IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\\n\\n
IntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
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Designed to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
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After a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
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Our innovative Book Series format brings you:
\n\n
\n\t
Topic Focused Publications - Each topic showcases high impact subject areas
\n\t
Renowned Editorial Expertise - Series Editors, Topic Editors, and a team of international Board Members that permanently support each Book Series
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Fast Publishing - quick turnaround which is unique for book publishing
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The benefit of ISSN and ISBN for increased citation and indexing possibilities
\n
\n\n\n\n
IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\n
IntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
We invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
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Note: Edited in October 2021
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1. Introduction
During the childhood years and into adolescence, the brain grows tremendously, causing a significant change in cognitive capacities. In later years of childhood and adolescence, many of the neurological changes correspond with advancements in perspective taking and reasoning; however, evidence from the early childhood years suggests that these changes more closely align with advancements in inhibitory control and executive functions more broadly [1, 2]. However, there are distinct developmental changes which inform our understanding of inhibitory control and which merit further discussion. Regardless, these developmental changes have profound impacts on children’s development overall, including academic and social outcomes. It is important to recognize, however, that children’s capacities to inhibit a prepotent response have been shown to vary by culture, as well as exposure to early adverse life events, and therefore a consideration of environment should be included when attempting to conduct research in this area or when making important policy or curriculum decisions. Nevertheless, research which utilizes inhibitory control (IC) training specifically within the early childhood ages demonstrates positive results, with more intensive training yielding more promising results.
2. Nature of inhibitory control during the early childhood years
Research has consistently demonstrated that the preschool years are a developmental time during which children experience profound growth in their ability to inhibit an unwanted response [3]. Younger preschool-age children are more likely to perseverate in their errors across multiple trials [4] by repeating a maladaptive behavior—for instance, a child who continues to shout out in class instead of raising their hand—whereas this pattern declines markedly by age 4. Similarly, 3-year-old children demonstrate an ability to inhibit an automatic prepotent response on a Simon Says task (e.g., Go/NoGo task [5]: children are trained to respond to one stimulus and are trained not to respond to a similar stimulus; see Table 1) for roughly one in four trials, in comparison to 4-year-old children who were successful on roughly 9 out of 10 trials [6]. Moreover, the impacts of inhibitory control on children’s cognitive capacities also seem to change as a function of age. For instance, younger preschool-age children’s inhibitory control capacities strongly predict their problem-solving strategy use and performance; however, older preschool-age children’s problem solving is better explained by their working memory capacities (see Table 1) rather than their inhibitory control abilities [7]. Relatedly, the development patterns of IC growth may not be limited to simply greater accuracy on relatively straightforward tasks. Older preschool-age children perform with greater success on more complicated tasks of IC than their younger peers [1], which may indicate that using multiple, progressive tasks when assessing IC may reveal important developmental patterns not captured by using a single task or by using multiple similar tasks. Overall, the findings on early childhood IC show robust and dramatic growth, particularly during the childhood years.
Key terms
Definitions
Executive functions (EF)
The constellation of foundation cognitive capacities, such as inhibitory control, working memory, and attention, which allow for later emergence of reasoning and problem solving
Inhibitory control (IC)
The cognitive capacity to inhibit a prepotent, automatic behavioral response
Working memory
A cognitive system for temporarily storing and managing information that is necessary for undertaking complex cognitive tasks
Theory of mind (ToM)
The understanding that others have mental states such as beliefs, desires, etc., which can vary from person to person or within one person over time
Go/NoGo task
Children are trained to respond to one stimulus (e.g., “Go” stimuli) and are trained not to respond to a similar stimulus (“NoGo” stimuli). This task measures behavioral inhibition
Day/Night Stroop task
Children are trained and must complete trials in which they say the word “night” when presented with an image of a sun on a white background and say “day” when presented with an image of a moon on a dark background. This task involves both behavioral inhibition and cognitive interference
Cognitive interference/interference control
It refers to attempts to suppress interference from competing stimuli. The response time of an IC task is usually considered as a measure of cognitive interference
Behavioral inhibition
It requires suppressing a behavioral response for a more optimal response. Cognitive interference and behavioral inhibition are two aspects of IC
Electroencephalogram (EEG)
A neurological testing that allows researchers to precisely measure brain activity during the behavioral tasks, which provides for a more complete examination and consideration of IC as a cognitive capacity
Inhibitory control training
A designed intervention that includes a training process which aimed at improving IC
Table 1.
A summary of definitions of the major concepts and techniques.
Although researchers agree on the tremendous growth of IC during this developmental age, there persists disagreement as to the specific nature of IC, and executive functions, during this time. Executive functions (EF) refer to the constellation of foundational cognitive capacities, such as inhibitory control, working memory, and attention [1], which allow for later emergence of reasoning and problem solving. In middle childhood and beyond, these executive function capacities can be considered as increasingly discrete processing mechanisms; however, during early childhood, these patterns remain more nebulous, and studies using confirmatory factor analysis have shown developmental differences in factor emergence and persistent factor unification into the childhood years. For instance, during the preschool years (broadly, ages 3 years to 6 years), studies using multiple assessments of inhibitory control, attention, and working memory yield a single unitary construct of executive function or inhibition generally [8, 9, 10, 11, 12], whereas studies of middle childhood have discerned multiple discrete factors, including working memory and attention shifting [13], and this trend continues and expands into later childhood and adolescence (see [14]).
The prevailing argument is that tasks of IC during the early childhood years necessitate activation of multiple other components of EF. take, for instance, the Day/Night Stroop task (see [15]; Table 1) in which a child is trained and must complete trials in which they say the word “night” when presented with an image of a sun on a white background and say “day” when presented with an image of a moon on a dark background. In this task, IC is typically measured by accuracy, with measurements of response time frequently included as well. This task clearly requires the child to inhibit the automatic response of verbalizing the association they have made between the sun and it being daytime, or between the moon being present during nighttime, and thus is inarguably a task of IC. However, some argue that this task measures additional facets of EF simply by the nature of the task. For instance, a child must have sustained attention throughout the assessment, and if the child loses focus for even a moment, the measurement of response time could be conflated, leading some scholars to argue that the attentional component of EF predicts IC [3, 16]. Similarly, the child must work to keep the rules of the moon/day and sun/night matching in the forefront of their mind during the assessment, and if they do not, then the accuracy measure could be conflated with working memory. Many researchers have argued, therefore, that the various EF components are highly integrated during the early childhood years and that these components emerge as more distinct with age and experience [1, 14].
As shown by the previous example, it is difficult for researchers to disentangle the various components of EF, from a measurement perspective, in early childhood. Researchers’ understanding and measurement of inhibitory control during the early childhood years should therefore be sensitive to the developmental nature of such phenomena and should perhaps consider using indices of a variety of executive function capacities. However, as described previously [14], a common conceptualization of EF in the early childhood literature seems to imply that EF and IC are analogous at this development time (e.g., [17]) or that IC developmentally precedes other domains of EF (e.g., [16]). Although IC contributes largely to early childhood EF, as demonstrated in the previous example, it may be problematic to consider these as synonymous. One argument in support of this claim is that children’s task performance on EF tasks most closely replicates issues of IC—that is, a child will persist in making prepotent errors, a classic demonstration of immature IC, while also activating other areas of EF, such as attention, working memory, etc. Although several arguments have been proposed to counter the position of equivocating EF with IC, most pertinent to the current chapter may be that IC itself may be multidimensional. Referring again to the aforementioned example, many researchers consider response time in the Day-Night Stroop task to be a measure of cognitive interference (sometimes referred to as interference control), which refers to attempts to suppress interference from competing stimuli, in contrast to behavioral inhibition which requires suppressing a behavioral response for a more optimal response [18, 19]. That is, the construct of inhibitory control as it pertains to developmental changes during the early childhood years requires both the cognitive power to limit attention to distractor stimuli and the behavioral power to engage an appropriate response.
