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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"197",leadTitle:null,fullTitle:"The Clinical Spectrum of Alzheimer's Disease -The Charge Toward Comprehensive Diagnostic and Therapeutic Strategies",title:"The Clinical Spectrum of Alzheimer's Disease",subtitle:"The Charge Toward Comprehensive Diagnostic and Therapeutic Strategies",reviewType:"peer-reviewed",abstract:"The Clinical Spectrum of Alzheimer's Disease: The Charge Toward Comprehensive Diagnostic and Therapeutic Strategies is highly informative and current. Acknowledged experts in the field critically review both standard and under-appreciated clinical, behavioral, epidemiological, genetic, and neuroimaging attributes of Alzheimer's disease. The collection covers diverse topics of interest to clinicians and researchers alike. Experienced professionals and newcomers to the field will benefit from the read. The strengths and weaknesses of current clinical, non-invasive, neuro-imaging, and biomarker diagnostic approaches are explained. The perspectives give fresh insights into the process of neurodegeneration. Readers will be enlightened by the evidence that the neural circuits damaged by neurodegeneration are much broader than conventionally taught, suggesting that Alzheimer's could be detected at earlier stages of disease by utilizing multi-pronged diagnostic approaches. 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She received her undergraduate degree from Cornell University, Ithaca, N.Y., M.D. from the Weill College of Medicine at Cornell University, and masters in public health (M.P.H.) from the Blumberg School of Public Health at Johns Hopkins University, Baltimore, MD. Dr. de la Monte completed her residency in Anatomical Pathology and fellowship in Pediatric Pathology at The Johns Hopkins Hospital, and a fellowship in Neuropathology at the Massachusetts General Hospital. She received postdoctoral research training at the Massachusetts General Hospital. Currently, Dr. de la Monte directs research on the role of insulin resistance as a mediator of neurodegeneration in relation to Alzheimer’s disease, alcoholism, obesity, diabetes, and development. 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Endometriosis is a chronic, nonmalignant, and estrogen‐dependent disease in which the endometrial glandular epithelium and stroma are found outside the uterine cavity (on the ovaries, peritoneum, or rectovaginal septum) [1].
\nThe most frequently type of endometriosis is endometrioma. Concretely, an endometrioma is considered as the presence of endometrial tissue at the ovarian level organized as a cyst [2]. The incidence of endometrioma is estimated to be 20–45% of patients with endometriosis [3]. It can be diagnosed by ultrasound with relatively high sensitivity of 74%, but with a very high specificity of 94%; therefore, its prevalence could be estimated quite precisely [1, 4].
\nAlthough endometriosis usually affects ovaries and peritoneum, deep endometriosis, defined as infiltration of the peritoneum by a minimum of 5 mm can affect other structures like urinary tract, fallopian tubes, and bowels [1, 3].
\nCompared to ovarian endometriosis, very little is known about deeply infiltrating endometriosis. In this form, endometriosis can spread beyond organ borders and infiltrate various structures like sacrouterine ligament, the rectovaginal septum, the fornix of the vagina, the rectosigmoid, the urinary bladder or the ureter or also the small intestine [1–5].
\nDespite its severity, endometriosis is a common benign gynecological disease [6].
\nThe prevalence of endometriosis is estimated to range from 2 to 10% in women of childbearing age and its prevalence rises up to 50% in women with infertility [7]. It is one of the most common gynecological problems that can affect women in their reproductive years [4].
\nEndometriosis is a complex and multifactorial disease and its etiology and pathogenesis have not yet been completely clarified [8].
\nMany authors have described a group of risk factors like retrograde menstruation caused by the obstruction of menstrual flow, low immunity, exposure to diethylstilbestrol during neonatal period, genetic predisposition [2–4]. Another theory suggests that endometrial tissue is distributed from the uterus to other parts of the body through the lymph system or blood system [5–8]. Surgical implants have also been cited in many cases where endometriosis is found in abdominal laparotomy scars, like after a cesarean section [9, 10].
\nOther authors suggest that risk factors for endometriosis are smoking, duration of period bleeding, length of the menstrual cycle, number of pregnancies, and number of miscarriages [3–9].
\nIn endometriosis, the ectopic endometrial tissue is morphologically similar to normal endometrium and it responds to ovarian hormones during cyclical changes similar to eutopic endometrium [11].
\nWomen with endometriosis may be asymptomatic, but the majority will present with pelvic pain, adnexal mass or subfertility/ infertility [3].
\nDefinitive diagnosis is made through direct operative visualization by laparoscopy (Figure 1) or laparotomy and histological confirmation [9].
\nTwenty‐four years old female patient, complaining of severe menstrual pain, with large endometrioma of the right ovary (5 cm).
On laparoscopy, endometriosis can appear as yellow‐brown discolorations, raised flame‐like patches, whitish opacifications or reddish irregularly shaped spots [1, 2].
\nPatients with endometriosis may present different clinical manifestations in different stages of the disease [10].
\nEndometriosis has four stages or types: stage I, minimal, with small lesions and shallow endometrial implants on the ovary; stage 2, mild, with light lesions and shallow implants on the ovary and the pelvic lining; stage 3, moderate, with deep and more implants on the ovary and pelvic lining; and stage 4, severe, with deep implants on the pelvic lining and ovaries [1–11].
\nOvarian endometriomas, which are a common feature of endometriosis, create a complex situation for infertile patients [5].
\nIn the opinion of many authors, endometriosis is one of the top three causes of female infertility and 30% to 40 % of women with endometriosis are infertile [5–6].
\nFadhlaoui et al. showed that women with endometriosis have a reduced monthly fecundity rate (2–10%) compared with fertile couples (15–20%) at the same age [11]. The mechanisms underlying reproductive failure remain controversial, especially in cases where ovaries and fallopian tubes are normal [7].
\nThe mechanism by which these endometriotic cysts lead to infertility may be related to mechanical stretching of the ovarian cortex as well as an inflammatory reaction with cytotoxic oxidative stress and increased fibrosis [1–3]. Surgery is the elective treatment for endometriomas and the most common technique is stripping of the endometrioma [11].
\nBoth the presence and surgical excision of endometriomas appear to be damaging to ovarian function and ovarian reserve [6].
\nWe made a systematic literature search on the PubMed database of English literature (search terms was endometrioma, surgery, ovarian reserve, assisted reproductive technologies) from 2010 to 2014 and cross referencing. We gave priority to meta‐analyses, randomized controlled trials reviews and cohort studies. We analyzed the benefits and disadvantages of surgical methods used to treat endometriosis.
\nThe treatment of endometriosis depends on the age of the patient, extent of disease, severity of symptom and the desired outcomes for fertility [1]. Despite maximal efforts, the therapy of first choice in the management of endometriosis is still unclear [12, 13].
\nBecause endometriosis is a chronic disease, medical therapy should be, at least in theory, the first choice of treatment, while surgical procedures should be reserved for patients who do not respond to conservative treatments and whose symptoms affect their quality of life or cause infertility [8].
\nThe aim of medical therapy is to achieve a hypoestrogenic status or to induce a pseudopregnancy [9]. Endometriosis implants can be regressively changed by means of suppression of ovarian function [11]. The drugs predominately used today are pure gestagens, progestatives, contraceptives, GnRH analogs, and danazol [5–7].
\nEvery medical treatment is tolerable but should only be used as long as it is necessary [12]. This type of treatment should reduce the number of surgical interventions and improve the quality of life [13, 14].
\nMedical therapy can be also applied prior to surgery to decrease the size of endometriotic implants and the extent of the operation [1].
\nAnother method consists of a combination of diagnostic laparoscopy with the removing of all visible endometriosis as far as possible followed by 3–6 months of endocrine therapy and a subsequent second‐look laparoscopy with resection of residual foci, adhesiolysis, and reconstruction of organs [10–14].
\nSo far there is no evidence that perioperative or postoperative hormonal treatment delays or prevents recurrence, reduce pelvic pain and patient\'s morbidity or increases pregnancy rates at a statistically significant level [15].
\nBecause endometriosis is a progressive and evolutive disease, which can cause anatomic destruction of the reproductive organs and infertility, surgical therapy has an important role [6–10].
\nThe surgical treatment for endometriosis can be conservative or radical. The benefit of surgical treatment is to reduce or reverse the damaging effects of endometriomas on the ovarian cortex, but this effect is controversial [14]. Surgery\'s aim is to remove macroscopic endometriosis implants, the adhesions, and restore normal pelvic anatomy [10].
\nEvidence indicates that the primary benefit of surgical treatment of endometriosis is relief of pelvic pain [7–10].
\nAnother argument in favor of surgical excision of endometriomas is related to the dangers of expected management, such as ovarian torsion, cyst rupture, and progression of endometriosis [6–10]. The risk of ovarian malignancy is debatable, as some authors reported that endometriosis can be associated with increased risk of clear cell ovarian cancer or low‐grade serous ovarian cancer [3]. Future research should be focused on understanding the mechanisms that might lead to malignant transformation of endometriosis to help identify the women at risk [4].
\nAs it was mentioned before, surgical treatment may be conservative or radical.
\nThe goal of conservative surgery is to remove or destroy endometrial abnormal proliferation without damaging the reproductive organs [8].
\nRadical surgery for endometriosis aims to eliminate all possible endometriosis implants found in pelvic and abdominal cavity, including hysterectomy and bilateral adnexectomy, and to excise of the deep endometriosis lesions that can involve the urinary and digestive organs, as well as the rectovaginal and/or vesicouterine space. However, this technique has to be of last resort because it is radical and definitive [16–19].
\nSurgery can be done through open surgery or by laparoscopy [10]. Minimally invasive techniques were proved to be feasible in treating endometriosis [14].
\nMany studies including two randomized controlled trials, comparing medical treatment with laparoscopic excision of endometrioma concluded that laparoscopic excision is associated with a decrease in symptoms such as dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain [10–15].
\nCompared to laparotomy, operative laparoscopy was proved to be the gold standard surgical approach for the diagnosis and treatment of endometriosis [12].
\nConcerning the open access, the decision to use this type of access is very important. It is recommended that laparotomy should be performed only in cases with massive endometriosis, in older patients or in cases where pelvic pain and discomfort are the main problems for the patients [10–15]. The selection should be done, because this type of treatment obviously takes longer operative time is more painful and it involves a longer hospital stay. The risks and side effects are also greater than for laparoscopy. It is therefore better to almost never use laparotomy as a treatment for endometriosis [14]. Therefore, laparotomy should only be reserved to very difficult cases.
\nLaparoscopy is a central component in the diagnosis of and therapy for endometriosis. Laparoscopy is initially used to diagnose endometriosis. Visualization of areas of endometriosis may be followed by excision or destruction by burning (Figure 2). This can be done simply with the diathermy or using the laser. However, the laser is expensive, time‐consuming, and almost never used now by leading endometriosis surgeons [10–12].
\nLaparoscopic incision of an endometriotic cyst of the ovary using diathermy.
Conventional laparoscopy has several proven advantages over laparotomy, like faster postoperative recovery, shorter length of hospital stay, cosmetic benefits, decreased blood loss, and fewer complications [16, 17]. However, laparoscopic management of advanced‐stage endometriosis requires pelvic dissection, which can increase the surgeon fatigue, operating time, rate of conversion to laparotomy, intraoperative, and postoperative complications [18].
