid of school, physical complains without a medical problem, sleep problems, low weight, overweight, do not work at school, and backward compared to other children. Concurrent validity of the two screening anxiety syndromes, generalized anxiety and anxiety with inhibition, as compared to DSM-IV anxiety diagnoses using the E-MiniKid standardized interview (Sheehan et al., 1998; 2000) showed Kappa agreement to be 0.53 and 0.68 respectively, and using Yule´s Y coefficient results were 0.65 and 0.92 respectively. Receiver Operating Characteristic Curves (ROC) analyses showed Area under the Curve (AUC) to be 0.82 and 0.78 respectively (\n\t\t\t\t\t\t\t\t\tCaraveo-Anduaga et al., 2011\n\t\t\t\t\t\t\t\t).
Psychiatric parental antecedents about anxiety, affective and substance-use disorders were obtained following the Family-history research criteria (Andreasen et al., 1977; 1986; Kendler et al., 1997) as was used in the general population study (Caraveo-Anduaga, 2011).
Functional impairment in children and adolescents was measured using the Brief Imparment Scale (BIS) (Bird et al., 2005) which is a 23-item questionnaire that has three sub-scales exploring interpersonal relationships, work/school performance and self-attitudes. Each question is responded in Likert scale with 4 options: 0= never or no problem; 1= some problems; 2= several problems; 3= serious problems. The internal consistency of the BIS in our population showed a Cronbach’s alpha of 0.87.
The Parent Practices Inventory (PPI) (Bauermeister et al. 1995 as presented in Barkley R., Murphy K. & Bauermeister J., 1998) is a 37-item questionnaire exploring child-rearing as well as disciplinary practices. Two dimensions were identified: a positive one that considers approval, acceptance, positive motivation and affection as predominant practices, while the negative dimension includes inconsistency, cohersion and negative affect. Each question is evaluated in a 4-point Likert scale: 0= never or almost never; 1= rarely; 2= frequently; 3= very frequently. The internal consistency of the PPI in our population showed a Cronbach’s alpha of 0.87.
The style of solving problems at home was explored with a 7-item scale adapted from answers used by Kessler in the National Comorbity Study. In the present study they were asked as follows: All persons solve their conflicts in different manners. How often do you and your spouse/partner display the following conducts when there is a conlict? Insults or swores; become furious; sulk or refuse to talk; stomp out of the room; say something to spite; threaten to hit; smash or kick something in anger. Each item is responded in a 4-point Likert scale: 0= never; 1= rarely; 2= sometimes; 3= always. The internal consistency of this scale in our population showed a Cronbach’s alpha of 0.98. If some kind of physical violence was reported on the previous scale, it was asked if the child have witnessed the episodes.
Field work started on May of 2005 and in an intensive way, children and adolescents aged 4 to 16 years attending the general health clinicians at the PHC were assessed. During the vacation period, months of July and August, attendance during the morning turn was numerous but after that, it was parctically reduced to the afternoon turn. Moreover, new elegible subjects became fewer, so that in December it was decided to end the incorporation phase of the study and start preparing the first follow-up evaluation.
Besides the clinical evaluation using the CBTD in a follow-up version, information about familial psychiatric antecedents of both parents, (that was initiated during the last two months of the incorporation phase), as well as the assessment of impairment in the child using the BIS were sistematically obtained. It is important to note that even tough follow-up evaluations were cost-free and that reminder of appointments were made, the participation of the study population was scarse as shown in Table 1. In order to deal with this, telephone interviews were carried out by the child psychiatrists working in the project under the supervision of the principal researcher (JC).
For the second follow-up, assessments started on July 2007; based on the previous field clinical work, it was decided to incorporate measures of parental child-rearing practices and of domestic violence. Also, besides clinical follow-up appointments at the PHC, and telephone interviews, it was decided to have home-interviews. For this purpose, psychologists with experience in community studies were trained in the use of all the instruments, and a computarized program was created in order to facilitate the assessments, control, and management of the information. This strategy probed to be more efficient as a higher participation of the study population was accomplished; altough losses were considerable as shown in Table 1. At each follow-up interview, we look for that preferably the informant would be the same person as in the initial assessment.
\n\t\t\t\tLongitudinal morbid risk in terms of the odds ratio was calculated using the random effects logistic regression analysis as our interest was in the individual development over time of dichotomous outcome variables (Twisk, 2003), for this chapter the two screening anxiety syndromes in children and adolescents.
Bivariate analyses between anxiety syndromes and each independent variable were performed. Scores of the different scales used in the study were converted into dummy variables using quartiles, where higher scores indicated major problems.As each independent variable of interest and its corresponding measure was incorporated at different times along the study period, the number of observations are somehow different in each analysis.
Multivariate analysis including all variables was performed in terms of the odds ratio using the random effects logistic regression analysis. It was assumed that child-rearing practices as well as the style of solving problems at home were the same during the two-year period.
\n\t\t\t\tA total cohort of 846 consecutive children and adolescents patients attended at the PHC was initially evaluated. Girls represented 55% and boys 45%, with a mean age of 9 years (s.d. 3.5). On 87% the informant was the child’s mother. For 60% of the cohort at least one follow-up was completed, and in 21%two follow-up interviews were done (Table 1).
\n\t\t\t\tChildren/ Adolescents | \n\t\t\t\t\t\t\t\tInitial Evaluation | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t|||
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t|
Interviewed | \n\t\t\t\t\t\t\t846 | \n\t\t\t\t\t\t\t100 | \n\t\t\t\t\t\t\t298 | \n\t\t\t\t\t\t\t35.2 | \n\t\t\t\t\t\t\t454 | \n\t\t\t\t\t\t\t53.7 | \n\t\t\t\t\t\t
Not interviewed | \n\t\t\t\t\t\t\t- | \n\t\t\t\t\t\t\t- | \n\t\t\t\t\t\t\t548 | \n\t\t\t\t\t\t\t64.8 | \n\t\t\t\t\t\t\t392 | \n\t\t\t\t\t\t\t46.3 | \n\t\t\t\t\t\t
Interviewed population
The total prevalence of the anxiety screening syndromes at the initial interview was 29.4% (95%CI: 26.4, 32.5) for the generalized anxiety syndrome, and 31.2% (95%CI: 26.4, 35.9) for the anxiety with inhibition syndrome. Both anxiety syndromes were slightly more frequently reported in boys than in girls. In adolescents anxiety syndromes were more frequent among girls. Prevalence of both anxiety syndromes tended to be somehow similar to the initial prevalence at the one-year follow-up, but they both considerably dimisnished at the two-year follow-up; prevalence of anxiety with inhibition decreased to be less than a half of the initial prevalence (Table 2).
\n\t\t\t\tThe analysis of the association between specific types of pychiatric parental antecedents and the two anxiety syndromes in the offspring shows that parental antecedents of anxiety-only, and comorbid anxiety with depression, as well as with substance abuse are significantly associated with both types of anxiety syndromes in the offspring. Parental antecedents of depression are associated with generalized anxiety syndrome in the offspring, but the odds ratio is considerably lower; and parental antecedents of substance abuse alone, are not significantly associated with neither anxiety syndromes in the offspring (Table 3).
\n\t\t\t\tFor this analysis, 741 observations were included; 187 correspond to observations on subjects presenting generalized anxiety, 25.5%, and 135 presenting anxiety with inhibition, 18.2%.
For the next tables, on the second column, the proportions of observations with each anxiety syndrome as related to scores on the BIS are presented. The odds ratio in tables represent the longitudinal strenght of the association between those observed subjects with anxiety syndromes within the corresponding quartile of the impairment scale as compared to observed subjects with anxiety syndromes within the first quartile.
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t||
Boys | \n\t\t\t\t\t\t\t\t(n= 88) | \n\t\t\t\t\t\t\t\t(n= 99) | \n\t\t\t\t\t\t\t\t(n= 128) | \n\t\t\t\t\t\t\t\t(n= 66) | \n\t\t\t\t\t\t\t\t(N= 381) | \n\t\t\t\t\t\t\t||
Generalized anxiety | \n\t\t\t\t\t\t\t\t29.5 | \n\t\t\t\t\t\t\t\t34.3 | \n\t\t\t\t\t\t\t\t36.0 | \n\t\t\t\t\t\t\t\t22.7 | \n\t\t\t\t\t\t\t\t31.5 (26.8, 36.2) | \n\t\t\t\t\t\t\t||
Anxiety with inhibition | \n\t\t\t\t\t\t\t\t43.2 | \n\t\t\t\t\t\t\t\t38.4 | \n\t\t\t\t\t\t\t\t28.0 | \n\t\t\t\t\t\t\t\t18.2 | \n\t\t\t\t\t\t\t\t33.3 (26.0, 40.6) | \n\t\t\t\t\t\t\t||
Girls | \n\t\t\t\t\t\t\t\t(n= 87) | \n\t\t\t\t\t\t\t\t(n= 112) | \n\t\t\t\t\t\t\t\t(n= 157) | \n\t\t\t\t\t\t\t\t(n= 109) | \n\t\t\t\t\t\t\t\t(N= 465) | \n\t\t\t\t\t\t\t||
Generalized anxiety | \n\t\t\t\t\t\t\t\t20.7 | \n\t\t\t\t\t\t\t\t29.5 | \n\t\t\t\t\t\t\t\t26.7 | \n\t\t\t\t\t\t\t\t33.0 | \n\t\t\t\t\t\t\t\t27.7 (23.6, 31.8) | \n\t\t\t\t\t\t\t||
Anxiety with inhibition | \n\t\t\t\t\t\t\t\t27.6 | \n\t\t\t\t\t\t\t\t39.3 | \n\t\t\t\t\t\t\t\t22.9 | \n\t\t\t\t\t\t\t\t30.3 | \n\t\t\t\t\t\t\t\t29.4 (23.2, 35.7) | \n\t\t\t\t\t\t\t||
\n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t | ||
Boys | \n\t\t\t\t\t\t\t\t(n= 15) | \n\t\t\t\t\t\t\t\t(n= 30) | \n\t\t\t\t\t\t\t\t(n= 54) | \n\t\t\t\t\t\t\t\t(n= 34) | \n\t\t\t\t\t\t\t\t(N= 133) | \n\t\t\t\t\t\t\t||
Generalized anxiety | \n\t\t\t\t\t\t\t\t53.3 | \n\t\t\t\t\t\t\t\t30.0 | \n\t\t\t\t\t\t\t\t40.7 | \n\t\t\t\t\t\t\t\t17.6 | \n\t\t\t\t\t\t\t\t33.8 (25.7, 42.0) | \n\t\t\t\t\t\t\t||
Anxiety with inhibition | \n\t\t\t\t\t\t\t\t40.0 | \n\t\t\t\t\t\t\t\t36.7 | \n\t\t\t\t\t\t\t\t24.1 | \n\t\t\t\t\t\t\t\t11.8 | \n\t\t\t\t\t\t\t\t25.6 (18.1, 33.1) | \n\t\t\t\t\t\t\t||
Girls | \n\t\t\t\t\t\t\t\t(n= 18) | \n\t\t\t\t\t\t\t\t(n= 45) | \n\t\t\t\t\t\t\t\t(n= 56) | \n\t\t\t\t\t\t\t\t(n= 46) | \n\t\t\t\t\t\t\t\t(N= 165) | \n\t\t\t\t\t\t\t||
Generalized anxiety | \n\t\t\t\t\t\t\t\t27.8 | \n\t\t\t\t\t\t\t\t20.0 | \n\t\t\t\t\t\t\t\t30.3 | \n\t\t\t\t\t\t\t\t32.6 | \n\t\t\t\t\t\t\t\t27.9 (21.0, 34.8) | \n\t\t\t\t\t\t\t||
Anxiety with inhibition | \n\t\t\t\t\t\t\t\t38.9 | \n\t\t\t\t\t\t\t\t20.0 | \n\t\t\t\t\t\t\t\t25.0 | \n\t\t\t\t\t\t\t\t15.2 | \n\t\t\t\t\t\t\t\t22.4 (16.0, 28.9) | \n\t\t\t\t\t\t\t||
\n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t | ||
Boys | \n\t\t\t\t\t\t\t\t(n= 9) | \n\t\t\t\t\t\t\t\t(n= 54) | \n\t\t\t\t\t\t\t\t(n= 51) | \n\t\t\t\t\t\t\t\t(n= 69) | \n\t\t\t\t\t\t\t\t(N= 183) | \n\t\t\t\t\t\t\t||
Generalized anxiety | \n\t\t\t\t\t\t\t\t11.1 | \n\t\t\t\t\t\t\t\t22.6 | \n\t\t\t\t\t\t\t\t34.7 | \n\t\t\t\t\t\t\t\t17.7 | \n\t\t\t\t\t\t\t\t23.2 (16.9, 29.4) | \n\t\t\t\t\t\t\t||
Anxiety with inhibition | \n\t\t\t\t\t\t\t\t11.1 | \n\t\t\t\t\t\t\t\t28.3 | \n\t\t\t\t\t\t\t\t14.3 | \n\t\t\t\t\t\t\t\t10.6 | \n\t\t\t\t\t\t\t\t16.9 (11.4, 22.5) | \n\t\t\t\t\t\t\t||
Girls | \n\t\t\t\t\t\t\t\t(n= 38) | \n\t\t\t\t\t\t\t\t(n= 60) | \n\t\t\t\t\t\t\t\t(n= 92) | \n\t\t\t\t\t\t\t\t(n= 81) | \n\t\t\t\t\t\t\t\t(N= 271) | \n\t\t\t\t\t\t\t||
Generalized anxiety | \n\t\t\t\t\t\t\t\t0.0 | \n\t\t\t\t\t\t\t\t15.5 | \n\t\t\t\t\t\t\t\t32.3 | \n\t\t\t\t\t\t\t\t21.2 | \n\t\t\t\t\t\t\t\t20.7 (15.8, 25.6) | \n\t\t\t\t\t\t\t||
Anxiety with inhibition | \n\t\t\t\t\t\t\t\t0.0 | \n\t\t\t\t\t\t\t\t17.2 | \n\t\t\t\t\t\t\t\t16.7 | \n\t\t\t\t\t\t\t\t11.2 | \n\t\t\t\t\t\t\t\t12.8 (8.7, 16.8) | \n\t\t\t\t\t\t\t
Prevalence of anxiety syndromes at the initial assessment and follow-ups
Nearly half of the observations on children and adolescents with any screening anxiety syndrome are reported as having considerable impairment and with strong longitudinal morbid risk in terms of the odds ratio. Another one fith of the observations on children and adolescents with any screening anxiety syndrome shows moderate impairment as well as moderate longitudinal morbid risk. Notably, one quarter of the observations on children and adolescents presenting anxiety with inhibition also shows some impairment with moderate longitudinal morbid risk (Table 4).