Turning to developing an appreciation for the role of IC for holistic development, the capacity for IC has important implications in terms of development across a number of domains [20]. For instance, although IC has been shown to predict children’s academic achievement generally throughout the childhood years [21], strong IC consistently predicts more proficient mathematical knowledge [16, 22, 23, 24] and numerical strategy use [25]. Moreover, IC has been implicated in children’s emergent literacy proficiency [16, 24] and language development [26]. The development of IC during the early childhood years additionally has profound implications for children’s social and emotional development [27], such as the emergence and development of social perspective taking [28], problem solving and emotional control [27], and suppressing disruptive behaviors and aggression [11]. As such, IC should be considered by researchers and practitioners alike for the implications this capacity may hold across areas of maladaptive academic and social development.
Research methodologies employed for assessing IC during the early childhood years can vary considerably, and each assessment offers a wealth of strengths yet, as mentioned previously, may be incomplete on its own. Therefore, much of the research studies in this area use more than one type of assessment or multiple assessments with considerable methodological overlap. An important consideration in measurement of IC, indeed of any cognitive faculty, during the early childhood years is the developmental appropriateness of the task (see [8], for review). For instance, children in this age range are often concurrently experiencing emerging literacy skills and are often not yet proficient readers; therefore, it would be inappropriate to use a task which requires even low reading requirements, as such a task would likely require a cognitive load too great to allow for successful task completion. Moreover, such a task when used with an emerging reader would result in contaminated measurement in that task performance may indicate a lack of understanding the rules of the task, the lack of proficiency in reading, or inhibitory control. Similarly, tasks to be used on a study of early childhood should be rather straightforward, without overly complicated instructions or numerous steps. Therefore, much of the research studies in the area of inhibitory control that focus on early child development utilize tasks or games which require no reading, with simple instructions provided to the child verbally and repeated if necessary, and these tasks typically include a generous training time to ensure that the child understands and can perform the task.
Many of the commonly employed tasks resemble that of the Day/Night Stroop task [15, 29] and the Go/NoGo task [1, 5, 19, 30], both of which were described in the previous paragraphs. Importantly, these two tasks differ in terms of cognitive interference with regard to the expectations for children’s behavioral responses. Specifically, the Day/Night Stroop task involves embedded rule use, thus requires children to produce a verbal response to multiple stimuli, and therefore requires that the children process and act on multiple rules (i.e., if moon, then “day,” but if sun, then “night”), whereas the Go/NoGo task only requires a behavioral response to a single stimulus (e.g., if “Simon Says,” then response; if not, then no response). This distinction has led some to argue that the Day/Night Stroop task may be more complex particularly for younger children than other tasks, and therefore performance on this and similar tasks may be indicative of greater IC capacities compared with Go/NoGo tasks (see, e.g., [31, 32]).
Consistent with the recommendation noted previously regarding the need to use multiple indices of IC when attempting to correctly assess children’s capacities, many researchers employ the use of neurological testing, such as an electroencephalogram (EEG), in concert with a behavioral task, such as the Go/NoGo task (e.g., [30]). Using neurological measurement, such as EEG, allows researchers to precisely measure brain activity during the behavioral tasks, which provides for a more complete examination and consideration of IC as a cognitive capacity particularly from a developmental perspective. That is, as the brain is experiencing tremendous growth during the early childhood years, it is important to capture how such physical growth corresponds with cognitive growth, and this is perhaps best done by measuring neural activity during a cognitive task.
Overall, EF generally, and inhibitory control specifically, undergoes dramatic growth during the preschool years, which has important implications for their development overall [1, 2]. Although EF is discernable as more discrete constructs in later ages of development, this has not been consistently demonstrated during the early childhood years [8, 9, 10, 11, 12], and thus researchers should consider possibly utilizing multiple tasks, including neurological assessments if possible [30], to provide a more comprehensive understanding of IC during the early childhood years.
2.1 Impacts of culture and environment on young children’s inhibitory control development
Consistent with other cross-cultural research which shows variation in the timing and emergence of children’s cognitive capacities (e.g., [33]), evidence of IC development from non-Western societies is not entirely consistent with that of Western societies, suggesting that children’s inhibitory control may be impacted by cultural and environmental factors [34]. For instance, a variety of studies comparing Chinese samples to Western samples may suggest that preschool-age children reared in Chinese cultures outperform their US counterparts on tasks of IC [34, 35], which has also been found in other non-Western cultures (e.g., Japan [36]). Importantly, comparing samples of non-Western cultures from African and Latin American communities [37] as well as cultures which share both Western and Eastern ideals (i.e., Turkey [38]) to Western has not yielded differences by culture. Overall, the cross-cultural research on IC development in early childhood may indicate that although there is a large universality in terms of IC development, cultural and societal mores may cause differences in children’s IC and development more broadly.
Moreover, in terms of implications of the cross-cultural research for child development more broadly, in Western cultures IC has been consistently shown to predict theory of mind (i.e., the understanding that others have mental states such as beliefs, desires, etc., which can vary from person to person or within one person over time [39]) particularly during the early childhood years [31], which holds implications for children’s social competence during early childhood and beyond; however, this predictive relation between IC and theory of mind has not consistently been demonstrated in cross-cultural samples to the same degree as in Western samples [40]. For example, a recent meta-analysis discussed that although IC and EF generally did predict theory of mind and mental state understanding across cultures, the strength of this prediction was weaker among studies assessing East Asian samples than several Western samples, including the USA, Canada, and Europe [31].
Other environmental factors, such as exposure to poverty or low socioeconomic opportunity, have also been shown to impact children’s cognitive development, including the development of EF during the early childhood years, with children from low-income families generally underperforming their more affluent peers [41, 42]; however, the recent work has turned to focus on the adaptive strengths of children raised in environments with higher rates of adversity [43]. For example, although children from low-income families have demonstrated less accuracy on a Go/NoGo task, they did not perform more slowly on the task [44]. Moreover, children from low-income families performed less accurately on a simple working memory task than with peers, but these group differences were eliminated when the task was made to be more complex [44]. A similar finding has been shown for children who have experienced familial trauma, and this may be true even when considering the impacts of poverty exposure. Children who have been reported as experiencing family trauma, as assessed by indices of post-traumatic stress disorder (PTSD), showed poorer global EF than non-traumatized children [45]; however, the effect size was weaker for IC task performance than other types of EF, such as working memory and processing speed. This may suggest that children who experience familial trauma may develop adaptive responses to their environments which allow them to inhibit prepotent responses as indicated by the IC task performance.
Similar to the pattern of IC mediating the impact of culture on early childhood competence, it may be that environmental exposure to poverty and adversity may additionally impact other areas of children’s development. Academic achievement and behavioral regulatory faculties are more strongly predicted by IC task performance for children from more affluent family backgrounds, for example, than their less affluent peers [46]. Additionally, among children attending a federally funded educational program for low-income families and their children, children with stronger IC performance were rated by their teachers as having better socio-emotional faculties and showed fewer internalizing behaviors (e.g., indications of anxiety and depression) than their low-income peers who performed less well on IC tasks [47, 48]. Children who experience other types of environmental adversity, such as children who experience violence or maltreatment at home, show similar patterns of poorer academic achievement and school adjustment, yet this relation is additionally explained by children’s IC [49]. In sum, although children who experience adverse early life events, or are raised in low-income families and neighborhoods, have shown to differ from more traditional samples in terms of academic achievement and socio-emotional competencies, these discrepancies may be explained by young children’s emerging IC faculties. Therefore, these children may show marked improvements in EF capacities, as well as other positive outcomes such as improved academic achievement, with IC training.