\nRobotic‐assisted laparoscopic surgery tries to overcome the disadvantages of conventional laparoscopy by offering improved dexterity, better coordination, and visualization of organs and less surgeon fatigue [19].
\nMany studies acknowledge that laparoscopy is especially indicated for patients with moderate or severe endometriosis or for those who accuse pain or infertility [4].
\nThe risk factors and disadvantages of laparoscopy include damage of organs adjacent to the affected areas and postoperative complications, such as adhesion formation or infection [8].
\nSome authors emphasized that the management of an endometrioma must focus on the complex pathology of this disease further confirming through ovarioscopy biopsies that endometriomas
Recently, in several studies, a new approach called transvaginal hydrolaparoscopy is mentioned. By this approach, an endometrioma could be confirmed by its appearance in gross anatomy and even removed in an early stage [8–12]. Transvaginal ovarioscopy, associated or not with ablation, is performed in numerous medical centers [15–18] and could be considered a variant of NOTES (natural orifice tranlumenal endoscopic surgery).
\nThe surgical procedures that can be performed during an operative laparoscopy usually include the excision or destruction of ovarian endometriosis (endometriomas) (Figure 3), the removal or destruction of endometrial implants, adhesiolysis, oophorectomy, hysterectomy, the removal of deep rectovaginal and rectosigmoid endometriosis, surgery of the bowel (usually enterectomy) or bladder, laparoscopic uterine nerve ablation (LUNA), and presacral neurectomy (PSN) [1–8].
\n\nAlthough the ovarian endometrioma is described as an ovarian cyst, its pathology is rather complex and completely different from other benign ovarian cysts [18–20]. According to Huhesdon, the majority of endometriomas are thought to be pseudocysts rather than intraovarian cysts, as the clear dissection plane between an endometrioma and ovarian cortex may not always exist, like in other benign ovarian cysts [19, 20].
\n\nWhile most endometrial implants can be treated using excision or/and coagulation, the most frequently used surgical procedures for the treatment of ovarian endometriosis are the excision of the cyst capsula or electro‐coagulation of the cyst wall (Figure 4) [7–10]. During excision, the endometrioma is aspirated followed by the removal of the cyst wall from the ovary cortex. However, this technique could reduce ovarian reserve and decrease the chances of fertility [10–14]. Concerning this last aspect, there is currently no randomized controlled trial to assess whether surgery is positively effective or not on pregnancy rates in moderate to severe endometriosis [19]. However, there are numerous nonrandomized uncontrolled studies with results indicating a postoperative pregnancy rate that varies widely from 30 to 67% [19–21].
\nExcision of an endometrioma: cleavage plane between the endometrioma and ovary, progressive dissection through divergent traction.
Enucleation of endometrioma of the right ovary.
The recommendations of the ESHRE guidelines for women with endometriomas who are undergoing surgery for infertility or pain, strongly support the laparoscopic excision rather than drainage and electrocoagulation of the endometrioma wall [21–23]. Several studies showed that the stripping technique is superior to drainage or ablative surgery because it reduces the recurrence of pain, and it is decreasing the recurrence and reoperation rates [18, 19].
\nAccording to the ESHRE Guideline, in infertile women with ovarian endometrioma bigger than 3 cm surgeons should perform excision of endometrioma capsule instead of ablative surgery because the studies show that it increases the spontaneous postoperative pregnancy rate (Figure 5) [20–23].
\n\nTechnique of laparoscopic removal of endometrioma begins by incision of the ovary and finding the dissection plane between the endometrial cyst and the ovarian parenchyma. Dissection may progress carefully and slowly in this fashion until its completion. However, to facilitate dissection the cyst may be opened, its content evacuated by aspiration, and the walls of the cyst literally stripped away by divergent traction (traction and counter‐traction) from the ovarian parenchyma. This is a commonly used technique [20–22]. In our opinion, evacuation of the cyst\'s contents should be performed carefully and complete, and at the end, the pelvic cavity immediately and thoroughly washed with saline or iodine–povidone solution to prevent iatrogenic spreading of endometriosis. The remaining ovarian parenchyma is coagulated by bipolar or monopolar cautery and could be left open or could be sutured [23]. We prefer to leave it open to allow drainage and avoid formation of intraovarian hematic collections that could lead to ovarian abscesses. Another possibility of surgical treatment is to electrocoagulate by diathermy or by laser energy the inner cavity of the cyst after evacuation instead of removing it [1, 4]. We consider that if the dissection is not amenable or hemostasis is difficult, those two methods could be combined in the sense that a part of the cyst wall could be left in the place but its inner surface coagulated as mentioned before.
\nExcision of endometrioma using monopolar hook.
As shown in this paper and in numerous studies, surgery performed on the ovaries may reduce the ovarian reserve and decrease the fertile potential in some women (especially infertile women with endometrioma or women with previous ovarian surgery) [4–8]. The ESHRE guideline for the management of women with endometriosis attempts to help these women and their physicians by suggesting surgical abstention, excepting cases of absolute indication [7].
\nIn patients with disease‐related symptoms, unilateral cysts, normal AMH, or sonographic features raising the suspicion for malignancy, ESHRE guidelines recommend surgery [8]. Another situation, where surgery is mandatory, is in patients who already have children. However, in all cases with endometriosis that are suitable for surgery, women should be counseled on the potential for decrease in ovarian reserve [14, 17].
\nNevertheless, the decision for surgery in patients who are diagnosed with infertility should be taken with a lot of caution because several studies indicated that an endometrioma does not appear to adversely affect IVF outcomes and in the same time surgical excision of an endometrioma does not appear to improve IVF outcomes [15].
\nThe most recent articles suggest that asymptomatic infertile patients, older patients, as well as those with diminished ovarian reserve or bilateral endometriomas, or those with prior surgical treatment, would benefit from proceeding directly to IVF [16].
\nConcerning the size of an endometrioma, it should be stressed that female patients with endometriomas less than 3 cm do not qualify for surgical treatment because the procedure of removing such a cyst decreases the ovarian reserve and does not positively influence the pregnancy rate. Small ovarian cysts less than 3 cm in diameter can be punctured and drained [7–10].
\n\n\nIn 2012, the Practice Committee of the American Society for Reproductive Medicine no longer recommended performing laparoscopy on asymptomatic women with infertility to check for endometriosis [10–13].
\nMore articles are reporting a reduction in ovarian reserve and antimulerrian hormone level after laparoscopic surgery for endometriomas. Frequently, during the surgery, normal ovarian tissue is excised with the endometrioma wall [10–14].
\nOvarian surgery might reduce the number of oocytes retrieved, to reduce the peak estradiol levels and to increase total FSH requirement, in conclusion the fertility is very low reduced. It has been reported that ovarian surgery can lead to ovarian failure in 15% of the cases [20–22].
\nA study conducted by Donnez et al. showed that a combined technique of excisional (cystectomy) and laser ablative surgery without ovarian suture could be the best compromise for sparing ovarian reserve [4–7].
\nWhen revising the technique of laparoscopic cyst removal in regard of the ovarian reserve, many authors consider it more deleterious than the other technique of emptying the cyst and thermal coagulation or laser vaporization of its wall. The main argument is that during dissection and stripping of the cyst, the surgeon cannot completely avoid removal or damaging of the healthy ovarian parenchyma. In order to establish the superiority of one technique over the other, Tsolakidas et al. performed a comparative study between the laparoscopic cystectomy and a more conservative procedure consisting of a combination of three methods (drainage of the cyst and vaporization by laparoscopy followed by 3 months of GnRh analogue). The results showed that antimullerian hormone level does not decline in women who underwent the more conservative procedure compared to those who underwent the stripping procedure [18–20].
\nThe idea of combining the two standardized procedures of cystectomy and of fenestration and vaporization was explored by Donnez et al. In his method, when approaching the hilus of the ovary, the excision of the cyst is stopped and CO2 laser is applied on the remaining tissue. He managed to demonstrate that six months later the volume of the operated on ovary and AFC does not differ significantly from the opposite side [21, 22].
\nTherefore, the decision to proceed with surgery should be considered carefully if the patient had previous ovarian surgery or she does not have any child [18].
\nFurther surgical procedures should not be attempted if initial surgery is not followed by a pregnancy, because it appears that fecundability is reduced or unaffected [23].
\nMoreover, it seems that the pregnancy rates decrease by almost twofolds in case of multiple procedures compared to initial surgery (22 vs. 40%) [23]. Indication for further surgical interventions must take into account several factors such as age, symptoms, ovarian reserve, the need for histological confirmation for certain type of cysts, and availability of skilled surgeons [20].
\nUsually, surgery for deeply infiltrating endometriosis is considered only if it is causing symptoms or if it might cause symptoms in the future. If surgical treatment is necessary, all the deep lesions must be excised in one operation to avoid the need for further surgery [19].
\nThe therapy for symptomatic deeply infiltrating endometriosis is the resection with healthy margins. The operations often include partial rectum resection and partial resection of the sacrouterine ligament. Hysterectomy is not obligatory and is not wanted by the mostly young patients and a lot of doctors. The interventions can mostly be performed as laparoscopic and if necessary vaginal‐assisted procedures (Figure 6) [20–23].
\n\nConcerning the deeply infiltrating endometriosis treatment, the 2012 National Institute for Health and Clinical Excellence (NICE) recommendations state that in case of conducting laparoscopy and finding possible stage‐I or stage‐II lesions, it is advisable to remove them, whereas for stage‐III or stage‐IV lesions, surgical treatment is the only method indicated [18–20].
\nDissection of deeply infiltrating endometriosis of the rectouterine pouch.
Auxiliary therapy after surgery is very important in order to eliminate or suppress residual lesions and prevent recurrence [21]. Advanced stage‐III and stage‐IV endometriosis will require surgical treatment consisting in the removal of the disease foci and restoring anatomical interrelations [22].
\nAccording to the American Society of Reproductive Medicine (ASRM), the treatment of stage‐I and stage‐II lesions with the use of laparoscopy slightly increases the percentage of pregnancies. In case of stage III and stage IV, correctly conducted laparoscopy significantly increases the percentage of pregnancies [18–23].
\nLaparoscopic uterine nerve ablation (LUNA) and laparoscopic presacral neurectomy (LPSN) are two procedures that involve cutting the nerves from the uterus in order to relieve chronic pain. Presacral neurectomy did provide better pain relief than laparoscopic treatment alone [10–12].
\nPelvic endometriosis is a late diagnosed, complex, and in many aspects, a mysterious disease that still raises many questions and requires further research.
\nNowadays, endometriosis can only be treated in up to 70% of cases with three major treatment options involving medical therapy, surgery, or combined treatment, with laparoscopy emerging as the main diagnostic and therapeutical tool for endometriosis and endometriomas. The most common surgical technique is stripping of the endometrioma; this technique can reduce ovarian reserve and decrease the chances of fertility.
\nThere is controversial evidence regarding removal of endometriomas because of the potential impact on ovarian reserve, but there are also undisputable benefits of this type of surgery, such as pain relief.