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t
Anxiety | \n\t\t\t\t\t\t\t\t9.4 (2.8, 31.8) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t\t8.7 (2.3, 33.2) | \n\t\t\t\t\t\t\t\t.001 | \n\t\t\t\t\t\t\t
Depression | \n\t\t\t\t\t\t\t\t3.9 (1.1, 14.2) | \n\t\t\t\t\t\t\t\t.040 | \n\t\t\t\t\t\t\t\t2.6 (0.8, 7.9) | \n\t\t\t\t\t\t\t\t.093 | \n\t\t\t\t\t\t\t
Substance abuse | \n\t\t\t\t\t\t\t\t1.0 (0.2, 5.7) | \n\t\t\t\t\t\t\t\t.979 | \n\t\t\t\t\t\t\t\t1.9 (0.3, 10.4) | \n\t\t\t\t\t\t\t\t.464 | \n\t\t\t\t\t\t\t
Anxiety depression | \n\t\t\t\t\t\t\t\t6.5 (2.4, 17.8) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t\t4.4 (1.6, 11.9) | \n\t\t\t\t\t\t\t\t.004 | \n\t\t\t\t\t\t\t
Anxiety, depression Substance abuse | \n\t\t\t\t\t\t\t\t21.7 (6.7, 70.6) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t\t5.2 (1.9, 14.5) | \n\t\t\t\t\t\t\t\t.002 | \n\t\t\t\t\t\t\t
Specific parental antecedents and anxiety syndromes in the offspring
No.obs: 1003; No. gps.433; Wald chi2=33.03; gl=5; p= 0.0000;Wald chi2=17.18;gl=5; p= 0.0042
\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t % | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t
0-4 | \n\t\t\t\t\t\t\t\t13.9 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t. | \n\t\t\t\t\t\t\t\t10.4 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t |
5-8 | \n\t\t\t\t\t\t\t\t18.1 | \n\t\t\t\t\t\t\t\t2.0 (0.8, 4.9) | \n\t\t\t\t\t\t\t\t.149 | \n\t\t\t\t\t\t\t\t25.9 | \n\t\t\t\t\t\t\t\t4.7 (1.7, 12.8) | \n\t\t\t\t\t\t\t\t.003 | \n\t\t\t\t\t\t\t
9-12 | \n\t\t\t\t\t\t\t\t22.5 | \n\t\t\t\t\t\t\t\t5.5 (2.0, 14.6) | \n\t\t\t\t\t\t\t\t.001 | \n\t\t\t\t\t\t\t\t17.8 | \n\t\t\t\t\t\t\t\t5.0 (1.6, 15.2) | \n\t\t\t\t\t\t\t\t.005 | \n\t\t\t\t\t\t\t
13-48 | \n\t\t\t\t\t\t\t\t45.5 | \n\t\t\t\t\t\t\t\t19.1 (6.6, 55.1) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t\t45.9 | \n\t\t\t\t\t\t\t\t20.6 (6.5, 65.9) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t
BIS impairment total score and anxiety syndromes
No.obs: 741; No. gps.540; Wald chi2=34.75;gl=3; p= 0.0000;Wald chi2=26.97;gl=3; p= 0.0000
Further analyses on the different sub-scales of the BIS show that interpersonal relationships are significantly impaired in all of the observations of anxious children and adolescents as compared to those observed in the first quartil (Table 5).
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t
0 | \n\t\t\t\t\t\t\t\t11.8 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | 12.6 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t |
1-2 | \n\t\t\t\t\t\t\t\t32.1 | \n\t\t\t\t\t\t\t\t4.3 (1.7, 10.7) | \n\t\t\t\t\t\t\t\t.002 | \n\t\t\t\t\t\t\t\t37.8 | \n\t\t\t\t\t\t\t\t4.5 (1.7, 11.6) | \n\t\t\t\t\t\t\t\t.002 | \n\t\t\t\t\t\t\t
3 | \n\t\t\t\t\t\t\t\t12.8 | \n\t\t\t\t\t\t\t\t11.7 (3.4, 40.5) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t\t12.6 | \n\t\t\t\t\t\t\t\t10.6 (2.7, 41.2) | \n\t\t\t\t\t\t\t\t.001 | \n\t\t\t\t\t\t\t
4-20 | \n\t\t\t\t\t\t\t\t43.3 | \n\t\t\t\t\t\t\t\t17.2 (6.1, 48.7) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t\t37.0 | \n\t\t\t\t\t\t\t\t10.0 (3.3, 30.4) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t
BIS interpersonal relationships sub-scale and anxiety syndromes
No.obs: 741; No. gps.540; Wald chi2=31.0;gl=3; p= 0.0000;Wald chi2=18.00;gl=3; p= 0.0004
Seventy percent of the observations on anxious children and adolescents show moderate to severe impairment on the school/work sub-scale of the BIS as compared to those observed in the first quartile (Table 6).
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t
0-1 | \n\t\t\t\t\t\t\t\t20.3 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | 17.8 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t |
2 | \n\t\t\t\t\t\t\t\t9.1 | \n\t\t\t\t\t\t\t\t0.8 (0.3, 2.3) | \n\t\t\t\t\t\t\t\t.725 | \n\t\t\t\t\t\t\t\t10.4 | \n\t\t\t\t\t\t\t\t1.0 (0.3, 2.8) | \n\t\t\t\t\t\t\t\t.992 | \n\t\t\t\t\t\t\t
3-5 | \n\t\t\t\t\t\t\t\t34.2 | \n\t\t\t\t\t\t\t\t3.7 (1.6, 8.4) | \n\t\t\t\t\t\t\t\t.002 | \n\t\t\t\t\t\t\t\t34.8 | \n\t\t\t\t\t\t\t\t3.4 (1.4, 8.2) | \n\t\t\t\t\t\t\t\t.006 | \n\t\t\t\t\t\t\t
6-21 | \n\t\t\t\t\t\t\t\t36.4 | \n\t\t\t\t\t\t\t\t14.7 (5.5, 39.4) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t\t37.0 | \n\t\t\t\t\t\t\t\t14.7 (4.9, 43.9) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t
BIS work/school performance sub-scale and anxiety syndromes
No.obs: 741; No. gps.540; Wald chi2=32.26;gl=3; p= 0.0000;Wald chi2=25.17;gl=3; p= 0.0000
Finally, on the self attitudes sub-scale, 85% of all the observations on children and adolescents presenting anxiety with inhibition show different degrees of impairment that are significantly diferent from those in the first quartile, as compared to 60% of the observations on children and adolescents with generalized anxiety syndrome (Table 7).
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t % | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t
0-1 | \n\t\t\t\t\t\t\t\t22.5 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | 14.1 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t |
2-3 | \n\t\t\t\t\t\t\t\t20.3 | \n\t\t\t\t\t\t\t\t1.0 (0.4, 2.4) | \n\t\t\t\t\t\t\t\t.978 | \n\t\t\t\t\t\t\t\t25.2 | \n\t\t\t\t\t\t\t\t3.5 (1.4, 9.2) | \n\t\t\t\t\t\t\t\t.010 | \n\t\t\t\t\t\t\t
4-5 | \n\t\t\t\t\t\t\t\t22.5 | \n\t\t\t\t\t\t\t\t3.7 (1.3, 10.4) | \n\t\t\t\t\t\t\t\t.012 | \n\t\t\t\t\t\t\t\t28.9 | \n\t\t\t\t\t\t\t\t7.5 (2.7, 21.1) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t
6-18 | \n\t\t\t\t\t\t\t\t34.7 | \n\t\t\t\t\t\t\t\t8.1 (3.0, 22.0) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t\t31.8 | \n\t\t\t\t\t\t\t\t8.5 (3.1, 23.6) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t
BIS self-attitudes sub-scale and anxiety syndromes
No.obs: 741; No. gps.540; Wald chi2=21.31;gl=3; p= 0.0001;Wald chi2=19.77;gl=3; p= 0.0002
Bivariate analyses between anxiety syndromes and the score on the style of solving problems at home scale (SSPHS) do not show a significant association with either anxiety syndrome in children and adolescents; however, a higher score on the SSPHS was close to be significantly associated with generalized anxiety (Table 8).
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t
7-8 | \n\t\t\t\t\t\t\t\t27.5 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | 26.4 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t |
9-11 | \n\t\t\t\t\t\t\t\t25.0 | \n\t\t\t\t\t\t\t\t1.2 (0.3, 6.1) | \n\t\t\t\t\t\t\t\t.784 | \n\t\t\t\t\t\t\t\t24.0 | \n\t\t\t\t\t\t\t\t1.2 (0.4, 3.3) | \n\t\t\t\t\t\t\t\t.790 | \n\t\t\t\t\t\t\t
12-15 | \n\t\t\t\t\t\t\t\t13.7 | \n\t\t\t\t\t\t\t\t0.2 (0.05, 1.2) | \n\t\t\t\t\t\t\t\t.089 | \n\t\t\t\t\t\t\t\t16.3 | \n\t\t\t\t\t\t\t\t0.7 (0.2, 2.1) | \n\t\t\t\t\t\t\t\t.526 | \n\t\t\t\t\t\t\t
16-28 | \n\t\t\t\t\t\t\t\t33.8 | \n\t\t\t\t\t\t\t\t3.4 (0.9, 11.9) | \n\t\t\t\t\t\t\t\t.060 | \n\t\t\t\t\t\t\t\t33.3 | \n\t\t\t\t\t\t\t\t2.3 (0.8, 6.6) | \n\t\t\t\t\t\t\t\t.129 | \n\t\t\t\t\t\t\t
More outrageous family environment and anxiety syndromes
No.obs: 794; No. gps.321; Wald chi2=12.75;gl=3; p= 0.0052;Wald chi2=4.42;gl=3; p= 0.22
Having witnessed physical violence at home was found significantly associated with generalized anxiety syndrome in children and adolescents, OR= 2.6. (95% CI: 1.2, 5.9), but not for anxiety with inhibition, OR= 1.3 (95% CI: 0.6, 2.6).
\n\t\t\t\tBivariate analyses show that a higher score on parental’s less positive reinforcement rearing practice is only associated with observations on children and adolescents with generalized anxiety as compared to those in the first quartile (Table 9).
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t
0-17 | \n\t\t\t\t\t\t\t\t25.7 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | 29.1 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t |
18-23 | \n\t\t\t\t\t\t\t\t17.2 | \n\t\t\t\t\t\t\t\t0.7 (0.3, 2.0) | \n\t\t\t\t\t\t\t\t.507 | \n\t\t\t\t\t\t\t\t21.2 | \n\t\t\t\t\t\t\t\t0.7 (0.3, 1.7) | \n\t\t\t\t\t\t\t\t.490 | \n\t\t\t\t\t\t\t
24-28 | \n\t\t\t\t\t\t\t\t25.6 | \n\t\t\t\t\t\t\t\t2.4 (0.8, 6.7) | \n\t\t\t\t\t\t\t\t.103 | \n\t\t\t\t\t\t\t\t17.3 | \n\t\t\t\t\t\t\t\t0.7 (0.3, 1.8) | \n\t\t\t\t\t\t\t\t.463 | \n\t\t\t\t\t\t\t
29-51 | \n\t\t\t\t\t\t\t\t31.5 | \n\t\t\t\t\t\t\t\t2.9 (1.1, 7.9) | \n\t\t\t\t\t\t\t\t.033 | \n\t\t\t\t\t\t\t\t32.4 | \n\t\t\t\t\t\t\t\t1.6 (0.7, 3.8) | \n\t\t\t\t\t\t\t\t.244 | \n\t\t\t\t\t\t\t
Less positive reinforcement practices and anxiety syndromes
No.obs: 1088; No. gps.444; Wald chi2=9.71;gl=3; p= 0.0212;Wald chi2=4.27;gl=3; p= 0.2336
Bivariate analyses show that exposure to a parental’s higher negative reinforcement is significantly associated with roughly one third of the observations on children and adolescents with either anxiety syndromes. However, the strenght of the association is higher on the offspring with general anxiety (Table 10).