2.2 Inhibitory control training in early childhood and implications for development
Efforts in establishing inhibitory control as an effective tool for cognitive improvements have proven successful across the life span [50]. Moreover, as the early childhood years are an important time for the development of EF generally, and IC specifically, as previously discussed, this developmental age range is ideal for examining the possible power of IC training. Several studies have examined the impacts of IC training on child outcomes, and these studies consistently yield positive findings [19, 21, 50, 51, 52, 53, 54, 55, 56].
Importantly, the outcomes of IC training have been shown to vary considerably based on the types of training. Studies have shown, for example, the training of more global EF capacities rather than IC specifically (e.g., [53, 55]) may be successful in expanding cognitive performance across a wide range of tasks. This aligns with the aforementioned discussion of the entanglement of multiple components of EF during early childhood (i.e., that many factor analytic studies have shown that in the early childhood years the distinct components of EF, such as working memory and IC, may not be as separately discernable as evidenced during the later years of development [8, 9, 10, 11, 12]). To test this, some researchers have attempted to gauge the effectiveness of IC training compared with training in other areas of EF, such as working memory; for instance, children who received 5 weeks of computerized IC training, compared with a group who received a parallel program of working memory training, showed improvements in task performance for the task on which they received training; however these improvements did not transfer to other tasks of EF [55]. Limited transfer effects have been reported elsewhere as well, such as children showing increased performance on methodologically and structurally similar tasks as to the training task, but not other tasks [51], although this increase in performance was sustained over many months. However, other research has shown considerable transfer effects, such as children showing enhanced reasoning abilities after training on a Go/NoGo task [19] and children, adolescents, and adults showing enhanced perspective-taking capacities after receiving IC training [50].
Other types of training have also shown to be successful in improving EF performance. Having children engage in reflective metacognition regarding their performance on difficult cognitive tasks, such as their performance in the Day/Night Stroop task, has shown to be effective in enhancing their performance on that task even compared with more traditional training procedures, such as practice and corrective feedback [54]. Additionally, training on language skills can have a positive impact on children’s IC, as such trainings require engaging in multiple components of EF (e.g., sustained attention), as well as IC specifically [57] such as by requiring the child to use the correct term for a specific item within a larger category of items. This aligns with the espoused conceptualization of early childhood IC as profoundly entangled within EF and is consistent with other research on EF trainings more broadly. For instance, children who received 12 sessions over 4 weeks of training that included working memory, IC, and cognitive flexibility showed significant improvements across a range of EF capacities, and these effects transferred to other areas of children’s cognition as well [58].
Additionally, outcomes of IC training may yield important changes at the level of neuronal and brain activity [54], which may not necessarily correspond with immediate changes in behavior. For instance, studies have shown that children who received an 8-week program of training which targeted children’s IC, working memory, and planning ability found that, for children who received the training, neural activity levels changed in the corresponding brain regions as expected; however children’s task performance after the training did not differ significantly from their pre-training performance [30]. Other studies have found that a single training session of metacognitive reflection about controlling impulsive behaviors may lead to decreased activation of the brain region responsible for processing conflicting information, which may indicate a lessened likelihood to process the information as conflicting, and therefore possibly indicating better adaptation in integrating new rule schemes [54].
Moreover, the positive impacts of receiving EF training have been found effective for children from low-income families as well. For instance, one study showed that when classrooms serving low-income families implemented a full year of an EF training that included a broad range of EF skills deeply integrated into the classroom curriculum, compared with classrooms that had no such program, children who received the training outperformed children in the control group on both simple and advanced tasks [52]. Indeed, children in the control group showed a decline in task performance for the more advanced tasks, which was not found for children who received the training. What’s more, the program was so successful that the control condition was not allowed to repeat, by request of the school, as the teachers and parents noted such profound change in terms of academics and student behavior that the school refused to continue the project without full implementation of the program in all classrooms. In concert with findings from more traditional samples which included less intensive training, these outcomes would indicate that children from low-income families might be an especially important area for future research, given the overwhelming strength of the results.
Although studies using IC training with children of incarcerated parents, or children who have experienced abuse or neglect, were not revealed during the current literature search, the previously discussed research of IC training during early childhood could be extended to these populations [45]. For instance, research on treatment approaches for anxiety and depression (common outcomes of trauma) with adults has shown that training individuals to develop better self-regulatory executive processes, such as attention, have shown promising results (see [45] for discussion). Given that children’s EF faculties are more nebulous and entangled than adults, it stands to reason that such approaches would yield additionally promising results during the early childhood years.
Moreover, such intervention approaches might be promising for researchers working in clinical settings. For instance, mindfulness training approaches that capitalize on EF processes, such as attentional focus, for children with anxiety have proven effective in reducing anxiety symptomology [59]. Such training has proven effective for children from low-income families as well [60], with positive effects extending beyond advanced EF development to include positive socio-emotional and behavioral changes as well. However, much of the research in this area has been conducted with older children, and examinations of the promise of mindfulness training during the early childhood years may not yet exist. This may be an important area for future research, as the implications for positive outcomes may be more robust with earlier intervention.
Overall, findings with regard to improving child outcomes during the early childhood years as they relate to IC training suggest that IC training may be effective to varying degrees. Although a few studies showed limited transfer effects, the most promising findings come from studies which implemented a broader EF training program rather than those which utilized specific IC training. Additionally, research studies with longer training programs, such as the 1-year program discussed above, yield stronger effects in terms of global child outcomes than did shorter programs. Studies involving brain imaging have also shown positive outcomes in terms of changes in brain activity, indicating that such training may be important for effecting long-term change.
3. Conclusions
The cognitive capacity to inhibit a prepotent, automatic response grows tremendously during the early childhood years corresponding with and as a function of profound brain development taking place at this time [1, 2]. At later ages, this cognitive ability is rather distinct from other foundational cognitive capacities, such as attention and working memory; however, considerable research suggests that during early childhood these distinctions are less clear, leading many researchers to consider and research EF as a more global function at this age [8, 9, 10, 11, 12, 13, 14].
Research which focuses on IC during the early childhood years typically utilizes simple, game-like tasks which require brief or no verbal response, and researchers typically utilize a variety of tasks which may assess various areas of EF, including the Day/Night Stroop task [15, 29] and the Go/NoGo task [1, 5, 19, 30]. Importantly, and with regard for the important growth occurring at this age in specific brain regions, many researchers use these tasks in combination with brain imaging [30], providing important insights into developmental changes taking place in brain and neuronal activity.
Importantly, the current chapter includes much literature on EF broadly rather than focusing specifically on IC and IC training. Although this is consistent with the current conceptualization of IC during this developmental time within the literature, this may have resulted in certain findings and trainings being included in the current discussion with which some researchers may disagree. Additionally, the current chapter focuses narrowly on a specific developmental window and thus is not representative of the research on IC across childhood.
For transparency, the literature review for the current chapter used the following databases: Google Scholar, ScienceDirect, and Web of Science. The keywords were executive function, inhibitory control (training), working memory, sustained attention, cognitive development, self-regulation, preschoolers, early childhood, children, cross-cultural, and risk population. Specifically, inhibitory control is a broad term in the research procedure, which has been expanded and is not limited to the executive function and cognitive development [61]. For ease of understanding, an at-risk population was defined as any potential risk factors (i.e., poverty or low income, neighborhood violence, family violence, family maltreatment, low social status, low education background, rural area). However, and as is the case with many reviews, the current chapter does not include findings from unpublished works, and thus the positive support for IC training as discussed here may be an artifact of publication bias.
Nevertheless, in creating IC training programs, much of the research has shown positive outcomes across a variety of training programs; however, as is to be expected, more promising and profound results accompany programs with more intensive training with longer durations [50, 51, 52, 53, 54, 55, 56, 57, 58]. Such training programs have proven effective across cultures and changes in the environment [52], including children from low-income backgrounds and children who have experienced profound early adverse life events. Although little research to date has examined IC training during early childhood in clinical samples, extending from the work discussed in this chapter, it would follow that IC training broadly, and perhaps mindfulness training specifically, may yield positive outcomes across domains.