\nFuture research is needed to identify the optimal surgical techniques, as well as the prospects for new procedures such as aspiration with sclerotherapy or drainage with endometrial ablation by plasma laser energy, which may cause less ovarian damage while allowing the best clinical outcomes.
\nSidonia Maria Saceanu, Stefan Patrascu, Anca Patrascu, Valeriu Surlin have nothing to disclose.
\nStefan Patrascu, Anca Patrascu, Valeriu Surlin have a contribution to the paper equal to that of the first author (Sidonia Maria Seceanu).
\nStroke is an insult to the brain tissue caused by a sudden interruption to the blood supply to the brain [1]. Sacco et al. gave an elaborate definition of stroke as a neurological deficit attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intra-cerebral haemorrhage (ICH), and subarachnoid haemorrhage (SAH) [2]. Stroke is highly prevalent and a second major cause of death and disability worldwide [2, 3, 4]. Stroke is a leading cause of dementia and depression. It can be classified on the basis of its aetiology as either ischaemic (87%) or haemorrhagic (13%) [5]. Ischaemic stroke results from occlusion of a cerebral artery which can be thrombotic or atherosclerotic (50%), embolic (25%) and micro-artery occlusion (lacunar stroke or infarcts) (25%) [5]. Haemorrhagic stroke is caused mainly by spontaneous rupture of blood vessels or aneurysms or secondary to trauma [5]. Early definitions of stroke and transient ischemic attack (TIA) focused on the duration of symptoms and signs. However, Sacco et al. [2], noted that use of clinical observations and modern brain imaging showed that the duration and reversibility of brain ischemia is variable. Brain tissue that is deprived of needed nutrients can, in some patients, survive without permanent injury for a considerable period of time, that is, several hours or even, rarely, days, while in most other individuals, irreversible damage (infarction) occurs quickly [2].
There has been a rise in the prevalence of stroke related disability in many countries [6]. A rise in the incidence of stroke in Zimbabwe from 31/100,000 to 57/100,000 in a decade was reported with fatality rates ranging from 22 to 58% at one month following stroke reported in Zimbabwe and other African studies [7].
The risk factors for stroke are generally similar to those for coronary heart diseases and other vascular diseases [4]. High blood pressure is one of the leading primary and secondary modifiable risk factors [5]. The other risk factors for stroke include smoking, low physical activity levels, unhealthy diet, abdominal obesity, diabetes and excessive consumption of alcohol [4]. Effective prevention strategies should include targeting the key modifiable risk factors such as hypertension, elevated lipids and diabetes.
Clinical manifestations of each stroke differ based on the part and side of the brain affected, extent of the lesion and the person’s general health. Some of the effects of stroke include numbness, weakness or paralysis on one side of the body opposite the side of the brain affected, slurred speech, difficulty thinking of words or understanding other people, confusion, sudden blurred vision or sight loss, being unsteady on your feet and severe headache [8]. Concerning the stroke warning signs, numbness on one side was surprisingly identified as the commonest warning (44%) while unspecified pain was the least cited (11%) in one of the studies [9]. Stroke can also result in psychological problems such as depression, anxiety, feeling helpless and thoughts of death or suicide, trouble sleeping and feelings of worthlessness [10]. In general, a right cerebrovascular accident may result in left hemiplegia or hemiparesis, difficulties with visuo-spatial memory, neglect of the left side of the body, poor judgement, and impulsivity, while a left cerebrovascular accident may cause right hemiplegia or hemiparesis, apraxia, and aphasia due to the location of the Broccas’ and Wernicke’s areas [11].
Stroke was associated with 43.7 million disability-adjusted life years annually around the world [5]. It is one of the most common neurological diseases in the black African and the leading cause of adult neurological admissions in West African sub-region, constituting up to 65% of such admissions [9]. Globally, 70% of strokes and 87% of both stroke-related deaths and disability-adjusted life years occur in low- and middle-income countries [4]. Approximately 60% of stroke patients acquire permanent disabilities and experience limitations in terms of mobility, vision, voice, speech, swallowing (dysphagia) and sexual function globally [4]. Stroke can cause multiple impairments which might need a variety of rehabilitation interventions [12]. Motor impairment is the most common deficit after stroke and the motor deficits increase fall risks and fall-related injuries. This in turn significantly affects the patients’ mobility, participation in their activities of daily living, social events and other occupational performance areas [13].
Stroke is a leading cause of functional impairments; with 20% of survivors requiring institutional care after three months and 15–30% being permanently disabled [14]. Many stroke patients experience activity limitation, restricted social participation, and psychological issues such as anxiety and depression some years after having stroke [15]. Approximately 65% of stroke patients are dependent on others to help them with everyday activities and the quality of life 2–5 years after stroke has been reported by many stroke survivors as poor [15].
Several researchers have studied the stroke survivor’s physical, social, psychological and emotional needs [16, 17, 18, 19]. Although most stroke patients receive rehabilitation, the lifelong need for care of stroke patients with disabilities has not been fully explored [17]. Despite calls for comprehensive stroke services to address long-term needs of patients, there had been little investigation of the perceived needs of stroke survivors in the long term or what determines such needs [20]. This area lacked a systematic approach to problem identification, had a poor evidence base, and was not underpinned by sound theoretical concepts hence there was need for further research in the area [15]. Similarly, needs of caregivers for stroke patients need further exploration.
Stroke Rehabilitation is a progressive, dynamic and goal-orientated process aimed at enabling a person with impairment as a result of stroke to reach their optimal physical, cognitive, emotional, communicative, social and functional activity level [21]. Stroke rehabilitation begins in the acute care hospital after the person’s overall condition has been stabilised, often within 24–48 hours after the stroke [22]. Stroke rehabilitation plays a vital role in lessening the effects of impairments and activity limitations, and in facilitating the return to active participation in community life and economic self-sufficiency after the stroke [12]. Internationally recognised best practice in the early management and rehabilitation of individuals following stroke includes collaborative and multidisciplinary assessment and treatment by a coordinated team of health care professionals [23]. A collaborative approach improves quality of life in stroke patients [12].
In the first weeks and months of recovery, the goals of rehabilitation are to help survivors become as independent as possible and to attain the best possible quality of life [21]. Although rehabilitation may not reverse the brain damage, it can substantially help people achieve the best possible long-term outcomes [22] through various ways that include facilitation of neuroplasticity of the brain. Rehabilitation is especially crucial during the early stages of recovery to regain independence when patients have little or no control over their affected muscles [22].
As part of stroke rehabilitation, occupational therapy (OT) involves the use of activities or training to improve or maintain the ability to live independently and cope with daily life for people with stroke [16]. The philosophy of occupational therapy is based on the concept that all humans have a need to become engaged in occupations [24], and that need is present even after stroke. Therefore, the role of the occupational therapist is to facilitate the patient’s continued participation in meaningful and purposeful daily activities and adaptation to the patient’s changed status. These occupations (all goal-directed engagement in self-care, work or leisure activities) can be termed as activities and participation areas in the International Classification of Functioning, Disability and Health (ICF) terminology [25]. According to the ICF framework, stroke results in activity limitation and participation restriction [26]. The ICF is a globally agreed framework and classification to define the spectrum of problems in the functioning of patients [27]. The ICF was also shown to be an essential tool for identifying and measuring efficacy and effectiveness of rehabilitation services [28]. Using the ICF takes a biopsychosocial approach which addresses the quality of life gap which is often left in favour of quantity of life.
Occupational Therapy in general, focuses on the assessment and treatment of individuals who are limited by physical injury or illness, psychosocial dysfunction, developmental or learning disabilities, or the ageing process through the use of purposeful activity and adaptive equipment and technology in order to maximise independence, prevent disability and maintain health [29]. Occupational therapists play a crucial role in the rehabilitation of stroke patients as they are experts at training patients to relearn complex bodily movements and avoid complications that could derail their progress later [30]. Occupational therapy is concerned with promoting health and wellbeing through participation in activities of everyday life and this is done by modifying the occupations and the environment in a therapeutic way to better support participation [23]. Occupational therapists also employ neurophysiologically based handling techniques meant to facilitate neuroplasticity of the brain. In some instances, occupational therapists can teach compensatory strategies when the old ways of functioning are no longer possible [30]. Therefore, occupational therapy for stroke includes interventions for physical, social, psychological and cognitive impairments [30]. The role of occupational therapists in stroke rehabilitation is particularly important because they focus on functional outcomes and getting clients back to doing everyday activities [11] which is usually unique to the profession. It is important that the interventions suit a patient’s needs [30].
The period of receiving services in stroke rehabilitation depends on the severity of disability and specific needs of the stroke survivor, although it has been proved that a great deal of stroke recovery occur within the first six months to a year following the onset of the stroke [31]. Occupational therapists work collaboratively with the patient to establish the impact of stroke on their performance of daily tasks, including personal care, domestic tasks, work and leisure activities; and in formulating a goal-focused program to develop the required skills for participation in daily life [23]. Given the variability in stroke complications, occupational therapists need to have a wide repertoire of techniques to help each client [11]. The treatment techniques in occupational therapy may include using occupational tasks to help improve cognitive abilities, teaching adaptations to meaningful activities to keep the client involved, and using task-specific movement to help with range of motion and motor control [11]. The occupational therapist can provide a patient with an assistive device or adjustments and adaptations in the environment, for example, in a patient’s home. This enables the patient to perform his/her ADLs independently and also dealing with other emotional or social issues that may result from stroke [30].
The occupational therapy process for stroke patients begins with an assessment of the patient’s roles, tasks and activities that are important for the patient [30]. An assessment is conducted to understand the impact of changes in motor function, sensation, coordination, visual perception, and cognition on the stroke patients and on the capacity to manage daily life tasks [23]. Assessment is also used to identify areas of individual and environmental difficulties and to enable patient-centred goal setting with the participation of both the patient and the caregiver [23]. The occupational therapist will then assess the ability to perform the roles, tasks and activities and if a limitation or restriction in some area is found, the occupational therapist will identify the performance components and craft the solution or intervention meant to restore, improve or maintain patient’s maximum level of performance [30]. Some of the performance components may include neuromuscular, cognitive and perceptual, language and psychosocial problems.
The occupational therapy interventions should therefore be able to address the patient’s needs and be provided in both the acute and rehabilitation phases [30]. For some stroke survivors, rehabilitation will be an on-going process to maintain and refine skills and could involve working with occupational therapists and other specialists in that field for months or even years after the stroke [22].
In order to adequately address challenges stroke patients face, there is need to identify the activities and areas of participation they consider important. This section is therefore based on a study done in Zimbabwe which sought to find out the activities and areas of participation considered important by stroke patients, the level of difficulty experienced in carrying out these activities and the reasons for attaching importance to these areas [32]. The study was cross sectional descriptive in nature and was done with 40 stroke patients consecutively selected as they came for their reviews at an outpatient stroke clinic at a central hospital in Zimbabwe [33]. An interview questionnaire adapted from the ICF checklist version 2.1a clinician form was administered by the researchers with consent after ethical approval (JREC….). Excluded were patients with significant cognitive and language impairments as it would have been difficult to communicate with them. In the study, 25 were female and 15 were male. Participants’ ages ranged from 34 to 81 years with the 50–59 years age group being the mode. These demographic characteristics are consistent with a study done by Mlambo et al. [34], which was done in South Africa and the participants’ ages ranged from 32 to 81 with a mean age of 52 years. The activities and areas of participation assessed during the study were obtained from the domains in the ICF checklist as alluded to earlier.