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t
1-5 | \n\t\t\t\t\t\t\t\t25.3 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | 23.5 | \n\t\t\t\t\t\t\t\t1.0 | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t |
6-8 | \n\t\t\t\t\t\t\t\t14.2 | \n\t\t\t\t\t\t\t\t0.4 (0.2, 1.2) | \n\t\t\t\t\t\t\t\t.112 | \n\t\t\t\t\t\t\t\t18.4 | \n\t\t\t\t\t\t\t\t0.9 (0.4, 2.4) | \n\t\t\t\t\t\t\t\t.918 | \n\t\t\t\t\t\t\t
9-12 | \n\t\t\t\t\t\t\t\t22.0 | \n\t\t\t\t\t\t\t\t1.5 (0.5, 4.3) | \n\t\t\t\t\t\t\t\t.442 | \n\t\t\t\t\t\t\t\t24.6 | \n\t\t\t\t\t\t\t\t1.8 (0.7, 4.4) | \n\t\t\t\t\t\t\t\t.186 | \n\t\t\t\t\t\t\t
13-37 | \n\t\t\t\t\t\t\t\t38.5 | \n\t\t\t\t\t\t\t\t5.6 (2.2, 14.3) | \n\t\t\t\t\t\t\t\t.000 | \n\t\t\t\t\t\t\t\t33.5 | \n\t\t\t\t\t\t\t\t2.8 (1.2, 6.8) | \n\t\t\t\t\t\t\t\t.018 | \n\t\t\t\t\t\t\t
High negative reinforcement practices and anxiety syndromes
No.obs: 1088; No. gps.444; Wald chi2=25.41;gl=3; p= 0.0000;Wald chi2=7.84;gl=3; p= 0.0494
Multivariable analysis using the random effects logistic regression shows that for both anxiety syndromes in children and adolescents parental psychiatric antecedents and a higher score on the BIS are the only two predictive variables significantly associated with the outcome. The contribution of parental psychiatric antecedents in terms of the odds ratio is considerably higher for generalized anxiety than for anxiety with inhibition, and impairment is higher in this latter syndrome than in generalized anxiety (Table 11).
\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t
No. of Familial antecedents | \n\t\t\t\t\t\t\t\t4.7 (1.8, 11.9) | \n\t\t\t\t\t\t\t\t.001 | \n\t\t\t\t\t\t\t\t1.9 (1.1, 3.4) | \n\t\t\t\t\t\t\t\t.024 | \n\t\t\t\t\t\t\t
Less positive reinforcement | \n\t\t\t\t\t\t\t\t1.3 (0.7, 2.4) | \n\t\t\t\t\t\t\t\t.365 | \n\t\t\t\t\t\t\t\t0.7 (0.5, 1.2) | \n\t\t\t\t\t\t\t\t.177 | \n\t\t\t\t\t\t\t
Higher negative reinforcement | \n\t\t\t\t\t\t\t\t1.2 (0.6, 2.2) | \n\t\t\t\t\t\t\t\t.626 | \n\t\t\t\t\t\t\t\t1.3 (0.8, 2.2) | \n\t\t\t\t\t\t\t\t.311 | \n\t\t\t\t\t\t\t
Conflict resolution | \n\t\t\t\t\t\t\t\t1.4 (0.8, 2.6) | \n\t\t\t\t\t\t\t\t.248 | \n\t\t\t\t\t\t\t\t1.0 (0.6, 1.6) | \n\t\t\t\t\t\t\t\t.980 | \n\t\t\t\t\t\t\t
Witnessed agression | \n\t\t\t\t\t\t\t\t0.6 (0.1, 2.5) | \n\t\t\t\t\t\t\t\t.455 | \n\t\t\t\t\t\t\t\t0.8 (0.2, 2.6) | \n\t\t\t\t\t\t\t\t.662 | \n\t\t\t\t\t\t\t
Impairment | \n\t\t\t\t\t\t\t\t1.9 (1.2, 3.3) | \n\t\t\t\t\t\t\t\t.011 | \n\t\t\t\t\t\t\t\t2.5 (1.4, 4.2) | \n\t\t\t\t\t\t\t\t.001 | \n\t\t\t\t\t\t\t
Sex female | \n\t\t\t\t\t\t\t\t0.7 (0.2, 3.0) | \n\t\t\t\t\t\t\t\t.684 | \n\t\t\t\t\t\t\t\t1.1 (0.4, 3.4) | \n\t\t\t\t\t\t\t\t.835 | \n\t\t\t\t\t\t\t
Age | \n\t\t\t\t\t\t\t\t1.1 (0.9, 1.3) | \n\t\t\t\t\t\t\t\t.264 | \n\t\t\t\t\t\t\t\t0.9 (0.8, 1.1) | \n\t\t\t\t\t\t\t\t.315 | \n\t\t\t\t\t\t\t
Predictor variables and anxiety syndromes
No.obs: 454; No. gps.:307; Wald chi2=17.90;gl=8; p= 0.0220;Wald chi2=18.32;gl=7; p= 0.0189
This study has shown that variables included for the surveillance of mental health problems in children and adolescents at a primary care setting, probed to be useful and complementary for the study of anxiety syndromes as defined in the CBTD. Furthermore, results are consistent with findings reported in the literature on child’s anxiety disorders as previously reviewed, although none to our knowledge have attempted to collect them as a whole in a primary care setting and evaluate their risk contribution for anxiety disorders in children and adolescents.
Results obtained on the association between specific parental’s psychiatric antecedents and the two anxiety syndromes replicated our previous findings in general population (Caraveo-Anduaga,2011) in that anxiety parental’s psychiatric antecedents either alone or comorbid with depression and substance abuse are significantly associated with the development of anxiety syndromes in their offspring.
The odds ratios in the present study are higher than most of the crude odds ratios found on the general population study. For example, the strength of the association between parental’s antecedents of anxiety-only and general anxiety syndrome in the offspring was OR= 5.7 (95% CI: 2.1, 15.9) in the general population, while in the present study is OR=9.4 (2.8, 31.8). An explanation for such differences is that regression coefficients calculated with logistic GEE analysis, as in the general population study, always will be lower than the coefficients calculated with a logistic random coefficient analysis as in the present study (Twisk, 2003).
One currently key issue is the extent to which diagnostic thresholds defining mental disorders represent unique entities that lead to functional impairment (Rapee et al., 2012). Results showed that, as expected, higher scores on the BIS were significantly associated with CBTD’s anxiety screening syndromes. For most observations on children and adolescents with the generalized anxiety syndrome, 68%, significant risk impairment was found, mainly on interpersonal relationships and work/school performance. Also, for 90% of the observations on children and adolescents reporting anxiety with inhibition, significant risk impairment is associated, and for this syndrome mainly on interpersonal relationships and self-attitudes. These findings are consistent with other reports in the literature, as previously reviewed (see 2.1.2) and contribution of this study is to have documented its presence and relevance in a primary care setting.
Moreover, it is important to highlight that in the present study only frequency of each symtom on the CBTD determined its rating for presence and persistance, so that impairment measurement was obtained irrespective of symptoms and syndromes. The significant association between the measurement of functional impairment and the CBTD’s screening anxiety syndromes not only enhance the accuracy and usefulness of these later, but also, impairments identified with the BIS, may become targets for specific interventions and eventually used as outcome indicators as signaled by Ezpeleta et al. (2006).
The exposure to a more outrageous family environment as evaluated by the SSPHS was not significantly associated with any anxiety syndrome in the offspring. However, having witnessed aggression at home was found associated only with generalized anxiety in children and adolescents. As reviewed, exposure to violence has been found as an independent predictor of different problems in boys as compared with girls (Yates et al., 2003; Moss, 2003). Further analysis is needed to bring more light about this issue.
Roughly, one third of the observations on children and adolescents reporting any screening anxiety syndrome have been exposed to more adverse child-rearing and parental practices, as measured by the two sub-sacles of the PPI. A less positive reinforcement rearing practice seems to be a risk only for generalized anxiety syndrome, while higher negative reinforcement is for both anxiety syndromes; however, the strenght of the association in terms of the odds ratio is higher for children and adolescents with generalized anxiety. Thus, generalized anxiety syndrome in children and adolescents is associated with more adverse child-rearing and parental practices than children and adolescents presenting anxiety with inhibition. As disscussed for impairment, results from the PPI sub-scales not only showed differences in their association with the two screening anxiety syndromes, but also the information is important for planning interventions.
Finally, among the variables included in the study, it is important to distinguish nonmodifiable risk factors from those that could be modifiable (Opler et al., 2010). Results evaluating the morbid risk of all independent variables on anxiety showed that familial psychiatric antecedent, mainly anxiety, is the major nonmodifiable risk factor for both anxiety syndromes, although slightly higher for generalized anxiety than for anxiety with inhibition syndrome. Impairment, which is the second mayor contributor, is actually a consequence of the psychopathology, so it seems that once an anxiety syndrome is detected, efforts should be directed toward the other modifiable risk factors such as rearing and parenting practices in order to prevent further impairment; diminishes suffering and modify maladjustment.
\n\t\t\tThe present report has confirmed that anxiety disorders in children and adolescents attending a primary care center in Mexico City are frequent, persistent and represent a great part of the unmet treatment needs of children’s mental health. In order to tackle this problem and enhace the role of primary care in the preventive actions that are needed, results from this pilot surveillance program on child’s mental health have developed and adapted simple and efficient tools that identified child’s core areas of difficulty associated with the two screening anxiety syndromes. Future work should be focused on acceptable and relatively simple interventions that, as part of a step-care strategy, could modify risk factors such as rearing and parenting practices, evaluating the impact on impairment measures.
\n\t\tThis is study was funded by The National Council of Science and Technology (CONACYT) award 2003-C01-60.We would like to thank: M Psic. Jorge L. López Jimenez; Dr. Julio López Hernández; Dra. Aurora Contreras Garza; Psic. Arlette Reyes Mejía; Enf. Nayely Meneses Zamudio; Psic. Blanca T. Rodríguez Gavia; Dra. Cynthia Rincón González; Psic. Araceli Aguilar Abrego; Psic. Brenda Jiménez Ramos; Psic. Alejandra Guerrero Carillo; Psic. Denisse Meza Mercado & Psic. Sergio Bernabé Castellanos, for their collaboration and participation in this study.
\n\t\tThe correct management of craniofacial differences (CFD’s) -including cleft lip with/without cleft palate (CL ± CP)- is still a challenge for clinicians treating such conditions, due to its treatment length and the different aspects that have to be holistically addressed in accordance with overall and craniofacial growth and development, speech and hearing, facial esthetics, and psychological self-perception of patients with such characteristics.
Although a universal treatment protocol has not been agreed among craniofacial teams worldwide [1], several parameters of evaluation and treatment have been set and reviewed periodically, following the recommended practices for the care of patients with craniofacial differences made by the ACPA (American Cleft-Palate Craniofacial Association) [2] (revised in 2018), based on the call of the Surgeon General of the United States on the needs for children with special health care [3]. A summary of such parameters appears below:
(a) The interdisciplinary team management of patients with craniofacial differences is essential; (b) Clinical expertise in diagnosis and treatment and optimal care for these patients is provided by teams with enough exposure to these patients each year; (c) The first evaluation is within the first few days or weeks of life (ideal), but referral for team evaluation and management is appropriate at any age; (d) Since the beginning, the family of a child with a craniofacial difference must be assisted in adjusting to the birth and consequent demands and stress of having a child with CFD; (e) Responsible adults must receive information about treatment procedures, options, risk factors, benefits, and costs to take informed decisions on the child’s behalf, and to prepare the whole family for all recommended procedures. The family (and patient, when is mature enough) participation and collaboration in treatment planning should be actively asked; (f) Team recommendations are basic to develop and implement treatment plans; (g) Complex diagnostic and surgical procedures should be restricted to centers with experienced health professionals; (h) Each team must be sensitive to linguistic, cultural, ethnic, psychosocial, economic, and physical factors affecting the relationships among the team, the patient and family; (i) Longitudinal follow-up of patients, including appropriate documentation and record-keeping is essential to monitor both short-term and long-term outcomes and falls under the responsibility of each team; (j) The effects on growth, function, appearance satisfaction and psychosocial well-being of the patient should be considered when performing evaluation of treatment outcomes.
Following these parameters, this chapter explain in detail our craniofacial orthodontics treatment algorithms for the patient with unilateral cleft lip and palate (UCLP) from mixed dentition onwards, which addressed all topics related with diagnosis and treatment planning for adolescents and young adults affected with this craniofacial difference.