Conflict of interest
The authors declare there is no conflict of interest.
\n',keywords:"early childhood, executive function, cross-cultural, low-income",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/69720.pdf",chapterXML:"https://mts.intechopen.com/source/xml/69720.xml",downloadPdfUrl:"/chapter/pdf-download/69720",previewPdfUrl:"/chapter/pdf-preview/69720",totalDownloads:904,totalViews:0,totalCrossrefCites:1,totalDimensionsCites:3,totalAltmetricsMentions:0,introChapter:null,impactScore:1,impactScorePercentile:67,impactScoreQuartile:3,hasAltmetrics:0,dateSubmitted:"April 8th 2019",dateReviewed:"July 19th 2019",datePrePublished:"October 24th 2019",datePublished:"April 22nd 2020",dateFinished:"October 24th 2019",readingETA:"0",abstract:"Young children’s capacity to monitor and control their thoughts and behaviors is influenced largely by inhibitory control, which grows rapidly during this age due to brain maturation. This capacity has important implications for children’s development, including academic and social outcomes, and has been shown to be influenced by culture and exposure to adverse life events such as poverty. Research suggests that this capacity, importantly, may be largely trainable, with appropriate training programs.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/69720",risUrl:"/chapter/ris/69720",book:{id:"8938",slug:"inhibitory-control-training-a-multidisciplinary-approach"},signatures:"Erin Ruth Baker, Qingyang Liu and Rong Huang",authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Nature of inhibitory control during the early childhood years",level:"1"},{id:"sec_2_2",title:"2.1 Impacts of culture and environment on young children’s inhibitory control development",level:"2"},{id:"sec_3_2",title:"2.2 Inhibitory control training in early childhood and implications for development",level:"2"},{id:"sec_5",title:"3. 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Brain Research. 2006;1110(1):166-174'},{id:"B42",body:'Molzhon A. Exploring the influence of socioeconomic status on the executive function and theory of mind skills of preschoolers [dissertation]. Richmond, VA: Virginia Commonwealth University; 2016'},{id:"B43",body:'Ellis BJ. Toward an adaptation-based approach to resilience. In: The Biology of Early Life Stress. Berlin: Springer; 2018. pp. 31-43'},{id:"B44",body:'St. John AM, Kibbe M, Tarullo AR. A systematic assessment of socioeconomic status and executive functioning in early childhood. Journal of Experimental Child Psychology. 2019;178:352-368'},{id:"B45",body:'DePrince AP, Weinzierl KM, Combs MD. Executive function performance and trauma exposure in a community sample of children. Child Abuse and Neglect. 2009;33(6):353-361'},{id:"B46",body:'Duncan RJ, McClelland MM, Acock AC. Relations between executive function, behavioral regulation, and achievement: Moderation by family income. Journal of Applied Developmental Psychology. 2017;49:21-30'},{id:"B47",body:'Liew J, Chen Q , Hughes JN. Child effortful control, teacher–student relationships, and achievement in academically at-risk children: Additive and interactive effects. Early Child Research Quarterly. 2010;25(1):51-64'},{id:"B48",body:'Rhoades BL, Greenberg MT, Domitrovich CE. The contribution of inhibitory control to preschoolers’ social–emotional competence. Journal of Applied Developmental Psychology. 2009;30(3):310-320'},{id:"B49",body:'Pears KC, Fisher PA, Bruce J, Kim HK, Yoerger K. Early elementary school adjustment of maltreated children in foster care: The roles of inhibitory control and caregiver involvement. Child Development. 2010;81(5):1550-1564'},{id:"B50",body:'Karbach J, Kray J. How useful is executive control training? Age differences in near and far transfer of task-switching training. Developmental Science. 2009;12(6):978-990'},{id:"B51",body:'Blakey E, Carroll DJ. A short executive function training program improves preschoolers’ working memory. Frontiers in Psychology. 2015;6:1827'},{id:"B52",body:'Diamond A, Barnett WS, Thomas J, Munro S. Preschool program improves cognitive control. Science. 2007;318(5855):1387-1388'},{id:"B53",body:'Dowsett SM, Livesey DJ. The development of inhibitory control in preschool children: Effects of “executive skills” training. Developmental Psychobiology: The Journal of the International Society for Developmental Psychobiology. 2000;36(2):161-174'},{id:"B54",body:'Espinet SD, Anderson JE, Zelazo PD. N2 amplitude as a neural marker of executive function in young children: an ERP study of children who switch versus perseverate on the dimensional change card sort. Developmental Cognitive Neuroscience. 2012;2:S49-S58'},{id:"B55",body:'Thorell LB, Lindqvist S, Bergman Nutley S, Bohlin G, Klingberg T. Training and transfer effects of executive functions in preschool children. Developmental Science. 2009;12(1):106-113'},{id:"B56",body:'Viterbori P, Usai MC, Traverso L, De Franchis V. How preschool executive functioning predicts several aspects of math achievement in Grades 1 and 3: A longitudinal study. Journal of Experimental Child Psychology. 2015;140:38-55'},{id:"B57",body:'Kray J, Ferdinand NK. How to improve cognitive control in development during childhood: potentials and limits of cognitive interventions. Child Development Perspectives. 2013;7(2):121-125'},{id:"B58",body:'Traverso L, Viterbori P, Usai MC. Improving executive function in childhood: evaluation of a training intervention for 5-year-old children. Frontiers in Psychology. 2015;6:525'},{id:"B59",body:'Semple RJ, Reid EF, Miller L. Treating anxiety with mindfulness: An open trial of mindfulness training for anxious children. Journal of Cognitive Psychotherapy. 2005;19(4):379'},{id:"B60",body:'Semple RJ, Lee J, Rosa D, Miller LF. A randomized trial of mindfulness-based cognitive therapy for children: Promoting mindful attention to enhance social-emotional resiliency in children. Journal of Child and Family Studies. 2010;19(2):218-229'},{id:"B61",body:'Beveridge M, Jarrold C, Pettit E. An experimental approach to executive fingerprinting in young children. Infant and Child Development: An International Journal of Research and Practice. 2002;11(2):107-123'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Erin Ruth Baker",address:"erbaker@albany.edu",affiliation:'
University at Albany, State University of New York, Albany, NY, United States
University at Albany, State University of New York, Albany, NY, United States
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\n
1. Introduction
\n
Aortic stenosis is the most frequent valve disease leading to intervention in developed countries, either surgery or catheter, and its incidence increases due to the aging population [1].
\n
The management of aortic stenosis has improved and evolved to a reduction in surgical aggression. Nowadays, the patients with intermediate risk are in the frontier of transcatheter aortic valve implantation (TAVI) and aortic valve replacement (AVR) and more than ever, the heart team has to be more accurate to choose between the different treatment options available, making the decision pathway more complex than a few year before. Our goal is to update the treatment of severe aortic stenosis in those patients where risk assessment scales indicate an intermediate risk. Here, we analyze the current treatment options and their results.
\n
\n
\n
2. Etiology and natural history
\n
Nowadays, degenerative calcific AS is the most common cause of AS in adults at older ages and represents the leading cause for aortic valve intervention [2, 3, 4]. In the other hand, bicuspid aortic valve affects 2% of the population and represents the most common indication for intervention at younger patients [5].
\n
The development of symptoms identifies a paramount point in the natural history of AS, and the interval from the onset of symptoms to the time of death is approximately 2 years in patients with heart failure, 3 years in those with syncope, and 5 years in those with angina, with a high risk of sudden death [6].
\n
\n
\n
3. Evaluation and severity classification of aortic stenosis
\n
Careful exploration for the presence of symptoms (shortness of breath on exertion, angina, dizziness, or syncope) is very important for right patient management. The characteristic systolic murmur draws attention and guides further diagnostic work in the right direction.