Half of the patients reported severe difficulty in lifting and carrying objects, while 43 and 38% of participants experienced complete and severe difficulties in fine hand use respectively [32]. About 20% had flexion contractures of the elbow and wrist joints of the affected side. These difficulties were due to the condition (stroke) which causes disturbances in muscle tone and loss of selective and isolated movements in the hand and arm [35] and this hinders execution of functional movements [36]. Thirty three percent of the participants had moderate difficulty in walking and used mobility aids while 20% had complete difficulty [32]. Half of the participants reported experiencing complete difficulty in using transportation like cars or buses. On driving, only 18 participants were drivers and 78% of them reported complete difficulty in the area [32].
On importance attached to these domains, all participants considered fine hand use and walking important, while 98% considered being able to use transportation important [32]. However, it was noted that none of the participants who were drivers had driving addressed by their therapist. Driving rehabilitation is an area that has not been fully explored by OTs in Zimbabwe. Driving is an important ADL and many stroke patients who were driving prior to their stroke wished to resume driving as noted by Kneebone and Lincoln [37]. A study by Duncan et al. [38] found that hand function and mobility were some of the key areas considered important by stroke patients.
Half of the participants in the study reported severe difficulties in dressing, 33% had moderate to severe difficulties in grooming while 65% had severe difficulty in bathing themselves [32]. About 73% had no difficulty in feeding and this can be explained by the exclusion of patients with speech and cognitive problems in the study. Speech and cognitive problems are often associated with feeding problems. Thirty three percent did not experience any difficulties in toileting while the remainder had mild to severe difficulties and used sanitary wear or were catheterised [32].
All aspects of self-care were considered as very important by all participants as they viewed these activities crucial for human survival [32]. This was also noted in a study by Aberg et al. [39] where the participants valued their independence in self-care activities.
In Chimusoro’s study [32], 78 and 75% of participants had complete difficulties in acquisition of goods and services, and preparing meals respectively. About half of the participants considered being able to prepare meals important, while 32% consisting mainly of male participants and elderly female participants did not view it as important since they had their meals prepared for them by caregivers. On doing housework, all male participants considered it as not applicable to them. This is common in the Zimbabwean and most African cultures where most if not all men, do not consider household chores as part of their ADLs. Therefore it would be irrelevant to engage a male patient in therapy sessions focusing on retraining household chores unless found necessary during the assessment process. The same notion applied to the elderly female patients who had long stopped doing those chores before suffering a stroke. These duties were done for them by children, grandchildren and/or caregivers [32]. This is where the aspect of interdependence is seen in the African culture. The elderly in Africa usually end up living with their children and grandchildren as compared to the Western culture where the elderly can be living alone and independence in home maintenance tasks becomes an important aspect of their lives.
All the participants did not have any difficulties in basic interpersonal interactions, formal and informal interactions [32]. Participants considered these areas important. However, 10 and 4% had mild and moderate difficulties in intimate relationships respectively. They attributed their problems in sexual function to their condition and felt it hindered maximum enjoyment of intimate relationships. They viewed their intimate relationships as important but were reluctant to share this with their therapist since they were not aware that the issue could be addressed in occupational therapy. Resumption of sexual activity for stroke patients is very important as cited by Edmans, although they may fail to articulate this to the therapist [40].
In this domain remunerative employment was not applicable to half of the participants as some were retired and some did not work prior to suffering the stroke. For the remaining half they reported complete difficulty and had not yet returned to their previous jobs. This is consistent with the findings by D’Alisa et al. [41] in which 40% had severe restrictions in employment issues. About 95% of patients to whom employment was applicable considered it as very important [41].
About 33% had moderate difficulties in economic self-sufficiency as they had financial problems due to their unemployment status. All the participants considered being self-sufficient important. In D’Alisa et al. [41], 15% had moderate to severe restrictions in economic self-sufficiency. This difference may be due to lack of a national social security system that cushions persons with disabilities in Zimbabwe as compared to more developed countries.
All participants considered it important to be reintegrated into the community. About 85% did not report any difficulty in participating in religious and spiritual activities and 95% considered them very important [32].
Fifty eight percent considered recreational activities as important. These recreational activities were mainly visiting friends and relatives, watching television, reading or listening to the radio [32]. There is a stark contrast in the type of recreational activities cited by the Zimbabwean sample as compared to other studies where participants reported restrictions in activities like golf, bowling, tennis and attending social clubs. The differences in the recreational activities can be explained by the differences in the socio-economic statuses of the samples. The culture of participating in recreational activities for leisure purposes need to be reinforced and further explored especially in low income groups where people mostly engage in productive activities whether paid or unpaid than they do in recreational activities.
Out of the 40 participants, 53% wanted to return to their work. They considered it very important because some were breadwinners and wanted to be able to look after their families [32]. In a study in Singapore by Kong and Yang [42], 14 out of 54 participants continued to be gainfully employed [42]. Of these 14, 11 were able to go back to previous jobs while 3 had to change jobs due to their physical limitations [42].
Thirty four percent wanted to be able to do their instrumental ADLs again [32]. These were mainly female participants who valued being able to look after their children and homes. Only 10% did not wish to return to any activity in particular and these were mainly elderly patients who had not been engaging in any activities that they considered important enough to return to [32]. In such cases, it would be necessary for the therapist to try to look for areas of interest for the patient so as to build a passion for doing activities that are meaningful to them and can also be used during therapy.
In summary, these findings give insight into the areas stroke patients consider important in the Zimbabwean context. They are consistent with other studies, for example, one study by Sumathipala [20], where stroke patients considered ADLs, social participation, mobility aids, home adaptations, housing and financial support as important [20].
The ICF is an important framework in guiding management of stroke patients as it can be used to assess and address all aspects of a person’s life without just focusing on his/her diagnosis [43]. Occupational therapy has an important role of facilitating a patient’s optimal functioning and independence through participation in meaningful and purposeful daily activities. The strength of occupational therapy lies in the ability to analyse activities/occupations. The occupations in which a person engages and the amount of time one spends doing the occupations is very specific to the circumstances and the culture in which a person lives [44]. Therefore, the effectiveness of occupational therapy and the quality of care can improve when culturally relevant occupations are selected and interventions are important to a person with stroke.
This section is based on a cross sectional pilot study done in Harare, Zimbabwe in 2020 with 35 stroke patients attending rehabilitation [45]. Mean age of participants was 58 years (S.D 8.8) and the greater proportion were female (
About 49% were employed [45], consistent with another study done on stroke survivors in Zimbabwe where less than half were working and the rest had no source of income [46]. Left cerebral Vascular Accidents accounted for 74.3% of the strokes. Study participants had a median duration with stroke diagnosis of 104 days (inter-quartile range 44–270). This is mainly the situation in Zimbabwe where most of the patients who come for rehabilitation have stroke duration of less than two years. Those who had stroke for more than two years will have inadequate funds to continue treatment, hence will not come for rehabilitation services.
The needs of participants were grouped into physical, instrumental, social, informational and emotional needs. Highlighted in Table 1 are the needs according to the groupings and it consists of 28 statements to which participants were expected to answer “yes” or “no” on whether they consider it a need.
Item | Need | Considered as a need by stroke patients | |
---|---|---|---|
Yes | No | ||
1 | To ease my pain, since nothing seems to ease it. | 35 (100%) | 0 |
2 | Help on walking and general moving | 35 (100%) | 0 |
3 | Help on how to get job done in my home (ADLs) such as cleaning, cooking, ironing and laundry | 35 (100%) | 0 |
4 | Help on how to do things like cutting my toenails, washing myself | 35 (100%) | 0 |
5 | Help on how to deal with fatigue | 35 (100%) | 0 |
6 | Learning about exercise | 35 (100%) | 0 |
7 | Help on how to bath independently | 35 (100%) | 0 |
8 | Help on dealing with bladder/ bowel problems (accidents, constipation, diarrhoea) | 32 (91.43%) | 3 (8.57%) |
9 | Help on how to prevent pressure sores | 30 (85.71) | 5 (14.29%) |
10 | Help on sight problems. | 29 (82.86%) | 6 (17.14%) |
11 | Help on getting back to driving | 19 (54.29%) | 16 (45.71%) |
12 | Help on swallowing problems. | 14 (40%) | 21 (60%) |
13 | Help on speech and communication problems | 12 (34.29%) | 23 (65.71%) |
14 | Help on hearing problems. | 4 (11.43%) | 31 (88.57%) |
15 | Additional aids or adaptations (kitchen appliances, stair lift, grab rails) if other please specify | 35 (100%) | 0 |
16 | Adaptations outside the home (e.g., ramps, rail) if other please specify | 33 (94.29%) | 2 (5.71%) |
17 | Help on how to occupy my day better (e.g., social outings, hobbies, leisure activities) | 35 (100%) | 0 |
18 | Help and advocacy in accessing social services | 34 (97.14%) | 1 (2.86%) |
19 | Help on how to travel using public transport such as buses and commuter omnibuses | 32 (91.43%) | 3 (8.57%) |
20 | More information about my stroke (e.g., what is stroke, why has it happened to me, how to avoid having another one) | 35 (100%) | 0 |
21 | Advice on how to improve my diet | 35 (100%) | 0 |
22 | Advice on how to manage my money better. | 33 (94.29%) | (5.71%) |
23 | Help on how to do shopping. | 32 (91.43%) | 3 (8.57%) |
24 | Advice on employment after stroke | 25 (71.43%) | 10 (28.57%) |
25 | Help and information on how to manage my physical relationship with my partner | 13 (37.14%) | 22 (62.86%) |
26 | Help on improving self-esteem, anger issues and other emotional issues If other please specify | 35 (100%) | 0 |
27 | Help on improving my memory and concentration. | 33 (94.29%) | 2 (5.71%) |
28 | Help on how to deal with emotional and behavioural changes | 34 (97.06%) | 1 (2.94%) |
Distribution of participants according to need (
Fourteen statements related to physical needs. All the participants in the study considered pain management, walking and general mobility, performing basic and instrumental activities of daily living (ADLs), engaging in recreational activities, dealing with fatigue and exercising as their physical needs post stroke [45]. Specific self-care needs cited were independent bathing and cutting toenails. Only 40% and about 11% cited swallowing and hearing problems respectively. Thus physical needs were the most common needs of stroke patients. This is because stroke mainly affects the physical components resulting in pain, reduced mobility, poor muscle strength, reduced speech and communication, problems with swallowing and incontinence and many other deficits which might results in decreased functioning and inability to cope [12]. In a similar study done in Australia, patients mostly over the age of 65 years needed assistance with performing ADLs, such as self-care [15], and this shows that this is a major need among all stroke patients regardless of location.