Mars et al. in 1987 introduced the GOSLON yardstick [4], which has become the standard diagnostic tool for patients with UCLP worldwide. Ozawa et al. in 2011 expanded the same classification for bilateral clefts [5]. This classification, based on dental casts, has proven to be a good and simple option to grade the malocclusion present and to give some hints on the level of difficulty in its correction. Other broader approaches -such as the original Huddart-Bodenham classification (used in deciduous dentition only) [6], or its modification used in both deciduous and permanent dentitions (proposed by Mossey et al. [7])-, are also other interesting approaches to classify all dental components present in UCLP and BCLP malocclusions. However, those indexes missed a common aspect that cannot be forgotten in a craniofacial orthodontic evaluation: the facial pattern in three dimensions that could worsen (or improve) the existing CL ± CP condition. The GOSLON does not consider frontal and lateral facial photographs or cephalometric radiographs, which are regular diagnostic records in orthodontics (taken digitally for these patients in the XXI century). These records are important to detect left-to-right bone vertical discrepancies that could make some UCLP cases more difficult to correct properly than previously thought. This is the reason why the orthodontic diagnosis (and its indicated treatment) cannot be established solely from study dental models. The GOSLON yardstick can be used as a classification system, but not as a determiner of treatment complexity without considering the 3D facial aspects of a complex malocclusion.
Having as a start point the GOSLON yardstick, our unit has developed a modified GOSLON yardstick (named GOSLON+), based not only on dental casts but also on frontal and facial digital photographs and radiographs. These records can be used to accurately determine the involvement of craniofacial orthodontics and craniofacial surgery in the resolution of unilateral (and bilateral) cases, depending on the degree of asymmetry associated with the cleft, following all aspects involved in a complete orthodontic diagnosis. The following diagram and the accompanying patients’ photographs (with full records) demonstrate our current diagnosis categories and changes in the treatment of patients with UCLP (modified from the original GOSLON) (Table 1, Figure 1), [4] Our modified classification considers the influence of facial and occlusal 3D aspects in the craniofacial overall diagnosis and the need for additional treatment created by the existing frontal asymmetry.
Group | Characteristics | Treatment | Prognosis |
---|---|---|---|
1± |
| Surgical orthodontics and surgical treatment for class II malocclusion. | Good/Fair (Depending of Degree of Facial Asymmetry [+]) |
2± |
| Surgical orthodontics and surgical treatment for moderate or complex class I malocclusion. | Excellent (None [−] to some Degree of Facial Asymmetry [+]) |
3± |
| Surgical orthodontics and surgical treatment for mild class III malocclusion. | Good/Fair (Depending of Degree of Facial Asymmetry [+]) |
4± |
| Surgical orthodontics and surgical treatment for severe class III malocclusion. | Fair (Depending of Degree of Facial Asymmetry [+]) |
5± |
| Surgical orthodontics and step-wise surgical treatment for extreme class III malocclusion. (Maxillary Osteogenic Distraction and Orthognathic Surgery). | Fair (Depending of Degree of Facial Asymmetry [+]) |
Modified GOSLON yardstick (GOSLON+) for patients with UCLP. A similar table apply to patients with BCLP.
Facial and intraoral characteristics of patients presenting the five different degrees of GOSLON+ yardstick. Observe that treatment prognosis further decreases when frontal and lateral facial photographs are included in the treatment algorithm to manage successfully the existing alveolar clefts.
It is well known that not all clefts are similar [6, 8, 9, 10, 11]. Moreover, patients affected by UCLP have some degree of facial asymmetry that affects the prognosis (Figure 1). This fact must be considered within the orthodontic-surgical diagnosis. Accordingly, their ortho-surgical treatment plan should not be the same either, due to the type and extension of cleft, the timing for the initiation of those treatments, and the individual needs for surgical treatment influencing the selection of surgical techniques. In addition to these factors that have a negative influence on facial growth, the expertise of the ortho-surgical team and the interdisciplinary management given to the patient is the last -but not the least- item to be considered for obtaining a satisfactory treatment outcome [12].
Based on this improved GOSLON classification, a description of the surgical orthodontic management for average and wide clefts will be addressed. After that, two different surgical orthodontics algorithms will be presented, with clinical cases to summarize the decision-making process applied in the surgical orthodontic care of patients with UCLP with different degrees of sagittal and transversal maxillary-mandibular involvement in the Clínica Noel Foundation at Medellin, Colombia, S.A.
The alveolar cleft -the space between the maxillary segments anterior to the incisor foramen- represents a lack of continuity of both maxillary dental arch and basal bone. Spatially, it can be represented as a pyramid placed on its side, with its base towards the labial side and its apex located in a posterior and superior position inside the cleft maxilla [13]. This gap should be ideally filled by a cancellous bone graft to restore its basal and alveolar normal architecture. This defect gives origin to a particular kind of critical-size segmental defect that creates a significant challenge for craniofacial surgeons, maxillofacial surgeons and craniofacial orthodontists [14].
From all the alternatives to fill completely the maxillary cleft, the secondary (intermediate or late) alveolar bone grafting (SABG) is still the gold standard treatment to restore the alveolar anatomy, either in mixed dentition or early permanent dentition [15]. The objectives of SABG include (1) to restore and stabilize the normal architecture of the maxilla; (2) to allow eruption of permanent lateral incisor and canine; (3) to provide support and elevation of the affected wing base; (4) to close present oronasal fistulas and (5) to provide “adequate” bone support to be restored later with prostodontics with/without dental implants, in case that a closure of the gap with dental eruption cannot be achieved [16, 17]. It has been our approach to limit its objectives to the first three in mixed dentition patients, due to the uncertain nature in time of this type of autografts and the impediment for free dental movement created by cortical grafts at early ages. However, two controversies proposed by Vig still remained valid today: which is the best bone graft type and the best donor site for harvesting? and what is the best timing for maxillary (dento-alveolar) expansion in patients requiring SABG [17]? A third controversy refers to whether the alveolar cleft can be repaired by a combination of bio-engineering alternatives currently available nowadays. Our treatment rationale tries to solve the first two questions as follows:
Several aspects have to be considered for obtaining a successful bone graft in such patients:
During mixed dentition stage, orthodontic treatment can be used previous to surgical treatment to increase maxillary dental arch width and length using the Quad-Helix [18, 19, 20, 21] (Figure 2). This appliance -developed by Ricketts while he was part of the Cleft Palate Clinic at UIC (currently the UIC Craniofacial Center) [22] and improved by Wilson and Wilson in the 80’s [20] and others- is currently applied to correct the collapse of the lateral maxillary segment behind the protruding premaxillary process [23]. In patients with UCLP, the bony palate anatomy presents a primary unilateral deficiency worsen by contraction of scar tissue, as a result of the neonatal surgical palatal closure [19, 23]. In addition to the dento-alveolar effect obtained in patients without clefts, the main bony effect of the Quad-Helix in UCLP cases is the expansion of the lateral maxillary shelves when the de-rotation of the maxillary molars is achieved [19, 23]. In such cases, dento-alveolar expansion before surgery results in similar treatment outcomes than in patients with maxillary expansion [24], with the benefit of working with minimum risk of creating secondary maxillary fistulas. Dento-alveolar expansion could also be obtained by other orthodontic appliances such as the reverse Quad-Helix (with poor correction of the molar rotation) [25], conventional or modified jointed fan (or butterfly) expander [26, 27, 28], NiTi palatal expander [29], or self-ligation appliances [30].
Recovery of normal transversal maxillary width with correct maxillary alignment after the use of Quad-Helix. a. Before Quad-Helix, b. At removal time. Notice the change in the cleft architecture and the creation of alveolar spacing for the alignment of the right maxillary canine.
Dento-alveolar maxillary expansion is usually followed by maxillary dentition segmental leveling and alignment (using an anterior [3*2] utility arch) [21, 31, 32, 33, 34]. In order to obtain similar results than those achieved using an inverse treatment protocol (alveolar grafting followed by orthodontics with maxillary expansion) [24], an orthodontic approximation of maxillary segments using a sectional arch approach -after obtaining proper maxillary width but before surgery- should be considered. In older patients, a mini-screws based molar distalization plus orthodontic dental retraction -by controlling the mesial inclination of the canine for greater bone approximation- is often required to create an alveolar defect with parallel walls to minimize the alveolar gap size when a segmental surgery is planned (Figure 3) [35, 36].
Modified First-Phase Orthodontic Strategies. In addition to the a. maxillary utility arch, two other strategies have been useful in the correct alignment of the maxilla prior to surgery: b. sectional approximation of maxillary segments; and c. mini-screw based distalization.
The suggested order of orthopedic-orthodontic procedures would be as follows: 1. Dento-alveolar maxillary expansion; 2. Maxillary segmental dental leveling and alignment; 3. Mini-screw based molar distalization (if needed in patients that have passed the appropriate timing for grafting) and 4. Orthodontic approximation of maxillary segments.
At the time of bone grafting, many craniofacial centers around the world use SABG during mixed dentition (5 to 12 years of age) before or during permanent canine eruption, taking advantage of the growth potential of the maxilla at this stage [37]. In our center, we use Intermediate or late SABG during mixed or early permanent dentition for GOSLON1–3 patients only. We usually perform such procedure in agreement with dental age characteristics of teeth around the cleft (permanent canine and lateral incisor when present). The ideal age range for surgical procedure should be when the canine on the cleft side is from less than 5 mm of its eruption place to a partially erupted canine (1/3 to ½ of crown visible). Late SABG cases with narrow alveolar clefts at the right age allows to work with bone graft stimulation (either with compression osteogenesis or RPE) to obtain excellent results in both cases (Figure 4) [24, 37]. Using SABG as an alveolar bone matrix, we achieve high degree of success in correcting the canine eruption and migration pathway [38]. The bone graft would give temporary bone support for the eruption of lateral incisor and/or canine without affecting the growth of the midface, with good outcomes similar to other centers in the world when compared with gingivoperiosteoplasty [21, 39]. Ideally, a complete closure of the space with no need for lateral incisor prosthesis is achieved when the migration of the canine occurs.
Intraoral Results of Iliac Crest Late Secondary Alveolar Bone performed at the Correct Time. a. Despite the fact that all teeth around the cleft were erupted at the initial evaluation, the patient still had intermediate mixed dentition and remaining eruption potential in the lateral incisor adjacent to the alveolar cleft; b. After late SABG and finishing restorative dentistry procedures. Note the closure of the alveolar cleft and the normal gingival architecture obtained by the application of orthodontic compression osteogenesis after cancellous iliac bone grafting.
In chosen candidates, cancellous iliac crest bone from the inner anterior portion of the crest is usually required to close mild-to-moderate type of fistulas (patients with UCLP GOSLON1 to 3 at the appropriate age) (Figure 4). This approach is used to restore momentarily alveolar bone continuity needed for dental movement [40, 41]. Figure 4 shows a case with such approach, with an excellent outcome. However, other harvesting sites such as tibia, mandibular symphysis or retromolar area can be successfully used for this purpose [23, 42, 43].
Of all types of bone graft (cortical, cancellous, or mixed), the fresh autogenous cancellous bone is the “ideal” source for reconstruction of bone integrity, due to the fact that it provides living bone cells and is immune-compatible enough to allow osteogenesis and full integration with the maxilla [40]. Autografts have as its main characteristic osteoproduction [44] -bone growth obtained from combined properties of osteoinduction (recruitment, proliferation, and transformation of osteoprogenitor MSC’s into osteoblasts) [45], osteopromotion (process of secondary support of bone healing and tissue regeneration, without capability of initiate bone formation) [46], osteoconduction (process of osseous and vascular cell ingrowth inside the 3D matrix scaffolding) [47], and “relative” osteogenesis (process of deposition of newly formed bone by osteoblasts at the fracture site)- that enhance osteoprogenitor MSC’s response according with autologous graft type. Allografts also share other advantages such as biocompatibility, and mechanical resistance vs. orthodontic remodeling depending on the graft source [48]. Iliac crest site morbidity, accessibility, and availability of areas of graft harvesting of other donor places create a supposedly difficulty that could be overcome with sufficient surgeon’s exposure to this approach [49] in a capabilities-based curriculum [50]. When a successful incorporation (or modeling) of a graft is achieved, the term osseointegration can be used under this definition (Figure 4) [51]. An optional surgical procedure for treating wide alveolar clefts will be described later.
At the Pre-surgical Planning Time of Post-Surgical Procedures. In cases where lateral incisor in the cleft area is partially missing, split in two by the cleft (creating two “real” supernumerary teeth), or absent, all options involved in the dental restoration of the patient must be considered:
When the lateral (and central incisor or canine, depending on the location of the cleft) present a missing portion, a composite restoration could be required either during or once the orthodontic treatment is finished to improve esthetic appearance (Figure 4).
Lateral incisor supernumeraries present additional difficulties to be addressed: their crowns usually are of decreased size, and the roots are short and with many irregularities and dehiscenses along the root length. Performing restorative procedures, such as extensive composite restauration on the wider tooth, are in order if the chosen supernumerary has its root firmly embedded in bone and the final orthodontic placement of the tooth leaves the root with enough alveolar bone on both sides.