\n
Echocardiography is the key diagnostic tool [7]. It discriminates the degree of valve calcification, LV function, and wall thickness; helps to identify other associated valve diseases or aortic pathology; and provides prognostic information. The severity of the stenotic lesion can be defined with Doppler echocardiographic measurements. Transoesophageal echocardiography (TOE) provides additional evaluation of concomitant mitral valve abnormalities, and become useful when transthoracic visualization is poor [8]. TOE has gained importance in the assessment and intraprocedure guidance and after TAVI or surgical interventions.
\n
Three-dimensional TOE offers a more detailed examination of valve anatomy than two-dimensional echocardiography and is useful for the assessment and planning of complex valve problems [8]. AS severity could be graded on the basis of a variety of hemodynamic and natural history data as shown in Table 1.
\n
\n
\n
\n\n
\n
Peak velocity (m/s)
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≥4
\n
\n
\n
Mean gradient (mmHg)
\n
≥40
\n
\n
\n
Indexed AVA (cm2/m2)
\n
<0.6
\n
\n
\n
AVA (cm2)
\n
<1
\n
\n
\n
Velocity ratio
\n
<0.25
\n
\n\n
Table 1.
Severe aortic stenosis measurement by echocardiography. The definitions apply only in the presence of normal flow conditions.
Based on the recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography [9].
\n
Multislice computed tomography (MSCT) and cardiac magnetic resonance (CMR) give additional data on the assessment of the ascending aorta when it is enlarged or to quantifying the valve area, coronary calcification, size and shape of the aortic valve annulus, and its distance to the coronary ostia, which aids in evaluation and prognosis. It is essential to evaluate the feasibility of the various access routes for TAVI, as this provides information on minimal luminal diameters, atherosclerotic plaque burden, the presence of aneurysms or thrombi, etc. [8]. MSCT plays an important role in the diagnostic work-up before transcatheter aortic valve implantation. The risk of radiation exposure—and of renal failure due to contrast injection—should, however, be taken into consideration.
\n
In patients with inadequate echocardiographic quality or discrepant results, CMR should be used to assess the severity of valvular lesions and to assess ventricular volumes and systolic function [8].
\n
In physically active patients, an exercise testing could be recommended for unmasking symptoms and for risk stratification of asymptomatic patients [10]. Also, exercise stress echocardiography may give prognostic information in asymptomatic severe aortic stenosis [10, 11]. In some patients, it may be necessary to proceed with cardiac catheterization and coronary angiography at the time of initial evaluation [7].
\n
Biomarkers. Several studies [12, 13, 14, 15] report that biomarkers such as B-type natriuretic peptide (BNP) have been shown to be related to functional class and prognosis, particularly in AS and MR. Natriuretic peptides have been shown to predict symptom-free survival and outcome in normal- and low-flow severe AS and may be useful in asymptomatic patients, helping to discriminate those patients who can benefit from an early intervention [13, 14, 15]. In fact, in the last ESC/EACTS guidelines for the management of valvular heart disease, natriuretic peptides may be of value for risk stratification and timing of intervention, particularly in asymptomatic patients (“markedly elevated BNP levels (>threefold age- and sex-corrected normal range) confirmed by repeated measurements without other explanations”) [8].
\n
\n
\n
4. Indications for intervention
\n
Here, we have to take notice of the patient’s status in order to choose the type of intervention and the correct timing of it. Early valve intervention should be strongly recommended in all symptomatic patients with severe AS, because it is the only effective treatment. “As long as the mean gradient remains >40 mmHg, there is virtually no lower ejection fraction limit for intervention, whether surgery or TAVI” [8].
\n
However, patients with severe comorbidities indicating a survival of <1 year and patients in whom is unlikely that the intervention will improve quality of life or survival should be excluded from further interventions.
\n
Asymptomatic patients. There is some disagreement about the optimal timing of surgery in asymptomatic patients, and the decision to operate on this kind of patient requires careful weighing of the benefits against the risks.
\n
The available studies do not provide convincing data to support the general recommendation of early SAVR, even in patients with asymptomatic and very severe aortic stenosis, and TAVI is not recommended in asymptomatic patients [7, 8]. However, subclinical adverse remodeling can precede the development of symptoms and LV dysfunction [16]. Musa et al. performed cardiac magnetic resonance (CMR) in 674 patients who had severe AS and were scheduled for surgical or transcatheter AVR. Myocardial fibrosis (scar) demonstrated by late gadolinium enhancement (LGE) on CMR was common (51%). In a median follow-up of 3.6 years (interquartile range, 2.6–5.9 years), 21.5% of patients had died. In multivariable analysis, scar (LGE positivity) was independently associated with all-cause and cardiovascular mortality (hazard ratios, 2.39 and 3.14, respectively). The elevated mortality was independent of whether the patients underwent surgical or transcatheter AVR and was similar in patients with infarct and noninfarct scar patterns. These findings raise the possibility that adverse remodeling has irreversible effects before symptoms develop: We may be waiting too long to treat these patients. The authors suggest that physicians might use scar burden to optimize the timing of intervention, a hypothesis currently being evaluated in a randomized trial (EVOLVED-AS) [16].
\n
Early elective surgery is indicated in asymptomatic patients with [8]:
depressed LV function not due to other causes and in patients who develop symptoms during exercise testing
abnormal exercise test showing symptoms on exercise clearly related to aortic stenosis
abnormal exercise test showing a decrease in blood pressure below baseline
predictors of symptom development and adverse outcomes: clinical characteristics (older age, presence of atherosclerotic risk factors), echocardiographic parameters (valve calcification, peak aortic jet velocity, LVEF, rate of hemodynamic progression, increase in mean gradient >20 mmHg with exercise, excessive LV hypertrophy, abnormal longitudinal LV function, and pulmonary hypertension), and biomarkers (>threefold age- and sex-corrected normal range).
When early elective surgery is considered in patients with normal exercise performance because of the presence of such outcome predictors, the operative risk should be low. In patients without predictive factors, watchful waiting appears safe and early surgery is unlikely to be beneficial.
\n
An update of proposed management strategy for patients with severe AS by Leal et al. [17] is shown in Figure 1, based on the ESC/EACTS and ACC/ AHA guidelines on the management of valvular heart disease [8, 18].
\n
Figure 1.
Management of severe aortic stenosis [8, 17, 18]. ACC/AHA recommendations have been shown in parentheses.
\n
\n
\n
5. Risk stratification
\n
Risk stratification applies to any sort of intervention and is required for weighing the risk of intervention against the expected natural history of VHD as a basis for decision making [8]. Nowadays, the STS score and logistic EuroSCORE II are the most commonly used. The EuroSCORE I overestimates operative mortality and its calibration of risk is poor, and it should no longer be used to guide decision making, but it has been used in many TAVI studies/registries and may still be useful to identify the subgroups of patients for decision between intervention modalities and to predict 1-year mortality [8]. The EuroSCORE II and the Society of Thoracic Surgeons (STS) scores more accurately discriminate high- and low-risk surgical patients and show better calibration to predict postoperative outcome after valvular surgery [8]. Current models do not include some risk factors that may be particularly important in the prediction of outcomes, including frailty, pulmonary hypertension (PH), porcelain aorta, and the presence of hepatic dysfunction.
\n
New scores have been developed to estimate the risk of 30-day mortality in patients undergoing TAVI, with better accuracy and discrimination, but not without certain limitations by a lack of consideration of frailty, disability, and cognitive function [19]. Examples of those are: FRANCE-2 risk score [20], the STS/ACC TVT registry predictive model [21], and the TAVR risk score based on data from the German aortic valve registry [22]. A new tool based on the STS/ACC TVT Registry™ is an application for from the STS/ACC TVT Registry™ an application for mobile devices and web, call “TAVR in-hospital mortality Risk app” [23], in order to inform physicians of the estimated risk of in-hospital mortality.