Sight problems, prevention of pressure sores and dealing with bladder and bowel problems were cited by more than 80% of participants as needs indicating that they are also common needs in this group.
These two aspects had a combined five needs (Table 1). There were two items on instrumental needs, and all participants indicated the need for additional aids or adaptations in the house while 94% cited need for adaptations outside the home. Under social needs, there were three items and about 97 and 91% respectively indicated the need for help and advocacy in accessing social services and using public transport. All participants needed help on how to engage in social outings, hobbies and leisure activities. Stroke survivors in this study faced societal barriers that can affect engagement in activities of daily living namely problems in using public transportation, lack of adaptations inside and outside the home environment as well as lack of aids and appliances to facilitate independence. Due to the economic situation in Zimbabwe, most places are not specifically adapted for people with disabilities to engage fully in social and daily activities, for example, inadequate provision of rails and ramps in public buildings for those who have problems with mobility [47]. Assistive devices like wheelchairs and modifications to the home environment are not available to the survivor soon after discharge to promote maximum participation [48], hence participants citing them as needs they require occupational therapists to meet. In Zimbabwe, wheelchair service provision and services are fragmented and poorly integrated [49]. The use of mobility devices such as wheelchairs, crutches and canes improves mobility, health and quality of life, and it enables those with mobility issues to mobilise without any restrictions [48]. Another study showed that stroke survivors had more participation restrictions as a result of environmental barriers [50]. Physical/structural and services/assistance were considered the dominant barriers to participation in activities of daily life for stroke survivors in China, hence there were considered to be among the most common needs presented by stroke survivors [51]. In another study on “Identification of rehabilitation needs after a stroke”, some of the most expressed needs of the participants were needs relating to adapted means of transportation and home visits from healthcare personnel [52]. Home visits might also help in noting any home adaptations that need to be done [53]. Social support should be provided to stroke survivors, including barrier-free facilities and occupational therapists should advocate for those services in the community.
Six items related to informational needs. All the participants needed information on their condition (stroke) and advice on diet. Over 90% needed advice on or help on better money management and shopping. Twenty-five participants needed advice on employment after stroke. The least cited as informational need had to do with managing physical relationships with partner/spouse (about 37%) (Table 1). The need to give more information about the condition is consistent with findings by Williams et al., where only 38% professed to know stroke warning signs and only 25% correctly interpreted their symptoms [54]. Similarly, Mckevitt, et al., reported more than half of their participants wanting more information about their stroke (cause, prevention of recurrence) [55]. This shows that this is a major concern among most stroke patients regardless of the part of the world they live, hence the need for occupational therapy intervention. Knowledge about the condition will also help them to adhere to the home programs they will be given and to seek for early treatment before any complications or permanent disability arises. With more knowledge about stroke, they could identify the disease immediately, resulting in a decrease in the time from symptom onset to hospital arrival, and a subsequent increase in the number of patients who may receive appropriate interventions [56]. It might also help them to know how to prevent any future recurrence of the condition and the services that might be beneficial to them in order to minimise any complications that may arise as a result of the condition.
Three items related to emotional needs. All items were cited as needs by more than 94% (improving memory and concentration (94.29%), self-esteem, anger and other emotional issues (100%) plus dealing with the emotional and behavioural changes (97.06%) (Table 1). This high proportion of more than 90% of the participants having emotional needs after stroke is probably because stroke affects the person’s ability to engage in daily living activities, communicate well with others and that can lead to increased dependence, feelings of low self-worth, (e.g., if the patient is incontinent) resulting in many psychological and emotional issues like depression [57]. The findings in this Zimbabwean study are consistent with a study on “Self-Reported Long-Term Needs After Stroke” where over one third of respondents reported experiencing emotional problems (including depression, crying) after the stroke [55]. Since emotional and psychological needs are liable to be neglected, post-stroke depression is a common complication which seriously impairs quality of life [18]. Therefore, psychological expertise and psychological support is needed by stoke survivors [18].
The majority of the participants in the Zimbabwean study perceived most of the needs in all categories as important and requiring intervention [45]. Physical needs rated as very important in this study were independent mobility and dealing with bladder and bowel incontinence. These aspects enable participants to be independent and to perform daily activities without restrictions. Participants also perceived informational needs as important [45]. Information on dietary issues is important among stroke patients as this might enhance recovery and help in minimising the intake of unhealthy foods such as saturated fats and too much sodium chloride which might even increase the risk of having a recurrent stroke [58]. Knowledge about one’s condition will conscientise them on the importance of receiving rehabilitation and adhering to one’s treatment and medications. The knowledge can also minimise complications and prevent future recurrence of the condition, hence this information is important among stroke patients [59]. Furthermore, knowledge and information about the condition is important since there is often confusion and a lack of information about surviving after a stroke, prevention of subsequent strokes, treatment, services, benefits and adaptions to property [60, 61]. Stroke survivors had to adapt to changes in their bodies as a result of stroke and adjust their expectations, including roles within the home and community [60]. This was particularly so for those of working age and hence the importance of knowledge on the condition.
In one study, stroke survivors experienced a lack of information about what had happened to them and did not realise they had had a stroke [62]. Relevant information is required at different times after a stroke, for example, information about benefits and services most needed after discharge from hospital [61]. Some survivors and carers are unsure which profession offers which service, and there can be role confusion related to an Occupational Therapist, a Physiotherapist, a Home Carer and a social worker, hence this information is also important among stroke patients who should know which services can address their specific needs [60].
The majority of the patients in the Zimbabwean study indicated that adaptations in the home environment were important [45]. Without these, stroke survivors are restricted in performing their daily activities and social roles resulting in increased dependency [63]. Without assistive technology, stroke survivors and other people with disabilities are often excluded, isolated and locked into poverty, resulting in increased burden of morbidity and disability [63]. This is similar to a study done to identify the long-term needs of stroke survivors using the ICF where the participants reported that home adaptations (such as stair or grab rails) provided after discharge from hospital enabled them to adapt to their physical disabilities by facilitating independence in walking, climbing stairs and ADLs [20]. Stroke patients saw this as important since these factors might create a significant barrier to their physical functioning and independence.
Pfavai [45] also revealed that emotional issues such as dealing with depression and behavioural changes were rated as important by more than 80% of the participants. Most of these are not easily seen unlike physical needs hence their importance might be overlooked by occupational therapists. These issues might affect recovery and engagement in daily occupations hence they were perceived as important by the participants. Emotional problems such as depression might also be fatal, in worst cases leading to suicide and general increased mortality, hence their importance must not be overlooked [64]. A sudden attack and poor prognosis had an appreciable effect on the psychological and emotional wellbeing of stroke survivors [18], hence they are important and should be addressed. Interventions usually focus on treating the disease, rather than the emotional needs of the patients. These emotional and psychological needs are liable to be neglected and post-stroke depression is a common complication which seriously impairs quality of life [18, 63].
Participants in Zimbabwe also perceived the need to engage in recreational pursuits as important in their lives [45]. This is one of the areas which are mostly neglected during intervention by occupational therapists. However, engaging in leisure and recreational activities is of importance since it improves physical health, enhances mental wellness, social interaction with others and it enables the stroke survivors to engage in activities which are meaningful in their lives [65]. In a study done on coping with the challenges of recovering from stroke, participants reported the importance of recreational activities and the great distress which was associated with the loss of hobbies and activities that had previously been a source of pleasure and achievement [62]. This is also in line with Rhoda et al., [66] where the participants highlighted the importance of engaging in recreational activities. Participants experienced social isolation, restriction to their homes which they felt could result in sadness and depression due to inability to engage in those activities which were normally found interesting before [66]. However, these activities should be client centred so that their benefits to each individual can be realised.
Access to public transport which is conducive and specifically adapted for people with disabilities was perceived as important by participants in Pfavai study [45]. This is important since lack of suitable transport results in participation restriction in activities such as religious activities, shopping and other social gatherings participants might want to engage in [47]. In a study done in China, physical/structural and services/assistance which include inaccessible public transport for those with disabilities were considered the dominant barriers to participation in activities of daily life for stroke survivors in China hence these needs are important and should be addressed [18]. Social support should be provided to stroke survivors, including barrier-free facilities [47]. Furthermore, the social security system for stroke survivors and other disabling conditions needs to be improved in low-income and middle-income countries.
Findings from Pfavai study [45] indicated that most of the needs of stroke patients were not being fully met including those needs participants rated as very important. Perceived unmet needs may reflect expectations and knowledge but may also indicate where service provision should be developed [55]. The needs which were mostly being fulfilled were physical needs such as pain management, exercises to facilitate walking and mobility in general, and self-care including independent bathing [45]. This is because these needs can be easily identified and their physical limitations can be easily noted compared to other needs such as emotional, informational and societal. The later ones are therefore less likely to be addressed. These findings are consistent with McKevitt
The emotional needs highlighted included how to deal with depression, anger issues, low self-esteem and behavioural changes as a result of stroke [45]. Emotional needs might be overlooked during the assessment process especially if the patient does not mention any emotional issues they might be experiencing. This is in line with a study done on the unmet needs of stroke patients where cognitive and emotional health needs such as concentration, memory, cognition, fatigue, and emotions were less likely to be fully met than physical needs despite physical needs being more common [15]. This affirms the requirement to implement strategies to help stroke survivors address the range of emotional problems they may experience [55]. Stroke rehabilitation usually focuses on physical impairments and assisting stroke survivors to develop functional independence. This may mean that services aimed at addressing the cognitive and emotional needs of stroke survivors are not adequately resourced [15]. This supports the results obtained in Pfavai [45] study where emotional needs were not being fully met compared to most of the physical needs [45]. Therapists need to be intentional in ensuring that emotional problems experienced by stroke survivors are adequately addressed.
Instrumental needs which were perceived as being unmet by more than 70% of the participants included adaptations outside the home environment and aids and adaptions inside the home environment [45]. Without these aids, stroke survivors are less able to perform their daily activities without restrictions [49]. However, due to the economic situation in Zimbabwe there is lack of resources in hospitals and assistive devices are scarce for those with performance limitations [45, 47]. There is also lack of transport and financial resources for the occupational therapists to do home adaptations for the patients soon after discharge [53]. This need might also be more than the 70% which was obtained in Pfavai study [45] since the study was partly done at a rehabilitation centre where the patients are given assistive devices such as wheelchairs for them to use before discharge and at a nominal fee after discharge. Stroke survivors have also reported that health systems are not responsive to their changing needs and that there is a lack of long-term re-assessment of their needs, [15]; hence some of the needs which might arise later during intervention may not be met.
Training on getting back to driving and information on how to do shopping were rated by more than 90% of participants as unmet [45]. These are some of the needs which are over looked during intervention. This might be due to lack of expertise among the concerned occupational therapists on driving rehabilitation. At the time of writing this chapter, there was no comprehensive module on driving in the University of Zimbabwe curriculum on occupational therapy undergraduate training. This might result in lack of expertise and confidence in addressing that need. This is also in line with a study done on coping with the challenges of recovering from stroke where loss of ability to drive a car was seen as a major challenge which required intervention and the ability to resume driving was spoken with deep emotion [62]. Driving was seen as representative of independence, a way to regain self-esteem, a means to access social support and to facilitate participation in valued activities [62]. This aspect however needs special training to avoid causing harm to patient and society.