If the lateral incisor is missing, an option would be to take advantage of performing an intermediate SABG followed by the mesial eruption of the canine. Later on, restorative procedures in conjunction with orthodontics will convert the canine anatomy in lateral anatomy, although some differences between normal and converted teeth remain regarding color and crown emergent profile from gingiva (Figure 5).
Intraoral Results of Guided Migration of Permanent Canine through SABG performed at the Correct Time. After successful SABG, the left maxillary canine was directed to erupt in a mesial position from its initial site. Note the hypertrophic gingiva surrounding the teeth on the repaired cleft site. The patient will require cosmetic dentistry procedures in addition to the correct bucco-lingual root torques delivered by the use of lower first bicuspid brackets on the maxillary canine (to act as lateral incisor) and first bicuspid (to act as canine). Protraction of the upper first molar to obtain a well-established class II relationship is under way.
Orthodontic procedures (regarding bracket type and bracket positioning -proper height and buccal-lingual crown inclination of canine and first bicuspid on the cleft side), periodontal procedures (to maintain or recover -partial or totally- the periodontal anatomy affected by decreased gingival thickness as a consequence of mesenchymal deficiency in patients GOSLON3+, 4, 4+, 5 and 5+) (Figure 6) and/or additional cosmetic dentistry/prosthodontic procedures (to transform with such strategies the maxillary canine in lateral incisor and the maxillary bicuspid in canine, and perform additional restorative work if needed) are necessary after SABG surgical procedure for an adequate dental characterization with good-to-fair periodontal condition (Figures 7 and 8). Optional plastic surgery procedures could be needed as well.
Periodontal Results of Connective Tissue Graft and Enamel Matrix Protein Application after Ortho-Surgical Procedures. This experimental procedure in cleft patients allow the clinicians working in poor anatomic conditions -due to the negative influence of a mesenchymal deficiency- to partially recover gingival architecture at the short-term follow-up. Long-term follow-up will give us answers regarding the success of the obtained periodontal stabilization. a. Initial intraoral left close-up photo. The patient has a wide left alveolar cleft with dental inclination of left permanent central incisor (moderate), and left permanent canine (severe); b. Intermediate intraoral left close-up photo. After a segmental maxillary advancement, moderate loss of periodontal attachment and apical migration of gingival margins was observed; c. After connective tissue graft plus enamel matrix protein infiltration. Notice the gain on gingival margins and periodontal thickness as a result of this approach; Surgical sequence: d. Harvesting of palatal connective tissue graft; e. graft waiting to be inserted below gingiva; f. Graft placement under keratinized gingiva; g. Emdogain® syringe used in this case.
Patient with UCLP GOSLON2 treated at Mixed Dentition stage. Initial records: a. Frontal facial photograph; b. Periapical radiograph of the alveolar cleft; c. Intraoral frontal view; Final records: d. Frontal facial photograph; e. Periapical radiograph of the alveolar cleft; f. Intraoral frontal view. The application of the compression osteogenesis strategy was fundamental to obtain normal periodontal architecture in the grafted area of the alveolar cleft.
Patient with UCLP GOSLON2 treated at Permanent Dentition stage. Initial records: a. Frontal facial photograph; b. Intraoral frontal view; Final records: c. Frontal facial photograph; d. Intraoral frontal view. A relatively normal dental and gingival architecture was obtained after the surgical management of a Two-piece LeFort I.
Our retention protocol for patients with normal skeletal relationships (GOSLON2 and 2+) or with mild skeletal discrepancies (GOSLON1, 1+ and 3) use Essix-type retainers. As our treatment approach is directed to obtain a maxillary arch without dental spaces if possible, we seldom use wrap-around maxillary retainers with dental temporary replacements. Our countdown-to-retention includes periodontal evaluation and treatment in patients with GOSLON3+ and more, to address the thin and receding gingiva in cleft-adjacent teeth, associated with genetically-driven periodontal ligament loss described previously (Figure 6). In those cases (which have received correction of existing moderate to severe skeletal discrepancies previously), a periodontal connective tissue graft plus dentin matrix protein injections to increase gingival volume and tissue support, and a dual retention strategy with an additional bonded lingual retainer in the maxillary anterior teeth is used.
Young patients affected by UCLP who have severe restriction of maxillary growth and wide oronasal fistulas (GOSLON4, 4+, 5 and 5+), or adult patients with UCLP in all categories of the GOSLON+ yardstick, have been historically (and unsuccessfully) treated using alveolar bone grafting (secondary or tertiary). In addition, inadequate closure of primary incisions, post-operative wound dehiscence and infections could potentially make bone grafting healing worse [35]. Mars et al. recognized that unilateral alveolar bone grafting success was limited to young patients with “average” maxillary growth (patients GOSLON1, 1+, 2, 2+, and 3) and normal gingival thickness compared with an age-matched normal population [4]. What was the problem? They found out that with increased limitation in maxillary craniofacial growth in patients with UCLP, there was an important compromise in making the maxillary segments meet closely to complete a successful bone graft and a greater difficulty to obtain a fair maxillary dentition by subsequent orthodontic treatment [4].
In order to obtain a surgically-created one-piece maxilla [52], craniofacial centers worldwide use strategies based on segmental maxillary advancements (described by Schuchardt [53]). This surgical technique and its modifications were currently used to manage the surgical closure of open bite [54, 55], transverse maxillary deficiency [55, 56, 57], or excess [55, 58]. The last two findings are common in patients with UCLP. After proper soft tissue management of severe and longstanding oronasal fistulas [12], this approach favors the 3D maxillary architecture prior to secondary orthognathic surgery, reduces prosthodontic needs and creates a more cost-effective alternative than using either conventional LeFort I advancement plus extensive prosthodontic replacement or interdental osteogenic distraction [58].
A combination of surgical fistula closure followed by a combination of Le Fort I advancements in two segments [59] plus immediate or delayed alveolar bone graft, depending on the need and extension of additional distraction osteogenesis/orthognathic surgery has been used regularly at the Clínica Noel Foundation since 2015, modified from Stal et al. [12] (Figure 9). This maxillary procedure could be performed alone or in combination with BSSO during the same surgical procedure. This modified approach produce good bone blood flow [60], and stability [61], with fair gingival architecture due to pre-existing periodontal conditions that can be worsened in some cases by local tension on the flaps during gingival closure [59] (Figure 5). Good-to-fair results regarding non-tension flap closure, bone-to-bone contact, and secondary bone healing have been obtained, depending on the degree of cleft maxillary hypoplasia present. For these patients, these successive surgical steps (oronasal fistula treatment followed by segmental maxillary approximation) could be realized previous or simultaneously to the placement of a narrow tertiary alveolar bone grafting and the realization of additional surgical mandibular procedures during orthognathic surgery.
Application of Segmental Maxillary Advancement to reduce the Alveolar Cleft prior to Final Bone Grafting. Pre-surgical records. a. Close-up of alveolar cleft, b. Occlusal view, c. Periapical radiograph, d. CT close-up occlusal view: 10 mm gap between internal radicular surfaces, e. CT occlusal maxillary view; Post-surgical records. f. Close-up of alveolar cleft, g. Occlusal view, h. Periapical radiograph, i. CT close-up occlusal view: 5 mm gap between internal radicular surfaces, j. CT occlusal maxillary view. The left segmental advancement reduced in half the distance to be covered by a tertiary bone grafting and increased the chances of closure success.
Distraction osteogenesis is a treatment technique that deals with the genesis and growth of new bone in a specific body area, through the application of gradual tensile stress [62, 63, 64, 65, 66]. Distraction Osteogenesis can be applied to the surgical correction of hypoplasias of the craniofacial skeleton to replace extensive bone and soft tissue deficiencies without requiring the use of bone grafts [67]. This technique additionally provides the benefit of expanding the overlying soft tissues, which are frequently deficient in these patients.
After the introduction of gradual elastic maxillary distraction to advance a segmental Le Fort I osteotomy (an incipient form of Distraction Osteogenesis -DO) by Wassmund [68], maxillary DO using facemask and elastic traction was successfully reintroduced by Molina and coworkers 60 years later [69], after several animal studies corroborated its feasibility [70, 71]. After the arrival of the Rigid External Distraction (RED) technique for its use for upper and mid-face hypoplasia in 1997 [72], Polley and Figueroa applied their maxillary DO technique in cleft patients [73, 74] and Figueroa and co-workers reported their immediate and long results in this population [75, 76]. In patients with either UCLP or BCLP that present severe maxillary hypoplasia (GOSLON 5 and 5+), worsened by previous pharyngeal repairs that apply additional tension to an already deficient cleft maxillary development, this alternative surgical technique allows the progressive forward displacement of the maxillary complex, while exerts moderate but increasing tension in the pharyngeal musculature that favors their rearrangement in the final maxillary position [73, 74, 75, 76].
Patients prior to the surgical procedure received preferably a customized rigid labial-palatal arch with external vertical hooks adapted partially from a face-bow, or with detachable external hooks located distal to the lateral incisors (Figure 10). These orthodontic options facilitate further distraction modifications and appliance removal in dental settings. After this, the patient was submitted to a high LeFort I osteotomy (in segments according to cleft type), avoiding tooth germs and external halo frame positioning. After 5–7 days latency period, active distraction is performed at 1 mm/day at 0.5 mm each 12 hours, until an additional 20% of the planned DO is achieved. Orthodontic follow-up is highly recommended to control the amount of distraction remaining, to change the direction of distraction when needed, and to give additional instructions to the patient and relatives on how to adjust the distraction if any AP and transverse maxilla-mandible asymmetry is developing. The average amount of maxillary RED distraction in such cases was 9.6 mm [76]. A consolidation period of 3+ months with the distractor in place must be observed to allow maxillary bone to mature from the initially delayed woven bone and guaranteed the obtained results.
Intraoral Tooth-Supported Devices for RED system. a. Customized rigid labial-palatal arch with external vertical hooks adapted partially from a face-bow, b. Customized rigid labial-palatal with detachable external hooks located distal to the lateral incisors.
Despite the appearance of other maxillary DO external and internal devices, the RED system allows the application of important pulling forces to advance the receding maxillary complex without risking external frame integrity, permits to correct direction of distraction due to their flexibility in distractors’ positioning on vertical and horizontals bars [77], and manage a wider range of maxillary distraction than internal DO devices. A maxillary cleft case treated with this approach appears below (Figure 11).
Patient with Maxillary Cleft undergoing Maxillary RED. a. Before maxillary DO; b. During Distraction Osteogenesis; c. After DO. Notice the improvement on maxillary projection at the infraorbital level.
Adult patients affected by CL ± CP require reduced treatment times while obtaining optimal craniofacial results. After obtaining a one-piece maxilla (Except in patients GOSLON2, some GOSLON2+, and GOSLON3 that finished ortho-surgical treatment at the end of SABG) and at the end of maxillary DO in patients GOSLON5 and 5+, the Craniofacial Ortho-Surgical team has to properly plan and execute orthognathic surgery that address three-dimensionally all problems related with the surgical correction of an asymmetric patient. Could a combination of treatments according to the state of the art be used to reduce treatment times in an interdisciplinary scheme? There are several contemporary alternatives from the orthodontic-surgical treatment stand point that can be used in this scenario: First, the re-appearance of self-ligating systems (with passive -regular [e.g. Damon™ System, Ormco Corp., Orange, CA] or CAD-CAM individualized brackets [e.g. Insignia™ System, Ormco Corp., Orange, CA]-, or interactive brackets [e.g. CCO™ System, Dentsply Sirona Orthodontics, York, PA]), and second, the spreading use of Surgical Treatment Acceleration (Surgery-First and Surgery-Early surgical approaches).
Both alternatives are not new. Passive Self-Ligation is an old therapeutic alternative available for clinical use in the 70’s [78] and 80’s [79]. The concept was commercially reintroduced in the late 90’s by the Ormco™ Task Force, to give origin to the Damon™ System [80, 81]. One of its objectives is supposedly to reduce clinical activity time and treatment time -reduction in wire changes and face-to-face clinical activity-, and increase clinical efficiency by simplifying orthodontic mechanics and materials. The passive effect of friction reduction by bracket design is especially noticed during tooth leveling and alignment in severe dental crowding, dentoalveolar expansion, and in less extent during major tooth movements [80, 81]. The second objective is to take advantage of the active use of orthodontic archwires with variable activation temperature. This is the most important change from early self-ligating appliances. Buehler and coworkers were the first to explain the physical properties of the Variable Transformation Temperature concept [82], while Tien and collaborators in 1982 described its application in orthodontics [83]. Later, Burstone and others published on the alloy characteristics and clinical behavior in depth [84, 85, 86, 87]. Thermo-activated wires allow clinicians (1) to use a differential alloy sequence, that permit early cross-sectional form changes and wire gauge increments to fill entirely the bracket’s slot at early treatment stages with early effect of torque, and (2) to take advantage of wider archforms than in current straight-wire systems. This characteristic is potentiated with self-ligation to produce a “free” vestibular tooth movement by using wider arch shapes on unconventional alloys in a shorter period of time [88, 89, 90]. Total appointment time and treatment length could be shorter due to the fulfillment of both objectives in most cases. However, no differences in the positions of incisors and the transverse dimension changes of the maxillary arch were found when self-ligated appliances and conventional-ligated appliances plus Quad-Helix were compared [91]. There is insufficient evidence to justify or contraindicate its use in surgical orthodontics in patients with CL ± CP [30].