\n
It remains essential not to rely on a single risk score figure when assessing patients or to determine unconditionally the indication and type of intervention.
\n
The role of the heart team is essential to take all of these data into account and adopt a final decision on the best treatment strategy. It is important to take into account patient’s life expectancy, expected quality of life, and patient preference, as well as local resources, in order to do a proper planning of intervention. There is a growing interest in the assessment of frailty, an overall marker of impairment of functional, cognitive, and nutritional status. Frailty is associated with increased morbidity and mortality after surgery and TAVI [24].
\n
Finally, the patient and family should be thoroughly informed and assisted in their decision on the best treatment option.
\n
Actual AHA/ACC guideline classifies patients with severe AS into four global risk categories: [19].
Low risk: STS <4% with no frailty, no comorbidity, and no procedure-specific impediments.
Intermediate risk: STS 4‑8% with no more than mild frailty or one major organ system compromise not to be improved postoperatively and minimal procedure-specific impediments.
High risk: STS >8%, or moderate-severe frailty, no more than two major organ systems compromise not to be improved postoperatively, or a possible procedure-specific impediment.
Prohibitive risk: preoperative risk of mortality and morbidity >50% at 1 year or ≥three major organ systems compromises not to be improved postoperatively or severe frailty or severe procedure-specific impediments.
\n
Thus, the current ESC/EACTS guidelines for the management of valvular heart disease [8] consider two global risk categories:
Low surgical risk (STS or EuroSCORE II < 4% or logistic EuroSCORE I < 10% and no other risk factors not included in these scores, such as frailty, porcelain aorta, and sequelae of chest radiation).
Increased surgical risk (STS or EuroSCORE II >4% or logistic EuroSCORE I > 10% or other risk factors not included in these scores such as frailty, porcelain aorta, and sequelae of chest radiation).
ESC/EACTS guidelines consider two categories (low and increased surgical risk).
Based on 2017 ACC Expert Consensus Decision Pathway for Transcatheter Aortic Valve Replacement in the Management of Adults with Aortic Stenosis and the 2017 ESC/EACTS Guidelines for the management of valvular heart disease [8, 19, 25].
\n
In conclusion, the decision to proceed with AVR or TAVI requires careful weighing of the potential for improved symptoms and survival and the morbidity and mortality of surgery and should be made by the heart team according to the individual patient characteristics. Checklist for choice of therapeutic intervention option (Table A1) could be consulted and printed from the additional material, in order to provide aspects that should be considered for the individual decision, based on the current recommendation of de ESC/EACTS guidelines.
\n
\n
\n
\n
\n
\n
\n\n
\n
\n
Favor TAVI
\n
Patient
\n
Favor AVR
\n
Patient
\n
\n\n\n
\n
Clinical characteristic
\n
\n
\n
STS/EuroScore II < 4% (EuroScore I < 10%)
\n
\n
\n
+
\n
\n
\n
\n
STS/EuroScore II > 4% (EuroScore I > 10%)
\n
+
\n
\n
\n
\n
\n
\n
Severe comorbidities
\n
+
\n
\n
\n
\n
\n
\n
Age <75 years
\n
\n
\n
+
\n
\n
\n
\n
Age >75 years
\n
+
\n
\n
\n
\n
\n
\n
Previous cardiac surgery
\n
+
\n
\n
\n
\n
\n
\n
Frailty
\n
+
\n
\n
\n
\n
\n
\n
Restricted mobility
\n
+
\n
\n
\n
\n
\n
\n
Suspicion of Endocarditis
\n
\n
\n
+
\n
\n
\n
\n
Anatomical and technical aspects
\n
\n
\n
Favorable access for transfemoral TAVI
\n
+
\n
\n
\n
\n
\n
\n
Unfavorable access for TAVI
\n
\n
\n
+
\n
\n
\n
\n
Sequelae of chest radiation
\n
+
\n
\n
\n
\n
\n
\n
Porcelain aorta
\n
+
\n
\n
\n
\n
\n
\n
Pervious and permeable CABG
\n
+
\n
\n
\n
\n
\n
\n
Expected patient-prosthesis mismatch
\n
+
\n
\n
\n
\n
\n
\n
Severe chest deformation
\n
+
\n
\n
\n
\n
\n
\n
Short distance between coronary ostia and aortic valve annulus
\n
\n
\n
+
\n
\n
\n
\n
Aortic root morphology unfavorable for TAVI (Bicuspid valve, severe calcification)
\n
\n
\n
+
\n
\n
\n
\n
Undergoing CABG or another cardiac surgery
\n
\n
\n
+
\n
\n
\n\n
Table A1.
Checklist for choice of therapeutic intervention option.
Based on 2017 ESC/EACTS guidelines for the management of valvular heart disease [8].
\n
\n
\n
6. Interventional therapeutic options
\n
\n
6.1 Surgical approach
\n
\n
6.1.1 Conventional AVR
\n
The conventional approach to AVR consists of a mid-line incision and full sternotomy, which provide a complete and comfortable access to the heart. Since it was first successfully carried out by Harken and Starr in 1960 [26, 27], there has been a continuous innovation in prosthetic technology and surgical techniques. All these collective efforts have resulted in improvements in both operative and long-term results [17]. Regardless of surgical approach, elected AVR is the gold standard for the treatment of severe AS. Several studies have shown short- and long-term outcomes, as well as improved quality of life. Operative outcomes following AVR were still improving in the past decade. Wu et al. [28], determined the economic value of the additional life given to patients undergoing AVR, and concluded that AVR is cost-effective for all ages, and still worthwhile in octogenarian and nonagenarian patients.
Minimally invasive surgery aims to minimize the degree of surgical intrusiveness. Currently, there are several surgical approaches. The partial sternotomy and right anterior minithoracotomy are the most frequently used incisions for a minimally invasive approach to the aortic valve. The choice of interventional approach depends on the patient’s anatomy as observed in preoperative imaging studies such as CT.
\n
The “J” incision is the most widely used approach among the partial upper hemisternotomy approach (Figure 2). Figure 3 shows the access view through right anterior minithoracotomy.
\n
Figure 2.
Partial upper hemisternotomy approach. Operative field distribution from surgeon view [17].
\n
Figure 3.
Right anterior thoracotomy through 2 or 3° intercostal space [17].
\n
\n
6.1.2.1 Advantages and disadvantages of MIS approaches in aortic stenosis
\n
Benefits have been observed in certain aspects such as:
reduction in bleeding and use of hemoderivatives
reduction in the pain perceived by the patient, which results in reduced consumption of analgesic [29, 30, 31]
less respiratory complications such as atelectasis by maintaining the integrity of the thorax [32]
better esthetic results, due to the reduced size of the surgical incisions and their relocation to less visible areas [33]
reduction on duration of hospitalization and time spent in intensive care units, which results on less expensive cost of the process.
\n
A certain consensus exists around the benefits mentioned above. There is also a question of the impact of MIS on duration of surgery. There is disparity in the results found in the literature. Once the learning curve has been overcome, these times tend to equal out, and there is no significant difference to be observed between the different approaches.
\n
\n
\n
\n
6.1.3 Rapid deployment prostheses
\n
Their use in association with MIS approaches, providing a reduction in surgical aggression in addition to the reduction in ECC and aortic clamping time. These designs have the common feature of being expandable, anchoring themselves to the aortic ring in a similar way to the devices used in TAVI. To date, there are two commercially available models: Perceval (LivaNova) and Intuity (Edwards Lifesciences). Those prostheses differ from each other in a few characteristics.