Skills on shopping independently were also perceived as unmet in Pfavai study [45], and this might be due to lack of resources to simulate the shopping environment or lack of funds to teach the patients in the actual environment. In a study that looked at the combined perceptions of people with stroke and their carers regarding rehabilitation needs one year after stroke [67], patients reported having to give up a task in advance and had limitations in more physically demanding activities such as going to buy groceries among other tasks, supporting the need to address shopping needs among stroke patients [67]. The importance of this need might be overlooked during interventions. Information and knowledge needs of stroke survivors should not be underestimated and should be considered when developing strategies to meet the rehabilitation needs of stroke survivors [68].
Another unmet need in the Zimbabwean study [45] was financial/money management after a stroke. Most stroke survivors lose their jobs after the incident of stroke, and cognitive components might also be affected resulting in inability to adequately manage their money. However, this need seemed to have been overlooked. Li et al. also noted that few studies have looked at the financial impact of stroke on the survivors and their families, indicating that this area’s importance might be underrated [18].
Early discharge of patients due to unavailability of beds might also result in some of the stroke patients’ needs not being adequately met. Although many individuals still have rehabilitation needs one year after stroke, rehabilitation is often concluded within the first three months, and follow up is not usually done hence some of the needs might not be adequately fulfilled [67].
The occupational therapist is the health professional who specifically addresses patients’ involvement in daily life situations, and as such, she/he should be well conversant with that particular aspect of patients’ lives. This in turn addresses one’s quality of life which is often neglected. Stroke patients’ perceived needs highlighted above provide patients’ perspectives which is critical in the development of patient-centred services by service providers. The commonly used functional outcome measures (e.g., the Barthel Index) may underestimate dependence leading to rehabilitation professionals and patients prioritising different needs. Not using meaningful occupations in treatment; lack of discharge planning, using interventions not perceived as driven by patient’s occupational goals, and use of interventions chosen by therapists without considering what the patient needs thereby placing the patient in a passive role were noted as major challenges [69]. The stroke patients’ perceptions help the therapists to tailor interventions to meet patients’ specific needs.
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These physiological events occur smoothly in normal healthy individual and/or under normal conditions. However, in certain cases, these molecular events are retarded resulting in hard-to-heal or chronic wounds arising from several factors such as poor venous return, underlying physiological or metabolic conditions such as diabetes as well as external factors such as poor nutrition. In most cases, such wounds are infected and infection also presents as another complicating phenomenon which triggers inflammatory reactions, therefore delaying wound healing. There has therefore been recent interests and significant efforts in preventing and actively treating wound infections by directly targeting infection causative agents through direct application of antimicrobial agents either alone or loaded into dressings (medicated). These have the advantage of overcoming challenges such as poor circulation in diabetic and leg ulcers when administered systemically and also require lower amounts to be applied compared to that required via oral or iv administration. This chapter will review and evaluate various antimicrobial agents used to target infected wounds, the means of delivery, and current state of the art, including commercially available dressings. Data sources will include mainly peer-reviewed literature, clinical trials and reports, patents as well as government reports where available.",book:{id:"5290",slug:"wound-healing-new-insights-into-ancient-challenges",title:"Wound Healing",fullTitle:"Wound Healing - New insights into Ancient Challenges"},signatures:"Omar Sarheed, Asif Ahmed, Douha Shouqair and Joshua Boateng",authors:[{id:"183108",title:"Dr.",name:"Joshua",middleName:null,surname:"Boateng",slug:"joshua-boateng",fullName:"Joshua Boateng"},{id:"183399",title:"Dr.",name:"Omar",middleName:null,surname:"Sarheed",slug:"omar-sarheed",fullName:"Omar Sarheed"},{id:"188082",title:"Mr.",name:"Asif",middleName:null,surname:"Ahmed",slug:"asif-ahmed",fullName:"Asif Ahmed"},{id:"188083",title:"Ms.",name:"Douha",middleName:null,surname:"Shouqair",slug:"douha-shouqair",fullName:"Douha Shouqair"}]},{id:"51825",doi:"10.5772/64611",title:"Roles of Matrix Metalloproteinases in Cutaneous Wound Healing",slug:"roles-of-matrix-metalloproteinases-in-cutaneous-wound-healing",totalDownloads:3629,totalCrossrefCites:20,totalDimensionsCites:39,abstract:"Wound healing is a complex process that consists of hemostasis and inflammation, angiogenesis, re-epithelialization, and tissue remodeling. Matrix metalloproteinases (MMPs) play important roles in wound healing, and their dysregulation leads to prolonged inflammation and delayed wound healing. There are 24 MMPs in humans, and each MMP exists in three forms, of which only the active MMPs play a role in the pathology or repair of wounds. The current methodology does not distinguish between the three forms of MMPs, making it challenging to investigate the roles of MMPs in pathology and wound repair. We used a novel MMP-inhibitor-tethered affinity resin that binds only the active form of MMPs, from which we identified and quantified active MMP-8 and active MMP-9 in a murine diabetic model with delayed wound healing. We showed that up-regulation of active MMP-9 plays a detrimental role whereas active MMP-8 is involved in repairing the wound in diabetic mice. These studies identified MMP-9 as a novel target for therapeutic intervention in the treatment of chronic wounds. A selective inhibitor of MMP-9 that leaves MMP-8 unaffected would provide the most effective therapy and represents a promising strategy for therapeutic intervention in the treatment of diabetic foot ulcers.",book:{id:"5290",slug:"wound-healing-new-insights-into-ancient-challenges",title:"Wound Healing",fullTitle:"Wound Healing - New insights into Ancient Challenges"},signatures:"Trung T. Nguyen, Shahriar Mobashery and Mayland Chang",authors:[{id:"183405",title:"Prof.",name:"Mayland",middleName:null,surname:"Chang",slug:"mayland-chang",fullName:"Mayland Chang"},{id:"191152",title:"Mr.",name:"Trung",middleName:null,surname:"Nguyen",slug:"trung-nguyen",fullName:"Trung Nguyen"},{id:"191153",title:"Prof.",name:"Shahriar",middleName:null,surname:"Mobashery",slug:"shahriar-mobashery",fullName:"Shahriar Mobashery"}]},{id:"63675",doi:"10.5772/intechopen.81208",title:"Wound Healing: Contributions from Plant Secondary Metabolite Antioxidants",slug:"wound-healing-contributions-from-plant-secondary-metabolite-antioxidants",totalDownloads:1331,totalCrossrefCites:7,totalDimensionsCites:20,abstract:"Plants by their genetic makeup possess an innate ability to synthesize a wide variety of phytochemicals that help them to perform their normal physiological functions and/or to protect themselves from microbial pathogens and animal herbivores. The synthesis of these phytochemicals presents the plants their natural tendency to respond to environmental stress conditions. These phytochemicals are classified either as primary or secondary metabolites. The secondary metabolites have been identified in plants as alkaloids, terpenoids, phenolics, anthraquinones, and triterpenes. These plant-based compounds are believed to have diverse medicinal properties including antioxidant properties. Plants have therefore been a potential source of antioxidants which have received a great deal of attention since increased oxidative stress has been identified as a major causative factor in the development and progression of several life-threatening diseases, including neurodegenerative and cardiovascular diseases and wound infection. Consequently, many medicinal plants have been cited and known to effect wound healing and antioxidant properties. This chapter briefly reviews antioxidant properties of medicinal plants to highlight the important roles medicinal plants play in wound healing.",book:{id:"7046",slug:"wound-healing-current-perspectives",title:"Wound Healing",fullTitle:"Wound Healing - Current Perspectives"},signatures:"Victor Y.A. Barku",authors:[{id:"261027",title:"Prof.",name:"Victor Y. A.",middleName:null,surname:"Barku",slug:"victor-y.-a.-barku",fullName:"Victor Y. A. Barku"}]},{id:"66793",doi:"10.5772/intechopen.85020",title:"The Impact of Biofilm Formation on Wound Healing",slug:"the-impact-of-biofilm-formation-on-wound-healing",totalDownloads:1434,totalCrossrefCites:7,totalDimensionsCites:16,abstract:"Chronic wounds represent an important challenge for wound care and are universally colonized by bacteria. These bacteria can form biofilm as a survival mechanism that confers the ability to resist environmental stressors and antimicrobials due to a variety of reasons, including low metabolic activity. Additionally, the exopolymeric substance (EPS) contained in biofilm acts as a mechanical barrier to immune system cells, leading to collateral damage in the surrounding tissue as well as chronic inflammation, which eventually will delay healing of the wound. This chapter will discuss current knowledge on biofilm formation, its presence in acute and chronic wounds, how biofilm affects antibiotic resistance and tolerance, as well as the wound healing process. We will also discuss proposed methods to eliminate biofilm and improve wound healing despite its presence, including basic science and clinical studies regarding these matters.",book:{id:"7046",slug:"wound-healing-current-perspectives",title:"Wound Healing",fullTitle:"Wound Healing - Current Perspectives"},signatures:"Rafael A. Mendoza, Ji-Cheng Hsieh and Robert D. Galiano",authors:[{id:"253607",title:"M.D.",name:"Rafael",middleName:null,surname:"Mendoza",slug:"rafael-mendoza",fullName:"Rafael Mendoza"},{id:"254018",title:"Dr.",name:"Robert",middleName:null,surname:"Galiano",slug:"robert-galiano",fullName:"Robert Galiano"},{id:"271116",title:"Mr.",name:"Ji-Cheng",middleName:null,surname:"Hsieh",slug:"ji-cheng-hsieh",fullName:"Ji-Cheng Hsieh"}]},{id:"63086",doi:"10.5772/intechopen.80215",title:"Medicinal Plants in Wound Healing",slug:"medicinal-plants-in-wound-healing",totalDownloads:2901,totalCrossrefCites:7,totalDimensionsCites:15,abstract:"Wound healing process is known as interdependent cellular and biochemical stages which are in trying to improve the wound. Wound healing can be defined as stages which is done by body and delayed in wound healing increases chance of microbial infection. Improved wound healing process can be performed by shortening the time needed for healing or lowering the inappropriate happens. The drugs were locally or systemically administrated in order to help wound healing. Antibiotics, antiseptics, desloughing agents, extracts, etc. have been used in order to wound healing. Some synthetic drugs are faced with limitations because of their side effects. Plants or combinations derived from plants are needed to investigate identify and formulate for treatment and management of wound healing. There is increasing interest to use the medicinal plants in wound healing because of lower side effects and management of wounds over the years. Studies have shown that medicinal plants improve wound healing in diabetic, infected and opened wounds. The different mechanisms have been reported to improve the wound healing by medicinal plants. In this chapter, some medicinal plants and the reported mechanisms will be discussed.",book:{id:"7046",slug:"wound-healing-current-perspectives",title:"Wound Healing",fullTitle:"Wound Healing - Current Perspectives"},signatures:"Mohammad Reza Farahpour",authors:[{id:"253340",title:"Prof.",name:"Mohammadreza",middleName:null,surname:"Farahpour",slug:"mohammadreza-farahpour",fullName:"Mohammadreza Farahpour"}]}],mostDownloadedChaptersLast30Days:[{id:"55736",title:"Haemodynamic