Surgical Treatment Acceleration is not a new technique either. During the 1960–1970’s, the early orthognathic surgery approaches were performed without orthodontist intervention (Surgery first -independent-), and subsequent orthodontic treatment was poorly encouraged by maxillofacial surgeons afterwards [92, 93, 94]. Several problems, including the lack of interrelation of orthodontic and surgical treatments, and difficulties for space generation needed for correct orthodontic decompensation, aroused from these early attempts. After the realization that occlusal relationships were a key component of orthognathic surgery results, the orthodontist gained a role in both craniofacial and maxillofacial teams with the objective to eliminate dental compensations before surgery and facilitate posterior orthodontic treatment [95]. The basic sequence of procedures is still applied today. However, creating a maxilla-mandibular decompensation, alignment, and correct maxilla-mandibular anterior and transversal relationships is a long process, even today. A different approach was proposed by Epker and Fish in [96]. They affirmed that it was best to perform surgical procedures as soon as possible to obtain immediate post-surgical benefits for orthodontic treatment (accelerated orthodontic movement after surgery following surgical correction), surgical improvement (early recovery of facial and dental function), and functional aspects (improvements on speech and deglution). Sugawara and Tohoku University/University of Connecticut group in 2009 proposed their Surgery First Approach (SFA) -also called Surgery-First/Early Orthognathic Approach (SFEA) [97]- combined with Skeletal Anchorage System (SAS) for the treatment of a skeletal Class III patient, obtaining excellent results based on the premises mentioned previously [98]. In 2019, the same group published its extensive follow-up on Temporo-Mandibular Symptoms and Function in Class III malocclusion using SFEA compared with Orthodontics-First Approach (OFA) patients, without significant differences between groups [99]. CES University, in conjunction with the mentioned consortium [100], and with the Universidad del Valle [101] have applied SFEA schemes in Latin-American patients. SFEA rely on performing orthognathic surgery at the beginning of treatment with minimal preoperative orthodontics [102]. This treatment protocol allows the reduction in time of pre-surgical treatment (obtaining one-year reduction in average), with the patient’s benefit of an early improvement in facial esthetics. It can be applied not only in patients with UCLP and Class III malocclusion (GOSLON3+ onwards), but also in patients with UCLP and Class II malocclusion (GOSLON 1 and 1+), with or without skeletal vertical discrepancies.
Chang Gung Memorial Hospital group general guidelines for such approach states the following advantages of the procedure as follows [103, 104]: (1) Shorter pre-surgical orthodontic treatment time; (2) Reduction in the difficulty of post-surgical treatment through Regional Acceleratory Phenomena (RAP) [104]; (3) Possibility of planning and computer-guided execution (CAD-CAM); (4) Same effect on ATM as with traditional scheme, in addition to the surgical and functional advantages already mentioned. The post-operative rapid (accelerated) orthodontic tooth movement after SFEA in both dental arches is significant and is due to the increase in odontoclasts activity and dentoalveolar metabolic changes [105]. However, some disadvantages of SFEA include: (1) The need of careful orthodontic-surgical planning; (2) The preparation of the orthodontic-surgical team; (3) The appearance of possible post-surgical orthodontic problems; (4) A poor post-operative stability [97], in opposition to favorable long-term stability reported previously [96].
Mahmood and coworkers suggested that implementing a modified Surgery-Early protocol to speed-up final orthodontic-surgical treatment for CL ± CP patients would be useful [102]. However, Seo and coworkers found smaller incisor overjet, maxillary intercanine and intermolar ratios, and ratio of intercanine and intermolar distance in a group of surgical patients with UCLP and Class III malocclusion prepared to be treated with SFEA, than in a non-cleft group with a dentofacial deformity. The same group had also smaller anterior teeth contact number and larger incisor overjet than patients with UCLP and Class III malocclusion treated with a conventional protocol [106]. These difficulties have to be weighed when planning surgical procedures under this approach.
As a summary of the SFEA application, this modified version of the steps for performing orthognathic surgery under this approach are [103]: (1) Short period (≤6 months) of AP and vertical maxilla-mandibular decompensating orthodontics before the operation; (2) Reduction of possible dental collisions and minimal decompensation of mandibular teeth, through segmental maxillary surgery planning, surgically assisted rapid palatal expansion, or post-operative orthodontic tooth movement; (3) First / Early Modified Surgery 3D Model; (4) First/Early surgery based on specific therapeutic planning. Total treatment time is shortened in around 1 year, depending of the complexity of the remaining orthodontic treatment [103]. Treatment results of a patient with UCLP GOSLON4+ are shown in Figure 12.
Patient with UCLP undergoing maxillo-mandibular asymmetry correction through Surgery-First/Early Approach and Passive Self-ligation. a. and b. Before treatment; c. and d. Previous to Surgery-Early Approach. Noticed the dental changes obtained in the maxillary dentition by the use of passive self-ligation appliances; e. and f. After Surgery-Early Approach; d. After the end of treatment. Treatment time before treatment-surgery: 6 months, 25 days; Total Treatment time: 20 months, 25 days.
The anterior information can be summarized to perform apparently different treatment choices in a rational order that will allow clinicians to identify the increasing difficulty of surgical orthodontic approaches used in the resolution of alveolar cleft with or without distraction osteogenesis and final orthognathic surgery (Figures 13 and 14).
Mixed dentition treatment algorithm for patients with UCLP. The final prognosis and outcome using this approach depends on severity of the cleft, the degree of mandibular deviation, and the surgical ability of the craniofacial team to obtain the desired goals.
Alternative treatment algorithm for adult patients with UCLP. A more expedite protocol following the same parameters (severity of the cleft, degree of mandibular deviation, and surgical ability of the craniofacial team) is performed in all patients with UCLP who have non-repaired clefts and require a definitive solution to their craniofacial difference.
Orthodontic treatment for patients with unilateral cleft lip and palate varies in the level of difficulty due to the increased involvement of orthodontic and surgical procedures involved, the correct timing of applying the complete treatment strategy, and the need of additional procedures to treat several dental anomalies present in teeth adjacent to the cleft, such as dental form and size anomalies, localized enamel hypoplasia, abnormal teeth number, and dental formation disturbances.
Our modified GOSLON+ yardstick allow us to categorize patients with UCLP in several discrete groups according to maxillary growth. Our treatment algorithms allow us to deliver appropriate treatment of the adolescent and young adult patients requiring effective orthodontic intervention for all surgical needs in our patient-based hospital settings in Colombia.
To CES University, who allowed me to experience all procedures described in this chapter.
To Universidad de Antioquia for their support.
To Clínica Noel Foundation to allow me access to all records used in this chapter.
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by"}},{type:"book",id:"10827",title:"Oral Health Care",subtitle:"An Important Issue of the Modern Society",isOpenForSubmission:!1,hash:"9a0ceb9ced4598aea3f3723f6dc4ea04",slug:"oral-health-care-an-important-issue-of-the-modern-society",bookSignature:"Lavinia Cosmina Ardelean and Laura Cristina Rusu",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg",editedByType:"Edited by",publishedDate:"August 17th 2022",editors:[{id:"180569",title:"Dr.",name:"Lavinia",middleName:null,surname:"Ardelean",slug:"lavinia-ardelean",fullName:"Lavinia Ardelean"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"11139",title:"Geochemistry and Mineral Resources",subtitle:null,isOpenForSubmission:!1,hash:"928cebbdce21d9b3f081267b24f12dfb",slug:"geochemistry-and-mineral-resources",bookSignature:"Hosam M. Saleh and Amal I. Hassan",coverURL:"https://cdn.intechopen.com/books/images_new/11139.jpg",editedByType:"Edited by",publishedDate:"August 17th 2022",editors:[{id:"144691",title:"Prof.",name:"Hosam M.",middleName:null,surname:"Saleh",slug:"hosam-m.-saleh",fullName:"Hosam M. Saleh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"235",title:"Gerontology",slug:"gerontology",parent:{id:"21",title:"Psychology",slug:"psychology"},numberOfBooks:4,numberOfSeries:0,numberOfAuthorsAndEditors:72,numberOfWosCitations:29,numberOfCrossrefCitations:42,numberOfDimensionsCitations:80,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicId:"235",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"7904",title:"Aging",subtitle:"Life Span and Life Expectancy",isOpenForSubmission:!1,hash:"4507619de679dfa85bc6e073d163f3c8",slug:"aging-life-span-and-life-expectancy",bookSignature:"Robert J. Reynolds and Steven M. Day",coverURL:"https://cdn.intechopen.com/books/images_new/7904.jpg",editedByType:"Edited by",editors:[{id:"220737",title:"Dr.",name:"Robert",middleName:null,surname:"J. Reynolds",slug:"robert-j.-reynolds",fullName:"Robert J. Reynolds"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6704",title:"Geriatrics Health",subtitle:null,isOpenForSubmission:!1,hash:"7cac7767e0b34391318cd4a680ca0d68",slug:"geriatrics-health",bookSignature:"Hülya Çakmur",coverURL:"https://cdn.intechopen.com/books/images_new/6704.jpg",editedByType:"Edited by",editors:[{id:"190636",title:"Associate Prof.",name:"Hülya",middleName:null,surname:"Çakmur",slug:"hulya-cakmur",fullName:"Hülya Çakmur"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6381",title:"Gerontology",subtitle:null,isOpenForSubmission:!1,hash:"bf232563c8fe15ef0848ed6ffb8f832d",slug:"gerontology",bookSignature:"Grazia D’Onofrio, Antonio Greco and Daniele Sancarlo",coverURL:"https://cdn.intechopen.com/books/images_new/6381.jpg",editedByType:"Edited by",editors:[{id:"272628",title:"Dr.",name:"Grazia",middleName:null,surname:"D'Onofrio",slug:"grazia-d'onofrio",fullName:"Grazia D'Onofrio"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5925",title:"Perception of Beauty",subtitle:null,isOpenForSubmission:!1,hash:"11f483d631557ad26d48b577e23a724f",slug:"perception-of-beauty",bookSignature:"Martha Peaslee Levine",coverURL:"https://cdn.intechopen.com/books/images_new/5925.jpg",editedByType:"Edited by",editors:[{id:"186919",title:"Dr.",name:"Martha",middleName:null,surname:"Peaslee Levine",slug:"martha-peaslee-levine",fullName:"Martha Peaslee Levine"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:4,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"60564",doi:"10.5772/intechopen.76249",title:"Ageing Process and Physiological Changes",slug:"ageing-process-and-physiological-changes",totalDownloads:7003,totalCrossrefCites:19,totalDimensionsCites:34,abstract:"Ageing is a natural process. Everyone must undergo this phase of life at his or her own time and pace. In the broader sense, ageing reflects all the changes taking place over the course of life. These changes start from birth—one grows, develops and attains maturity. To the young, ageing is exciting. Middle age is the time when people notice the age-related changes like greying of hair, wrinkled skin and a fair amount of physical decline. Even the healthiest, aesthetically fit cannot escape these changes. Slow and steady physical impairment and functional disability are noticed resulting in increased dependency in the period of old age. According to World Health Organization, ageing is a course of biological reality which starts at conception and ends with death. It has its own dynamics, much beyond human control. However, this process of ageing is also subject to the constructions by which each society makes sense of old age. In most of the developed countries, the age of 60 is considered equivalent to retirement age and it is said to be the beginning of old age. In this chapter, you understand the details of ageing processes and associated physiological changes.",book:{id:"6381",slug:"gerontology",title:"Gerontology",fullTitle:"Gerontology"},signatures:"Shilpa Amarya, Kalyani Singh and Manisha Sabharwal",authors:[{id:"226573",title:"Ph.D.",name:"Shilpa",middleName:null,surname:"Amarya",slug:"shilpa-amarya",fullName:"Shilpa Amarya"},{id:"226593",title:"Dr.",name:"Kalyani",middleName:null,surname:"Singh",slug:"kalyani-singh",fullName:"Kalyani Singh"},{id:"243264",title:"Dr.",name:"Manisha",middleName:null,surname:"Sabharwal",slug:"manisha-sabharwal",fullName:"Manisha Sabharwal"}]},{id:"55388",doi:"10.5772/intechopen.68944",title:"Beauty, Body Image, and the Media",slug:"beauty-body-image-and-the-media",totalDownloads:7768,totalCrossrefCites:5,totalDimensionsCites:12,abstract:"This chapter analyses the role of the mass media in people’s perceptions of beauty. We summarize the research literature on the mass media, both traditional media and online social media, and how they appear to interact with psychological factors to impact appearance concerns and body image disturbances. There is a strong support for the idea that traditional forms of media (e.g. magazines and music videos) affect perceptions of beauty and appearance concerns by leading women to internalize a very slender body type as ideal or beautiful. Rather than simply being passive recipients of unrealistic beauty ideals communicated to them via the media, a great number of individuals actually seek out idealized images in the media. Finally, we review what is known about the role of social media in impacting society’s perception of beauty and notions of idealized physical forms. Social media are more interactive than traditional media and the effects of self‐presentation strategies on perceptions of beauty have just begun to be studied. This is an emerging area of research that is of high relevance to researchers and clinicians interested in body image and appearance concerns.",book:{id:"5925",slug:"perception-of-beauty",title:"Perception of Beauty",fullTitle:"Perception of Beauty"},signatures:"Jennifer S. Mills, Amy Shannon and Jacqueline Hogue",authors:[{id:"202110",title:"Dr.",name:"Jennifer S.",middleName:null,surname:"Mills",slug:"jennifer-s.