Perceval (LivaNova): it is useful on patients in which a reduction in surgery time may have a paramount impact, or those where it is necessary to carry out mixed procedures [35, 36]. A recent multicenter study reports a reduction on mean crossclamp and cardiopulmonary bypass times, and a significant improvement in clinical status was observed postoperatively in the majority of patients [37]. The Perceval valve implantation could be easily performed by offering a significant reduction in crossclamping and CPB times compared with both the traditional valve prostheses and the other sutureless prostheses available on the market, even when performed via a minimally invasive approach [37]. It remains important for the continuation of the patient’s follow-up, in order to provide further assessment of long-term valve performance [37].
Intuity (Edwards Lifesciences): it is made by the conjunction between the Edwards Perimount bioprosthesis, the clinical and hemodynamic results of which are widely known, and the experience in the development of the Sapien transcatheter prosthesis. The mode of implantation for this prosthesis allows the aortic clamping and extracorporeal circulation times to be reduced. Reports of early outcomes have shown an important reduction in aortic crossclamp and cardiopulmonary bypass (CPB) [38, 39]. These findings were confirmed in both the European TRITON [40] and the US TRANSFORM trials [41]. Even more important, these times were reduced significantly in combined cardiac procedures [38].
TAVI was developed as an alternative to AVR in the very or extremely high-risk patient population, and its first implantation in man was performed by Cribier [42] in 2002. Since then, there has been a nonstop development of less invasive strategies with lower mortality, lower morbidity, and less invasiveness [43].
\n
\n
6.1.4.1 Implantation techniques
\n
TAVI is currently carried out using two main approaches, transfemoral and transapical. If this is not feasible, then the other two main approaches could be used namely trans-axillary artery or transaortic approaches. It is, therefore, highly recommended to perform an adequate preoperative assessment of the degree of peripheral arterial disease through imaging studies such as CT.
\n
\n
\n
6.1.4.2 TAVI results
\n
The results of the PARTNER I Cohort A trial also have important implications. The primary endpoint of the trial was met, with TAVI found not to be inferior to aortic valve replacement for all-cause mortality at 1 year. Death at 30 days was lower than expected in both arms of the trial: TAVI mortality (3.4%) was the lowest reported in any series, despite an early generation device and limited previous operator experience. Aortic valve replacement mortality (6.5%) was lower than the expected operative mortality (11.8%). On 2015, the 5-year follow-up result of the PARTNER I trial was published [44]; they screened 3105 patients, of whom 699 were enrolled (348 assigned to TAVR, 351 assigned to SAVR). At 5 years, risk of death was 67·8% in the TAVR group compared with 62.4% in the SAVR group (hazard ratio 1.04, 95% CI 0.86–1.24; p = 0.76). They recorded no structural valve deterioration requiring surgical valve replacement in either group. Moderate or severe aortic regurgitation occurred in 40 (14%) of 280 patients in the TAVR group and two (1%) of 228 in the SAVR group (p < 0.0001), and was associated with the increased 5-year risk of mortality in the TAVR group [44].
\n
\n
\n
\n
\n
\n
7. Intermediate risk patients: who are they? And how do we have to manage them?
\n
As we described before, currently AHA/ACC guideline for the management of patients with valvular heart disease [7, 19] defines the intermediate-risk patients as those who has an STS 4–8% with no more than mild frailty or one major organ system compromise not to be improved postoperatively and minimal procedure-specific impediments. In the other hand, the European guidelines define such patient as at “increased surgical risk” (STS or EuroSCORE II >4% or logistic EuroSCORE I > 10% or other risk factors not included in these scores such as frailty, porcelain aorta, and sequelae of chest radiation) [8].
\n
This cohort of patients has two therapeutic options, surgical AVR or TAVI, and the decision pathway goes through the accurate interpretation of all data by the Heart Team.
\n
Nowadays, increased operator experience and enhanced transcatheter valve systems have led to a worldwide trend to use TAVI in patients who are at low or intermediate risk [45]. This tendency has been evaluated in small observational studies, but since most patients who are currently recommended for surgery are at low or intermediate risk, the expansion of the use of TAVI demands more rigorous clinical-trial validation [46]. The intermediate-surgical-risk trials were approved comparing TAVI to surgery, with the balloon-expandable SAPIEN XT valve (PARTNER 2 trial) and the self-expandable CoreValve (SUrgical Replacement and Transcatheter Aortic Valve Implantation trial (SURTAVI trial)) [46, 47].
\n
The PARTNER 2 trial [46] was a multicenter, randomized control trial conducted, which enrolled 2032 patients with severe symptomatic aortic stenosis and intermediate-surgical-risk, and randomized them in a 1:1 fashion across the TAVI arm and the surgical arm [48]. After 2 years, the all-cause mortality or disabling stroke was similar in the TAVI group and the SAVR group (19.3 vs. 21.1%, p = 0.33 and p = 0.001 for noninferiority). In the transfemoral access cohort, TAVI demonstrated a lower mortality and disabling stroke (hazard ratio = 0.79; 95% CI = 0.62–1.00; p = 0.05). TAVI resulted in larger aortic valve areas, lower rates of acute kidney injury, severe bleeding, and new-onset atrial fibrillation; SAVR resulted in fewer major vascular complications and less paravalvular aortic leak [49]. As a result of the PARTNER 2 trial, the current guideline from the American Heart Association and American College of Cardiology recommended TAVI as an alternative to surgery in patients at intermediate surgical risk [18, 48].
\n
The SURTAVI trial [47] analyzes the self-expanding CoreValve in intermediate-risk patients and was a randomized, multicenter control trial, which recruited a total of 1746 patients [46]. The combined primary endpoint (all-cause mortality or disabling stroke) at 24 months was 12.6% in the TAVI group and 14.0% in the surgery group. Residual aortic regurgitation and need for pacemaker implantation were more frequent among TAVI patients. In the other hand, SAVR was associated with the higher rates of atrial fibrillation, acute kidney injury, and transfusion requirements. The TAVI resulted in lower mean gradients and larger aortic valve areas than surgery did. Structural valve deterioration at 24 months did not occur in either group. SURTAVI revealed that CoreValve TAVI was not inferior to surgery in patients with intermediate surgical risk [49].
\n
Bicuspid aortic valves: the extreme and asymmetrical calcification noted with bicuspid valves can prevent adequate expansion of the valve frame of TAVI valves, affecting valve hemodynamics, and leading to higher aortic valve gradients and more paravalvular leaks [48].
\n
Prostheses thrombosis: the Portico Re-sheathable Transcatheter Aortic Valve System U.S. Investigational Device Exemption (PORTICO IDE) study evaluates TAVI with either a Portico valve (St. Jude Medical) or a commercially available valve. Computed tomography (CT) was performed in a subgroup of patients to assess the stent frame of the implanted valve. A finding of reduced leaflet motion on CT in a patient who had had a stroke after TAVI and similar findings in an asymptomatic patient at one clinical site led to a closer look of this observation. Additional CT review by the core laboratory revealed that this finding was not isolated, which prompted a more extensive investigation. This findings encourage to create two registries to evaluate the prostheses thrombosis (SAVORY registry and RESOLVE registry), and find out that therapeutic anticoagulation with warfarin, but not therapy with antiplatelet drugs, prevented and effectively treated this phenomenon. Better characterization of this observation is needed to determine its frequency and evaluate its clinical effect [50].
\n
Durability: intermediate surgical-risk patients are expected to survive longer after TAVI when compared to higher-risk patients; the broad application of TAVI in low-risk patients should be limited until in vivo durability results are available for the TAVI prostheses [48]. While structural valve deterioration in surgically replaced valves has been thoroughly investigated, long-term follow-up data for TAVI valves implanted in patients remain sparse [48].