Monitoring in the Intensive Care Unit",slug:"haemodynamic-monitoring-in-the-intensive-care-unit",totalDownloads:3369,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Monitoring is a cognitive aid that allows clinicians to detect the nature and extent of pathology and helps assessment of response to therapy. The cardiovascular system is the most commonly monitored organ system in the critical care setting. It helps identify the presence and nature of shock and guides response to resuscitation by detection of cardiac rate and rhythm, evaluation of volume state, cardiac contractility and systemic vascular resistance. Newer technologies allow greater assessment of oxygen delivery to vulnerable tissues. We discuss the nature, history, modalities and interpretation of the most commonly available haemodynamic monitoring methods in clinical use currently.",book:{id:"5756",slug:"intensive-care",title:"Intensive Care",fullTitle:"Intensive Care"},signatures:"Mainak Majumdar",authors:[{id:"86678",title:"Dr.",name:"Mainak",middleName:null,surname:"Majumdar",slug:"mainak-majumdar",fullName:"Mainak Majumdar"}]},{id:"51825",title:"Roles of Matrix Metalloproteinases in Cutaneous Wound Healing",slug:"roles-of-matrix-metalloproteinases-in-cutaneous-wound-healing",totalDownloads:3628,totalCrossrefCites:20,totalDimensionsCites:37,abstract:"Wound healing is a complex process that consists of hemostasis and inflammation, angiogenesis, re-epithelialization, and tissue remodeling. Matrix metalloproteinases (MMPs) play important roles in wound healing, and their dysregulation leads to prolonged inflammation and delayed wound healing. There are 24 MMPs in humans, and each MMP exists in three forms, of which only the active MMPs play a role in the pathology or repair of wounds. The current methodology does not distinguish between the three forms of MMPs, making it challenging to investigate the roles of MMPs in pathology and wound repair. We used a novel MMP-inhibitor-tethered affinity resin that binds only the active form of MMPs, from which we identified and quantified active MMP-8 and active MMP-9 in a murine diabetic model with delayed wound healing. We showed that up-regulation of active MMP-9 plays a detrimental role whereas active MMP-8 is involved in repairing the wound in diabetic mice. These studies identified MMP-9 as a novel target for therapeutic intervention in the treatment of chronic wounds. A selective inhibitor of MMP-9 that leaves MMP-8 unaffected would provide the most effective therapy and represents a promising strategy for therapeutic intervention in the treatment of diabetic foot ulcers.",book:{id:"5290",slug:"wound-healing-new-insights-into-ancient-challenges",title:"Wound Healing",fullTitle:"Wound Healing - New insights into Ancient Challenges"},signatures:"Trung T. Nguyen, Shahriar Mobashery and Mayland Chang",authors:[{id:"183405",title:"Prof.",name:"Mayland",middleName:null,surname:"Chang",slug:"mayland-chang",fullName:"Mayland Chang"},{id:"191152",title:"Mr.",name:"Trung",middleName:null,surname:"Nguyen",slug:"trung-nguyen",fullName:"Trung Nguyen"},{id:"191153",title:"Prof.",name:"Shahriar",middleName:null,surname:"Mobashery",slug:"shahriar-mobashery",fullName:"Shahriar Mobashery"}]},{id:"63086",title:"Medicinal Plants in Wound Healing",slug:"medicinal-plants-in-wound-healing",totalDownloads:2898,totalCrossrefCites:7,totalDimensionsCites:15,abstract:"Wound healing process is known as interdependent cellular and biochemical stages which are in trying to improve the wound. Wound healing can be defined as stages which is done by body and delayed in wound healing increases chance of microbial infection. Improved wound healing process can be performed by shortening the time needed for healing or lowering the inappropriate happens. The drugs were locally or systemically administrated in order to help wound healing. Antibiotics, antiseptics, desloughing agents, extracts, etc. have been used in order to wound healing. Some synthetic drugs are faced with limitations because of their side effects. Plants or combinations derived from plants are needed to investigate identify and formulate for treatment and management of wound healing. There is increasing interest to use the medicinal plants in wound healing because of lower side effects and management of wounds over the years. Studies have shown that medicinal plants improve wound healing in diabetic, infected and opened wounds. The different mechanisms have been reported to improve the wound healing by medicinal plants. In this chapter, some medicinal plants and the reported mechanisms will be discussed.",book:{id:"7046",slug:"wound-healing-current-perspectives",title:"Wound Healing",fullTitle:"Wound Healing - Current Perspectives"},signatures:"Mohammad Reza Farahpour",authors:[{id:"253340",title:"Prof.",name:"Mohammadreza",middleName:null,surname:"Farahpour",slug:"mohammadreza-farahpour",fullName:"Mohammadreza Farahpour"}]},{id:"67217",title:"Nursing Implications in the ECMO Patient",slug:"nursing-implications-in-the-ecmo-patient",totalDownloads:2528,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"Effective care and positive outcomes of the extracorporeal membrane oxygenation (ECMO) patient necessitate optimal interdisciplinary management from the healthcare team, including expert care from specially trained registered nurses (RNs). It is incumbent upon the RN caring for the ECMO patient to excel in both time management and assessment skills, as this population often demands care delivery at the pinnacle of intensive care unit (ICU) acuity. Astute and nuanced monitoring of neurological status, bleeding risk with potential (often massive) transfusions, poor hemodynamics, and integrity of the ECMO pump itself are only the few specialized areas of focus that must share priority with traditional nursing considerations involving the critically ill, such as prevention of pressure injuries and bloodstream infections. These high-intensity medical foci must be balanced with ethical considerations, as the ultimate goal of returning the patient to their normal life is not always possible. These demands highlight the dynamic proficiency of the RN caring for the ECMO patient. The following chapter will highlight the importance of specialized nursing care in the critically ill patient supported with ECMO.",book:{id:"7878",slug:"advances-in-extracorporeal-membrane-oxygenation-volume-3",title:"Advances in Extracorporeal Membrane Oxygenation",fullTitle:"Advances in Extracorporeal Membrane Oxygenation - Volume 3"},signatures:"Alex Botsch, Elizabeth Protain, Amanda R. Smith and Ryan Szilagyi",authors:[{id:"298623",title:"Mr.",name:"Alexander",middleName:null,surname:"Botsch",slug:"alexander-botsch",fullName:"Alexander Botsch"}]},{id:"66239",title:"Echocardiography Evaluation in ECMO Patients",slug:"echocardiography-evaluation-in-ecmo-patients",totalDownloads:2184,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Extracorporeal membrane oxygenation (ECMO) is a special form of organ support for selected cases of cardiovascular and severe respiratory failure. Echocardiography is a diagnostic and monitoring tool widely used in all aspects of ECMO support. The pathophysiology of ECMO, and its distinct effects on cardiorespiratory physiology, requires an echocardiographer with high skills to understand the interaction between the ECMO and the patient. In this chapter, we present the main application of echocardiography in ECMO patients and some general concepts on the ECMO working. ECMO, such as the standard cardiopulmonary bypass employed in cardiac surgery, V-V (veno-venous), can support the insufficient respiratory system by oxygenating and removing carbon dioxide from the blood. VA-ECMO (venous-arterial) can support haemodynamics by providing mechanical circulatory assistance. Today, ECMO can be used as bridge to decision, waiting for the development of the clinical conditions to support with other devices the evolution of cardiorespiratory failure or stop the assistance. Echocardiography (transthoracic (TTE) or transoesophageal (TOE)) can be used primarily to take decisions regarding appropriateness of ECMO support, therefore to control cannula insertion and confirm final position, to modify number and position of the cannulae in case of malfunctioning of these, and, finally, to assess clinical progress and suitability for weaning from ECMO.",book:{id:"7878",slug:"advances-in-extracorporeal-membrane-oxygenation-volume-3",title:"Advances in Extracorporeal Membrane Oxygenation",fullTitle:"Advances in Extracorporeal Membrane Oxygenation - Volume 3"},signatures:"Luigi Tritapepe, Ernesto Greco and Carlo Gaudio",authors:[{id:"284893",title:"Prof.",name:"Luigi",middleName:null,surname:"Tritapepe",slug:"luigi-tritapepe",fullName:"Luigi Tritapepe"},{id:"294005",title:"Prof.",name:"Ernesto",middleName:null,surname:"Greco",slug:"ernesto-greco",fullName:"Ernesto Greco"},{id:"294006",title:"Prof.",name:"Carlo",middleName:null,surname:"Gaudio",slug:"carlo-gaudio",fullName:"Carlo Gaudio"}]}],onlineFirstChaptersFilter:{topicId:"173",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:11,numberOfPublishedChapters:91,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:108,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:332,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:11,numberOfPublishedChapters:142,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:124,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:22,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:12,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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His present research includes organic synthesis, drug discovery and development, biochemistry, nanoscience, and nanotechnology.",institutionString:"Visiting Scientist at Lipid Nanostructures Laboratory, Centre for Smart Materials, School of Natural Sciences, University of Central Lancashire",institution:null},{id:"428125",title:"Dr.",name:"Vinayak",middleName:null,surname:"Adimule",slug:"vinayak-adimule",fullName:"Vinayak Adimule",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/428125/images/system/428125.jpg",biography:"Dr. Vinayak Adimule, MSc, Ph.D., is a professor and dean of R&D, Angadi Institute of Technology and Management, India. He has 15 years of research experience as a senior research scientist and associate research scientist in R&D organizations. He has published more than fifty research articles as well as several book chapters. He has two Indian patents and two international patents to his credit. Dr. Adimule has attended, chaired, and presented papers at national and international conferences. He is a guest editor for Topics in Catalysis and other journals. He is also an editorial board member, life member, and associate member for many international societies and research institutions. His research interests include nanoelectronics, material chemistry, artificial intelligence, sensors and actuators, bio-nanomaterials, and medicinal chemistry.",institutionString:"Angadi Institute of Technology and Management",institution:null},{id:"284317",title:"Prof.",name:"Kantharaju",middleName:null,surname:"Kamanna",slug:"kantharaju-kamanna",fullName:"Kantharaju Kamanna",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284317/images/21050_n.jpg",biography:"Prof. K. Kantharaju has received Bachelor of science (PCM), master of science (Organic Chemistry) and Doctor of Philosophy in Chemistry from Bangalore University. He worked as a Executive Research & Development @ Cadila Pharmaceuticals Ltd, Ahmedabad. He received DBT-postdoc fellow @ Molecular Biophysics Unit, Indian Institute of Science, Bangalore under the supervision of Prof. P. Balaram, later he moved to NIH-postdoc researcher at Drexel University College of Medicine, Philadelphia, USA, after his return from postdoc joined NITK-Surthakal as a Adhoc faculty at department of chemistry. Since from August 2013 working as a Associate Professor, and in 2016 promoted to Profeesor in the School of Basic Sciences: Department of Chemistry and having 20 years of teaching and research experiences.",institutionString:null,institution:{name:"Rani Channamma University, Belagavi",country:{name:"India"}}},{id:"158492",title:"Prof.",name:"Yusuf",middleName:null,surname:"Tutar",slug:"yusuf-tutar",fullName:"Yusuf Tutar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/158492/images/system/158492.jpeg",biography:"Prof. Dr. Yusuf Tutar conducts his research at the Hamidiye Faculty