-mills",fullName:"Jennifer S. Mills"}]},{id:"59227",doi:"10.5772/intechopen.73385",title:"Differentiating Normal Cognitive Aging from Cognitive Impairment No Dementia: A Focus on Constructive and Visuospatial Abilities",slug:"differentiating-normal-cognitive-aging-from-cognitive-impairment-no-dementia-a-focus-on-constructive",totalDownloads:1353,totalCrossrefCites:3,totalDimensionsCites:6,abstract:"Constructive and visuospatial abilities in normal and in pathological aging (cognitive impairment, no dementia, CIND) are investigated. The sample includes 188 participants over 60 years of age, divided in 2 groups: healthy subjects (MMSE ≥28), without cognitive complaints, and individuals with CIND (MMSE between 24 and 27 and subjective cognitive complains). Drawing of cube and drawing of house, Benton Visual Retention Test (BVRT), and Block design are used to test the hypothesis that short visuoconstructive and visuospatial tests can distinguish normal from pathological cognitive aging in its very early stages. Results proved the discriminative sensitivity of BVRT general assessment criteria and of omissions and distortions in CIND. The diagnostic sensitivity of a modification of Moore and Wike [1984] scoring system for house and cube drawing tasks was confirmed as well. Drawing of cube and house could be used for quick screening of CIND in subjects over 60. Principal component analysis with oblimin rotation was performed to explore the different dimensions in the visuospatial and visuoconstructive abilities in old age. A four-factor structure was established, all four factors explaining 71% of the variance.",book:{id:"6381",slug:"gerontology",title:"Gerontology",fullTitle:"Gerontology"},signatures:"Radka Ivanova Massaldjieva",authors:[{id:"75907",title:"Associate Prof.",name:"Radka Ivanova",middleName:null,surname:"Massaldjieva",slug:"radka-ivanova-massaldjieva",fullName:"Radka Ivanova Massaldjieva"}]},{id:"59658",doi:"10.5772/intechopen.74748",title:"Ageing Better in the Netherlands",slug:"ageing-better-in-the-netherlands",totalDownloads:1193,totalCrossrefCites:1,totalDimensionsCites:4,abstract:"The Dutch National Care for the Elderly Programme was an initiative organized by the Netherlands Organisation for Health Research and Development (ZonMw) between 2008 and 2016. The aim of the programme was to collect knowledge about frail elderly, to assess their needs and to provide person-centred and integrated care better suited to their needs. The budget of EUR 88 million was provided by the Dutch Ministry of Health, Welfare and Sports. Putting the needs of elderly people at the heart of the programme and ensuring their active participation were key to the programme’s success. The programme outcomes included the establishment of eight geriatric networks around the medical universities with 650 organisations and the completion of 218 projects. These projects, involving 43,000 elderly people and 8500 central caregivers, resulted in the completion of 45 PhD theses and the publication of more than 400 articles and the development of 300 practice toolkits, one database and a website, www.beteroud.nl. The Dutch National Care for the Elderly Programme has since developed into a movement and continues under the consortium Ageing Better, made up of eight organisations. Through the use of ambassadors, Ageing Better promotes the message that ageing is not a disease but a new phase of life.",book:{id:"6381",slug:"gerontology",title:"Gerontology",fullTitle:"Gerontology"},signatures:"Betty Meyboom-de Jong, Klaske Wynia and Anjo Geluk-Bleumink",authors:[{id:"224997",title:"Emeritus Prof.",name:"Betty",middleName:null,surname:"Meyboom-De Jong",slug:"betty-meyboom-de-jong",fullName:"Betty Meyboom-De Jong"},{id:"232900",title:"Dr.",name:"Klaske",middleName:null,surname:"Wynia",slug:"klaske-wynia",fullName:"Klaske Wynia"},{id:"232901",title:"Mrs.",name:"Anjo",middleName:null,surname:"Geluk-Bleumink",slug:"anjo-geluk-bleumink",fullName:"Anjo Geluk-Bleumink"}]},{id:"55890",doi:"10.5772/intechopen.69529",title:"Mindfulness Meditation and the Perception of Beauty: Implications for an Ecological Well-Being",slug:"mindfulness-meditation-and-the-perception-of-beauty-implications-for-an-ecological-well-being",totalDownloads:1428,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"Meditation is a first-person method for contemplating ourselves and the world, with more than 2500 years of history, rooted in the philosophical and contemplative traditions of the east. The present chapter aims to explore this worldview in order to demonstrate its relevance to our capacity for the appreciation of beauty. To this end, the aesthetic experience, the contemplative experience and their relationship with the practice of mindfulness are analysed. We suggest that the contemplative meditative experience bestows a state of consciousness and acceptance of life which places the practitioner in a progressive encounter with a self-concept that begins to detach from a static sense of the self and from the categories that define it, so that it may be experienced as an ongoing mental event, removed from cultural ideals of beauty or positivity. The result of this de-identification from the static self is a greater degree of psychological flexibility and a more genuine way of seeing the world, leading to a new perception of the self that is connected to an experience of freedom, and contributes to one’s own well-being, as well as to that of others and of the environment.",book:{id:"5925",slug:"perception-of-beauty",title:"Perception of Beauty",fullTitle:"Perception of Beauty"},signatures:"Álvaro I. Langer, Carlos Schmidt and Edwin Krogh",authors:[{id:"199843",title:"Dr.",name:"Álvaro",middleName:null,surname:"Langer",slug:"alvaro-langer",fullName:"Álvaro Langer"},{id:"201865",title:"MSc.",name:"Carlos",middleName:null,surname:"Schmidt",slug:"carlos-schmidt",fullName:"Carlos Schmidt"},{id:"201866",title:"Dr.",name:"Edwin",middleName:null,surname:"Krogh",slug:"edwin-krogh",fullName:"Edwin Krogh"}]}],mostDownloadedChaptersLast30Days:[{id:"60564",title:"Ageing Process and Physiological Changes",slug:"ageing-process-and-physiological-changes",totalDownloads:7024,totalCrossrefCites:19,totalDimensionsCites:34,abstract:"Ageing is a natural process. Everyone must undergo this phase of life at his or her own time and pace. In the broader sense, ageing reflects all the changes taking place over the course of life. These changes start from birth—one grows, develops and attains maturity. To the young, ageing is exciting. Middle age is the time when people notice the age-related changes like greying of hair, wrinkled skin and a fair amount of physical decline. Even the healthiest, aesthetically fit cannot escape these changes. Slow and steady physical impairment and functional disability are noticed resulting in increased dependency in the period of old age. According to World Health Organization, ageing is a course of biological reality which starts at conception and ends with death. It has its own dynamics, much beyond human control. However, this process of ageing is also subject to the constructions by which each society makes sense of old age. In most of the developed countries, the age of 60 is considered equivalent to retirement age and it is said to be the beginning of old age. In this chapter, you understand the details of ageing processes and associated physiological changes.",book:{id:"6381",slug:"gerontology",title:"Gerontology",fullTitle:"Gerontology"},signatures:"Shilpa Amarya, Kalyani Singh and Manisha Sabharwal",authors:[{id:"226573",title:"Ph.D.",name:"Shilpa",middleName:null,surname:"Amarya",slug:"shilpa-amarya",fullName:"Shilpa Amarya"},{id:"226593",title:"Dr.",name:"Kalyani",middleName:null,surname:"Singh",slug:"kalyani-singh",fullName:"Kalyani Singh"},{id:"243264",title:"Dr.",name:"Manisha",middleName:null,surname:"Sabharwal",slug:"manisha-sabharwal",fullName:"Manisha Sabharwal"}]},{id:"55388",title:"Beauty, Body Image, and the Media",slug:"beauty-body-image-and-the-media",totalDownloads:7775,totalCrossrefCites:5,totalDimensionsCites:12,abstract:"This chapter analyses the role of the mass media in people’s perceptions of beauty. We summarize the research literature on the mass media, both traditional media and online social media, and how they appear to interact with psychological factors to impact appearance concerns and body image disturbances. There is a strong support for the idea that traditional forms of media (e.g. magazines and music videos) affect perceptions of beauty and appearance concerns by leading women to internalize a very slender body type as ideal or beautiful. Rather than simply being passive recipients of unrealistic beauty ideals communicated to them via the media, a great number of individuals actually seek out idealized images in the media. Finally, we review what is known about the role of social media in impacting society’s perception of beauty and notions of idealized physical forms. Social media are more interactive than traditional media and the effects of self‐presentation strategies on perceptions of beauty have just begun to be studied. This is an emerging area of research that is of high relevance to researchers and clinicians interested in body image and appearance concerns.",book:{id:"5925",slug:"perception-of-beauty",title:"Perception of Beauty",fullTitle:"Perception of Beauty"},signatures:"Jennifer S. Mills, Amy Shannon and Jacqueline Hogue",authors:[{id:"202110",title:"Dr.",name:"Jennifer S.",middleName:null,surname:"Mills",slug:"jennifer-s.-mills",fullName:"Jennifer S. Mills"}]},{id:"56505",title:"Aesthetics of the Naked Human Body: From Pornography (Sexualised Lust Object) to Iconography (Aesthetics of Human Nobility and Wisdom) in an Anthropology of Physical Beauty",slug:"aesthetics-of-the-naked-human-body-from-pornography-sexualised-lust-object-to-iconography-aesthetics",totalDownloads:2102,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"In many religious circles and philosophies of life, the human body is excluded from the realm of spirituality and meaning. Due to a dualistic approach, nudity is viewed as merely a physical and corporeal category. In social media, there is the real danger that the naked human body is exploited for commercial gain. Advertisements often leave the impression that the body, very specifically the genitals, is designed merely for physical desire and corporeal chemistry. They become easily objects for lust, excluded from the beauty of graceful existence and noble courage. It is argued that the naked human body is not designed for pornographic exploitation and promiscuous sensuality but for compassionate intimacy and nurturing care in order to instil a humane dimension in human and sexual encounters. In this regard, antiquity and the Michelangelesque perspective can contribute to a paradigm shift from abusive exploitation to the beauty of vulnerable sensitivity. In order to foster an integrative approach to theory formation in anthropology, the methodology of stereometric thinking is proposed.",book:{id:"5925",slug:"perception-of-beauty",title:"Perception of Beauty",fullTitle:"Perception of Beauty"},signatures:"Daniel J Louw",authors:[{id:"200645",title:"Prof.",name:"Daniel",middleName:"Johannes",surname:"Louw",slug:"daniel-louw",fullName:"Daniel Louw"}]},{id:"56059",title:"A Plastic Surgeon’s Perspective on Stereotyping and the Perception of Beauty",slug:"a-plastic-surgeon-s-perspective-on-stereotyping-and-the-perception-of-beauty",totalDownloads:1920,totalCrossrefCites:0,totalDimensionsCites:1,abstract:"In the world of plastic surgery, misconceptions may lead to irrational requests or outcomes not appreciated by patients. Those who manage aesthetics should always listen and recognize the variability of cultural identities, desires, attitudes, anxieties and uncertainties of the patient. Emerging from a diversity of cultures and its transforming trends, the scope of cosmetic surgery and its practice reflect not only the individual’s personality, but also the culture as a whole. When counseling an individual, one has to recognize that even in groups of seemingly identical social or cultural standards; there are subtle differences in expectations. To illustrate the potential for inaccuracy of ethnic profiling in the field of plastic surgery authors quote their own work on Asian subjects and facial beauty and resort to experience of others. To reaffirm their opinion and to exemplify how sometimes “fine” differences in the perception of beauty exist, an original study that evaluates the preferences among selected groups of Latina women in respect to buttock aesthetics has been included. This dissertation will focus on how cultural factors influence beauty perception; strengthen the fact that beauty is in the eye of the beholder and how variable differences exist even between small subgroups.",book:{id:"5925",slug:"perception-of-beauty",title:"Perception of Beauty",fullTitle:"Perception of Beauty"},signatures:"Johanna D’Agostino and Marek Dobke",authors:[{id:"17590",title:"Dr.",name:"Marek K.",middleName:null,surname:"Dobke",slug:"marek-k.-dobke",fullName:"Marek K. Dobke"},{id:"201244",title:"Dr.",name:"Johanna",middleName:null,surname:"D'Agostino",slug:"johanna-d'agostino",fullName:"Johanna D'Agostino"}]},{id:"80326",title:"Anti-Senescence Therapy",slug:"anti-senescence-therapy",totalDownloads:111,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The development of therapeutic strategies aimed at the aging process of cells has attracted increasing attention in recent decades due to the involvement of this process in the development of many chronic and age-related diseases. Interestingly, preclinical studies have shown the success of a number of anti-aging approaches in the treatment of a range of chronic diseases. These approaches are directed against aging processes such as oxidative stress, telomerase shortening, inflammation, and deficient autophagy. Many strategies has been shown to be effective in delaying aging, including antiaging strategies based on establishing healthy lifestyle habits and pharmacological interventions aimed at disrupting senescent cells and senescent-associated secretory phenotype. Caloric restriction and intermittent fasting were reported to activate autophagy and reduce inflammation. In turn, immune-based strategies, senolytic agents, and senomorphics mediate their effects either by eliminating senescent cells through inducing apoptosis or by disrupting pathways by which senescent cells mediate their detrimental effects. In addition, given the association of the decline in the regenerative potential of stem cells with aging, many experimental and clinical studies indicate the effectiveness of stem cell transplantation in preventing or slowing the progress of age-related diseases by enhancing the repairing mechanisms and the secretion of many growth factors and cytokines.",book:{id:"10935",slug:null,title:"Mechanisms and Management of Senescence",fullTitle:"Mechanisms and Management of Senescence"},signatures:"Raghad Alshadidi",authors:null}],onlineFirstChaptersFilter:{topicId:"235",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82112",title:"Comparative Senescence and Lifespan",slug:"comparative-senescence-and-lifespan",totalDownloads:17,totalDimensionsCites:0,doi:"10.5772/intechopen.105137",abstract:"The word senescence is derived from the Latin word “senex” (meaning old). In biology, senescence is a process by which a cell ages and permanently stops dividing. Senescence is a natural universal phenomenon affecting all living organisms (e.g., humans, animals, and plants). It is the process of growing old (aging). The underlying mechanisms of senescence and aging at the cellular level are not fully understood. Senescence is a multifactorial process that can be induced by several stimuli including cellular stress, DNA damage, telomere shortening, and oncogene activation. The most popular theory to explain aging is the free radical theory. Senescence plays a role in the development of several age-related chronic diseases in humans (e.g., ischemic heart disease, osteoporosis, and cancer). Lifespan is a biological characteristic of every species. The lifespan of living organisms ranges from few hours (with mayfly) to potential eternity (with jellyfish and hydra). The maximum theoretical lifespan in humans is around 120 years. The lifespan in humans is influenced by multiple factors including genetic, epigenetic, lifestyle, environmental, metabolic, and endocrine factors. There are several ways to potentially extend the lifespan of humans and eventually surpass the maximum theoretical lifespan of 120 years. The tools that can be proposed include lifestyle, reduction of several life-threatening diseases and disabilities, hormonal replacement, antioxidants, autophagy inducers, senolytic drugs, stem cell therapy, and gene therapy.",book:{id:"10935",title:"Mechanisms and Management of Senescence",coverURL:"https://cdn.intechopen.com/books/images_new/10935.jpg"},signatures:"Hassan M. Heshmati"},{id:"81638",title:"Aging and Neuropsychiatric Disease: A General Overview of Prevalence and Trends",slug:"aging-and-neuropsychiatric-disease-a-general-overview-of-prevalence-and-trends",totalDownloads:30,totalDimensionsCites:0,doi:"10.5772/intechopen.103102",abstract:"The increasing trend of life-expectancy is becoming a significant demographic, societal and economic challenge. Currently, global number of people above sixty years of age is 900 million, while United Nations expect this number to rise to over 1.4 billion in 2030 and over 2.5 billion by 2050. Concordant to this trend, numerous physiological changes are associated with aging and brain-related ones are associated with neuropsychiatric diseases. The main goal of this chapter is to identify the most important neuropsychiatric diseases to assess in older patients to help to promote health and prevent diseases and complications associated with chronic illness, as these changes are progressive and require important psychological and setting-related social adjustments. Findings identify several health-aspects highly present in elderly: stroke, white matter lesions, dementia rise with age, changes in levels of neurotransmitters and hormones, depression as well as the bereavement following loss of the loved one, and the most common neurodegenerative disease—Alzheimer’s disease and Parkinson’s. In conclusion, studying the aging process should include all developmental, circumstantial, and individual aspects of aging. This offers opportunities to improve the health of elderly by using a wide range of skills and knowledge. Thus, further studies are necessary to elucidate what can be done do to improve the aging process and health of elderly in the future.",book:{id:"10935",title:"Mechanisms and Management of Senescence",coverURL:"https://cdn.intechopen.com/books/images_new/10935.jpg"},signatures:"Jelena Milić"},{id:"80326",title:"Anti-Senescence Therapy",slug:"anti-senescence-therapy",totalDownloads:111,totalDimensionsCites:0,doi:"10.5772/intechopen.101585",abstract:"The development of therapeutic strategies aimed at the aging process of cells has attracted increasing attention in recent decades due to the involvement of this process in the development of many chronic and age-related diseases. Interestingly, preclinical studies have shown the success of a number of anti-aging approaches in the treatment of a range of chronic diseases. These approaches are directed against aging processes such as oxidative stress, telomerase shortening, inflammation, and deficient autophagy. Many strategies has been shown to be effective in delaying aging, including antiaging strategies based on establishing healthy lifestyle habits and pharmacological interventions aimed at disrupting senescent cells and senescent-associated secretory phenotype. Caloric restriction and intermittent fasting were reported to activate autophagy and reduce inflammation. In turn, immune-based strategies, senolytic agents, and senomorphics mediate their effects either by eliminating senescent cells through inducing apoptosis or by disrupting pathways by which senescent cells mediate their detrimental effects. In addition, given the association of the decline in the regenerative potential of stem cells with aging, many experimental and clinical studies indicate the effectiveness of stem cell transplantation in preventing or slowing the progress of age-related diseases by enhancing the repairing mechanisms and the secretion of many growth factors and cytokines.",book:{id:"10935",title:"Mechanisms and Management of Senescence",coverURL:"https://cdn.intechopen.com/books/images_new/10935.jpg"},signatures:"Raghad Alshadidi"},{id:"79828",title:"Cellular Senescence in Bone",slug:"cellular-senescence-in-bone",totalDownloads:119,totalDimensionsCites:0,doi:"10.5772/intechopen.101803",abstract:"Senescence is an irreversible cell-cycle arrest process induced by environmental, genetic, and epigenetic factors. An accumulation of senescent cells in bone results in age-related disorders, and one of the common problems is osteoporosis. Deciphering the basic mechanisms contributing to the chronic ailments of aging may uncover new avenues for targeted treatment. This review focuses on the mechanisms and the most relevant research advancements in skeletal cellular senescence. To identify new options for the treatment or prevention of age-related chronic diseases, researchers have targeted hallmarks of aging, including telomere attrition, genomic instability, cellular senescence, and epigenetic alterations. First, this chapter provides an overview of the fundamentals of bone tissue, the causes of skeletal involution, and the role of cellular senescence in bone and bone diseases such as osteoporosis. Next, this review will discuss the utilization of pharmacological interventions in aging tissues and, more specifically, highlight the role of senescent cells to identify the most effective and safe strategies.",book:{id:"10935",title:"Mechanisms and Management of Senescence",coverURL:"https://cdn.intechopen.com/books/images_new/10935.jpg"},signatures:"Danielle Wang and Haitao Wang"},{id:"79668",title:"Identification of RNA Species That Bind to the hnRNP A1 in Normal and Senescent Human Fibroblasts",slug:"identification-of-rna-species-that-bind-to-the-hnrnp-a1-in-normal-and-senescent-human-fibroblasts",totalDownloads:81,totalDimensionsCites:0,doi:"10.5772/intechopen.101525",abstract:"hnRNP A1 is a member of the hnRNPs (heterogeneous nuclear ribonucleoproteins) family of proteins that play a central role in regulating genes responsible for cell proliferation, DNA repair, apoptosis, and telomere biogenesis. Previous studies have shown that hnRNPA1 had reduced protein levels and increased cytoplasmic accumulation in senescent human diploid fibroblasts. The consequence of reduced protein expression and altered cellular localization may account for the alterations in gene expression observed during senescence. There is limited information for gene targets of hnRNP A1 as well as its in vivo function. In these studies, we performed RNA co-immunoprecipitation experiments using hnRNP A1 as the target protein to identify potential mRNA species in ribonucleoprotein (RNP) complexes. Using this approach, we identified the human double minute 2 (HDM2) mRNA as a binding target for hnRNP A1 in young and senescent human diploid fibroblasts cells. It was also observed that alterations of hnRNP A1 expression modulate HDM2 mRNA levels in young IMR-90 cells. We also demonstrated that the levels of HDM2 mRNA increased with the downregulation of hnRNP A1 and decrease with the overexpression of hnRNP A1. Although we did not observe a significant decrease in HDM2 protein level, a concomitant increase in p53 protein level was detected with the overexpression of hnRNP A1. Our studies also show that hnRNP A1 directly interacts with HDM2 mRNA at a region corresponding to its 3′ UTR (untranslated region of a gene). The results from this study demonstrate that hnRNP A1 has a novel role in participating in the regulation of HDM2 gene expression.",book:{id:"10935",title:"Mechanisms and Management of Senescence",coverURL:"https://cdn.intechopen.com/books/images_new/10935.jpg"},signatures:"Heriberto Moran, Shanaz A. Ghandhi, Naoko Shimada and Karen Hubbard"},{id:"79295",title:"Genetic and Epigenetic Influences on Cutaneous Cellular Senescence",slug:"genetic-and-epigenetic-influences-on-cutaneous-cellular-senescence",totalDownloads:136,totalDimensionsCites:0,doi:"10.5772/intechopen.101152",abstract:"Skin is the largest human organ system, and its protective function is critical to survival. The epithelial, dermal, and subcutaneous compartments are heterogeneous mixtures of cell types, yet they all display age-related skin dysfunction through the accumulation of an altered phenotypic cellular state called senescence. Cellular senescence is triggered by complex and dynamic genetic and epigenetic processes. A senescence steady state is achieved in different cell types under various and overlapping conditions of chronological age, toxic injury, oxidative stress, replicative exhaustion, DNA damage, metabolic dysfunction, and chromosomal structural changes. These inputs lead to outputs of cell-cycle withdrawal and the appearance of a senescence-associated secretory phenotype, both of which accumulate as tissue pathology observed clinically in aged skin. This review details the influence of genetic and epigenetic factors that converge on normal cutaneous cellular processes to create the senescent state, thereby dictating the response of the skin to the forces of both intrinsic and extrinsic aging. From this work, it is clear that no single biomarker or process leads to senescence, but that it is a convergence of factors resulting in an overt aging phenotype.",book:{id:"10935",title:"Mechanisms and Management of Senescence",coverURL:"https://cdn.intechopen.com/books/images_new/10935.jpg"},signatures:"Tapash Jay Sarkar, Maiko Hermsmeier, Jessica L. Ross and G. 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The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{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"}}}}]},series:{item:{id:"13",title:"Veterinary Medicine and Science",doi:"10.5772/intechopen.73681",issn:"2632-0517",scope:"Paralleling similar advances in the medical field, astounding advances occurred in Veterinary Medicine and Science in recent decades. These advances have helped foster better support for animal health, more humane animal production, and a better understanding of the physiology of endangered species to improve the assisted reproductive technologies or the pathogenesis of certain diseases, where animals can be used as models for human diseases (like cancer, degenerative diseases or fertility), and even as a guarantee of public health. Bridging Human, Animal, and Environmental health, the holistic and integrative “One Health” concept intimately associates the developments within those fields, projecting its advancements into practice. This book series aims to tackle various animal-related medicine and sciences fields, providing thematic volumes consisting of high-quality significant research directed to researchers and postgraduates. It aims to give us a glimpse into the new accomplishments in the Veterinary Medicine and Science field. 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After almost 32 years of teaching at the University of Trás-os-Montes and Alto Douro, she recently moved to the University of Évora, Department of Veterinary Medicine, where she teaches in the field of Animal Reproduction and Clinics. Her primary research areas include the molecular markers of the endometrial cycle and the embryo–maternal interaction, including oxidative stress and the reproductive physiology and disorders of sexual development, besides the molecular determinants of male and female fertility. She often supervises students preparing their master's or doctoral theses. 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He teaches various degree courses in zootechnics, sheep production, and agricultural sciences and natural resources.\n\nDr. Ronquillo’s research focuses on the evaluation of sustainable animal diets (StAnD), using native resources of the region, decreasing carbon footprint, and applying meta-analysis and mathematical models for a better understanding of animal production.",institutionString:null,institution:{name:"Universidad Autónoma del Estado de México",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null},{id:"28",title:"Animal Reproductive Biology and Technology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/28.jpg",isOpenForSubmission:!0,editor:{id:"177225",title:"Prof.",name:"Rosa Maria Lino Neto",middleName:null,surname:"Pereira",slug:"rosa-maria-lino-neto-pereira",fullName:"Rosa Maria Lino Neto Pereira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9wkQAC/Profile_Picture_1624519982291",biography:"Rosa Maria Lino Neto Pereira (DVM, MsC, PhD and) is currently a researcher at the Genetic Resources and Biotechnology Unit of the National Institute of Agrarian and Veterinarian Research (INIAV, Portugal). 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He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. 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