of Pharmacy, Department of Basic Pharmaceutical Sciences, Division of Biochemistry, University of Health Sciences, Turkey. He is also a faculty member in the Molecular Oncology Program. He obtained his MSc and Ph.D. at Oregon State University and Texas Tech University, respectively. He pursued his postdoctoral studies at Rutgers University Medical School and the National Institutes of Health (NIH/NIDDK), USA. His research focuses on biochemistry, biophysics, genetics, molecular biology, and molecular medicine with specialization in the fields of drug design, protein structure-function, protein folding, prions, microRNA, pseudogenes, molecular cancer, epigenetics, metabolites, proteomics, genomics, protein expression, and characterization by spectroscopic and calorimetric methods.",institutionString:"University of Health Sciences",institution:null},{id:"180528",title:"Dr.",name:"Hiroyuki",middleName:null,surname:"Kagechika",slug:"hiroyuki-kagechika",fullName:"Hiroyuki Kagechika",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180528/images/system/180528.jpg",biography:"Hiroyuki Kagechika received his bachelor’s degree and Ph.D. in Pharmaceutical Sciences from the University of Tokyo, Japan, where he served as an associate professor until 2004. He is currently a professor at the Institute of Biomaterials and Bioengineering (IBB), Tokyo Medical and Dental University (TMDU). From 2010 to 2012, he was the dean of the Graduate School of Biomedical Science. Since 2012, he has served as the vice dean of the Graduate School of Medical and Dental Sciences. He has been the director of the IBB since 2020. Dr. Kagechika’s major research interests are the medicinal chemistry of retinoids, vitamins D/K, and nuclear receptors. He has developed various compounds including a drug for acute promyelocytic leukemia.",institutionString:"Tokyo Medical and Dental University",institution:{name:"Tokyo Medical and Dental University",country:{name:"Japan"}}},{id:"94311",title:"Prof.",name:"Martins",middleName:"Ochubiojo",surname:"Ochubiojo Emeje",slug:"martins-ochubiojo-emeje",fullName:"Martins Ochubiojo Emeje",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94311/images/system/94311.jpeg",biography:"Martins Emeje obtained a BPharm with distinction from Ahmadu Bello University, Nigeria, and an MPharm and Ph.D. from the University of Nigeria (UNN), where he received the best Ph.D. award and was enlisted as UNN’s “Face of Research.” He established the first nanomedicine center in Nigeria and was the pioneer head of the intellectual property and technology transfer as well as the technology innovation and support center. Prof. Emeje’s several international fellowships include the prestigious Raman fellowship. He has published more than 150 articles and patents. He is also the head of R&D at NIPRD and holds a visiting professor position at Nnamdi Azikiwe University, Nigeria. He has a postgraduate certificate in Project Management from Walden University, Minnesota, as well as a professional teaching certificate and a World Bank certification in Public Procurement. Prof. Emeje was a national chairman of academic pharmacists in Nigeria and the 2021 winner of the May & Baker Nigeria Plc–sponsored prize for professional service in research and innovation.",institutionString:"National Institute for Pharmaceutical Research and Development",institution:{name:"National Institute for Pharmaceutical Research and Development",country:{name:"Nigeria"}}},{id:"436430",title:"Associate Prof.",name:"Mesut",middleName:null,surname:"Işık",slug:"mesut-isik",fullName:"Mesut Işık",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/436430/images/19686_n.jpg",biography:null,institutionString:null,institution:{name:"Bilecik University",country:{name:"Turkey"}}},{id:"268659",title:"Ms.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/268659/images/8143_n.jpg",biography:"Dr. Zhan received his undergraduate and graduate training in the fields of preventive medicine and epidemiology and statistics at the West China University of Medical Sciences in China during 1989 to 1999. He received his post-doctoral training in oncology and cancer proteomics for two years at the Cancer Research Institute of Human Medical University in China. In 2001, he went to the University of Tennessee Health Science Center (UTHSC) in USA, where he was a post-doctoral researcher and focused on mass spectrometry and cancer proteomics. Then, he was appointed as an Assistant Professor of Neurology, UTHSC in 2005. He moved to the Cleveland Clinic in USA as a Project Scientist/Staff in 2006 where he focused on the studies of eye disease proteomics and biomarkers. He returned to UTHSC as an Assistant Professor of Neurology in the end of 2007, engaging in proteomics and biomarker studies of lung diseases and brain tumors, and initiating the studies of predictive, preventive, and personalized medicine (PPPM) in cancer. In 2010, he was promoted to Associate Professor of Neurology, UTHSC. Currently, he is a Professor at Xiangya Hospital of Central South University in China, Fellow of Royal Society of Medicine (FRSM), the European EPMA National Representative in China, Regular Member of American Association for the Advancement of Science (AAAS), European Cooperation of Science and Technology (e-COST) grant evaluator, Associate Editors of BMC Genomics, BMC Medical Genomics, EPMA Journal, and Frontiers in Endocrinology, Executive Editor-in-Chief of Med One. He has\npublished 116 peer-reviewed research articles, 16 book chapters, 2 books, and 2 US patents. His current main research interest focuses on the studies of cancer proteomics and biomarkers, and the use of modern omics techniques and systems biology for PPPM in cancer, and on the development and use of 2DE-LC/MS for the large-scale study of human proteoforms.",institutionString:null,institution:{name:"Xiangya Hospital Central South University",country:{name:"China"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"418340",title:"Dr.",name:"Jyotirmoi",middleName:null,surname:"Aich",slug:"jyotirmoi-aich",fullName:"Jyotirmoi Aich",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038Ugi5QAC/Profile_Picture_2022-04-15T07:48:28.png",biography:"Biotechnologist with 15 years of research including 6 years of teaching experience. Demonstrated record of scientific achievements through consistent publication record (H index = 13, with 874 citations) in high impact journals such as Nature Communications, Oncotarget, Annals of Oncology, PNAS, and AJRCCM, etc. Strong research professional with a post-doctorate from ACTREC where I gained experimental oncology experience in clinical settings and a doctorate from IGIB where I gained expertise in asthma pathophysiology. A well-trained biotechnologist with diverse experience on the bench across different research themes ranging from asthma to cancer and other infectious diseases. An individual with a strong commitment and innovative mindset. Have the ability to work on diverse projects such as regenerative and molecular medicine with an overall mindset of improving healthcare.",institutionString:"DY Patil Deemed to Be University",institution:null},{id:"349288",title:"Prof.",name:"Soumya",middleName:null,surname:"Basu",slug:"soumya-basu",fullName:"Soumya Basu",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035QxIDQA0/Profile_Picture_2022-04-15T07:47:01.jpg",biography:"Soumya Basu, Ph.D., is currently working as an Associate Professor at Dr. D. Y. Patil Biotechnology and Bioinformatics Institute, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India. With 16+ years of trans-disciplinary research experience in Drug Design, development, and pre-clinical validation; 20+ research article publications in journals of repute, 9+ years of teaching experience, trained with cross-disciplinary education, Dr. Basu is a life-long learner and always thrives for new challenges.\r\nHer research area is the design and synthesis of small molecule partial agonists of PPAR-γ in lung cancer. She is also using artificial intelligence and deep learning methods to understand the exosomal miRNA’s role in cancer metastasis. Dr. Basu is the recipient of many awards including the Early Career Research Award from the Department of Science and Technology, Govt. of India. She is a reviewer of many journals like Molecular Biology Reports, Frontiers in Oncology, RSC Advances, PLOS ONE, Journal of Biomolecular Structure & Dynamics, Journal of Molecular Graphics and Modelling, etc. She has edited and authored/co-authored 21 journal papers, 3 book chapters, and 15 abstracts. She is a Board of Studies member at her university. She is a life member of 'The Cytometry Society”-in India and 'All India Cell Biology Society”- in India.",institutionString:"Dr. D.Y. Patil Vidyapeeth, Pune",institution:{name:"Dr. D.Y. Patil Vidyapeeth, Pune",country:{name:"India"}}},{id:"354817",title:"Dr.",name:"Anubhab",middleName:null,surname:"Mukherjee",slug:"anubhab-mukherjee",fullName:"Anubhab Mukherjee",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y0000365PbRQAU/ProfilePicture%202022-04-15%2005%3A11%3A18.480",biography:"A former member of Laboratory of Nanomedicine, Brigham and Women’s Hospital, Harvard University, Boston, USA, Dr. Anubhab Mukherjee is an ardent votary of science who strives to make an impact in the lives of those afflicted with cancer and other chronic/acute ailments. He completed his Ph.D. from CSIR-Indian Institute of Chemical Technology, Hyderabad, India, having been skilled with RNAi, liposomal drug delivery, preclinical cell and animal studies. He pursued post-doctoral research at College of Pharmacy, Health Science Center, Texas A & M University and was involved in another postdoctoral research at Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Santa Monica, California. In 2015, he worked in Harvard-MIT Health Sciences & Technology as a visiting scientist. He has substantial experience in nanotechnology-based formulation development and successfully served various Indian organizations to develop pharmaceuticals and nutraceutical products. He is an inventor in many US patents and an author in many peer-reviewed articles, book chapters and books published in various media of international repute. Dr. Mukherjee is currently serving as Principal Scientist, R&D at Esperer Onco Nutrition (EON) Pvt. Ltd. and heads the Hyderabad R&D center of the organization.",institutionString:"Esperer Onco Nutrition Pvt Ltd.",institution:null},{id:"319365",title:"Assistant Prof.",name:"Manash K.",middleName:null,surname:"Paul",slug:"manash-k.-paul",fullName:"Manash K. Paul",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/319365/images/system/319365.png",biography:"Manash K. Paul is a scientist and Principal Investigator at the University of California Los Angeles. He has contributed significantly to the fields of stem cell biology, regenerative medicine, and lung cancer. His research focuses on various signaling processes involved in maintaining stem cell homeostasis during the injury-repair process, deciphering the lung stem cell niche, pulmonary disease modeling, immuno-oncology, and drug discovery. He is currently investigating the role of extracellular vesicles in premalignant lung cell migration and detecting the metastatic phenotype of lung cancer via artificial intelligence-based analyses of exosomal Raman signatures. Dr. Paul also works on spatial multiplex immunofluorescence-based tissue mapping to understand the immune repertoire in lung cancer. Dr. Paul has published in more than sixty-five peer-reviewed international journals and is highly cited. He is the recipient of many awards, including the UCLA Vice Chancellor’s award and the 2022 AAISCR-R Vijayalaxmi Award for Innovative Cancer Research. He is a senior member of the Institute of Electrical and Electronics Engineers (IEEE) and an editorial board member for several international journals.",institutionString:"University of California Los Angeles",institution:{name:"University of California Los Angeles",country:{name:"United States of America"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/219081/images/system/219081.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals. He is currently working on the protective activity of phenolic compounds in disorders associated with oxidative stress and inflammation.",institutionString:null,institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Dr.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. 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