\n
\n
\n
8. Conclusions
\n
Nowadays, the patients with intermediate risk are in the frontier of TAVI and surgical AVR, and more than ever, the heart team has to be more accurate to choose between the different treatment options available. Current expansion of TAVI into lower surgical risk patients encourages the need to remain cautious about unbridled expansion into those patients, as many questions remain about valve durability, leaflet thrombosis, and higher rates of paravalvular leak and permanent pacemakers [48]. Meanwhile, the surgical approach has improved and evolved to a reduction in surgical aggression. TAVI and minimally invasive aortic valve replacement [51] have become alternatives to surgical aortic valve replacement via median sternotomy (SAVR) to treat severe aortic stenosis (AS). Despite increased interest and utilization, few studies have directly compared TAVI and miniAVR. MiniAVR maintains potential advantages over SAVR, including the implantation of a durable prosthesis and low rates of perioperative myocardial infarction and paravalvular leak. It is associated with longer aortic crossclamp and cardiopulmonary bypass (CPB) times; however, the use of rapid deployment valves can circumvent this. Studies comparing TAVI and miniAVR demonstrate decreased postoperative mortality, valvular regurgitation, and incidence of stroke in the miniAVR cohorts [51].
\n
From economic point of view, it is clear that for high-risk operable patients, TAVI is currently a more expensive therapy and probably a less effective alternative to surgical AVR, with an incremental cost-effectiveness ratio (ICER) that may be acceptable for high-income countries, but definitely not for the moderate- or low-income countries [52]. When use of TAVI is extended to include a larger number of moderate- to low-risk patients suitable for AVR, overall economic results become less favorable. When manufacturers reduce the exuberant cost of the valve and its accessories, TAVI may become the predominant therapy for patients with severe aortic stenosis. [52].
\n
Finally, it is clear that both strategies will be the cornerstones in the modern AVR era, but the situations in which to apply each strategy have not yet been clearly delineated. More studies are needed to compare TAVI and miniAVR in low- and intermediate-risk patients. However, the current practice guidelines give a good pathway to choose the adequate therapeutic option in each individual case.
\n
\n
Acknowledgments
\n
We want to give thanks to the cardiac surgery team at Policlinica de Guipuzcoa and Hospital Clinico Universitario de Valladolid, and especially to our colleagues: I. Gallo, A. Saenz, I. Perez-Moreiras, and A. Granda y E. Berruti.
\n
\n
Appendix
\n
\n',keywords:"aortic stenosis, aortic stenosis surgery, aortic stenosis management, aortic stenosis open heart surgery, aortic stenosis treatment, aortic stenosis valve replacement, TAVR procedure, TAVR approaches, TAVR access sites, TAVR, TAVI",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/65141.pdf",chapterXML:"https://mts.intechopen.com/source/xml/65141.xml",downloadPdfUrl:"/chapter/pdf-download/65141",previewPdfUrl:"/chapter/pdf-preview/65141",totalDownloads:1070,totalViews:0,totalCrossrefCites:0,dateSubmitted:"September 20th 2018",dateReviewed:"December 10th 2018",datePrePublished:"January 24th 2019",datePublished:"September 25th 2019",dateFinished:"January 10th 2019",readingETA:"0",abstract:"The management of aortic stenosis has improved and evolved to a reduction in surgical aggression. Nowadays, patients with intermediate risk are in the frontier of transcatheter aortic valve implantation (TAVI) and aortic valve replacement (AVR). Our goal is to update the treatment of severe aortic stenosis in those patients through a research of the recent literature, in order to analyze the current treatment options and their results. This cohort of patients has two therapeutic options, surgical AVR or TAVI, and the decision pathway goes through the accurate interpretation of all data by the Heart Team. It is clear that both strategies will be the cornerstones in the modern AVR era, but the situations in which to apply each strategy have not yet been clearly delineated. More studies are needed to compare TAVI and miniAVR in low- and intermediate-risk patients. However, the current practice guidelines give a good pathway to choose the adequate therapeutic option in each individual case.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/65141",risUrl:"/chapter/ris/65141",signatures:"Omer Leal, Diego Sanchez-Valenzuela and Juan Bustamante-Munguira",book:{id:"8218",type:"book",title:"Aortic Stenosis",subtitle:"Current Perspectives",fullTitle:"Aortic Stenosis - Current Perspectives",slug:"aortic-stenosis-current-perspectives",publishedDate:"September 25th 2019",bookSignature:"Peter Magnusson",coverURL:"https://cdn.intechopen.com/books/images_new/8218.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-78923-852-5",printIsbn:"978-1-78923-851-8",pdfIsbn:"978-1-83962-232-8",isAvailableForWebshopOrdering:!0,editors:[{id:"188088",title:"Dr.",name:"Peter",middleName:null,surname:"Magnusson",slug:"peter-magnusson",fullName:"Peter Magnusson"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"158616",title:"Dr.",name:"Juan",middleName:null,surname:"Bustamante-Munguira",fullName:"Juan Bustamante-Munguira",slug:"juan-bustamante-munguira",email:"jbustamantemunguira@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Autonomous University of Madrid",institutionURL:null,country:{name:"Spain"}}},{id:"166873",title:"Dr.",name:"Omer",middleName:null,surname:"Leal",fullName:"Omer Leal",slug:"omer-leal",email:"omerleal82@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"286358",title:"Dr.",name:"Diego",middleName:null,surname:"Sanchez-Valenzuela",fullName:"Diego Sanchez-Valenzuela",slug:"diego-sanchez-valenzuela",email:"difersan2@hotmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Etiology and natural history",level:"1"},{id:"sec_3",title:"3. Evaluation and severity classification of aortic stenosis",level:"1"},{id:"sec_4",title:"4. Indications for intervention",level:"1"},{id:"sec_5",title:"5. Risk stratification",level:"1"},{id:"sec_6",title:"6. Interventional therapeutic options",level:"1"},{id:"sec_6_2",title:"6.1 Surgical approach",level:"2"},{id:"sec_6_3",title:"6.1.1 Conventional AVR",level:"3"},{id:"sec_7_3",title:"6.1.2 Minimally invasive surgical (MIS) approaches",level:"3"},{id:"sec_7_4",title:"6.1.2.1 Advantages and disadvantages of MIS approaches in aortic stenosis",level:"4"},{id:"sec_9_3",title:"6.1.3 Rapid deployment prostheses",level:"3"},{id:"sec_10_3",title:"6.1.4 Transcatheter aortic valve implantation (TAVI)",level:"3"},{id:"sec_10_4",title:"6.1.4.1 Implantation techniques",level:"4"},{id:"sec_11_4",title:"6.1.4.2 TAVI results",level:"4"},{id:"sec_15",title:"7. Intermediate risk patients: who are they? And how do we have to manage them?",level:"1"},{id:"sec_16",title:"8. Conclusions",level:"1"},{id:"sec_17",title:"Acknowledgments",level:"1"},{id:"sec_17",title:"Appendix",level:"1"}],chapterReferences:[{id:"B1",body:'Schmitto JD, Mohr FW, Cohn LH. Minimally invasive aortic valve replacement: How does this perform in high-risk patients? Current Opinion in Cardiology. 2011;26(2):118-122\n'},{id:"B2",body:'Chambers JB. Aortic stenosis. European Journal of Echocardiography. 2009;10(1):i11-i19\n'},{id:"B3",body:'Freeman RV, Otto CM. Spectrum of calcific aortic valve disease: Pathogenesis, disease progression, and treatment strategies. Circulation. 2005;111(24):3316-3326\n'},{id:"B4",body:'Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. The New England Journal of Medicine. 1999;341(3):142-147\n'},{id:"B5",body:'Kurtz CE, Otto CM. Aortic stenosis: Clinical aspects of diagnosis and management, with 10 illustrative case reports from a 25-year experience. Medicine (Baltimore). 2010;89(6):349-379\n'},{id:"B6",body:'Ross J Jr, Braunwald E. Aortic stenosis. Circulation. 1968;38(1 Suppl):61-67\n'},{id:"B7",body:'Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: Executive summary: A report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2014;129:2440-2492\n'},{id:"B8",body:'Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal. 2017;38(36):2739-2791. DOI: 10.1093/eurheartj/ehx391\n'},{id:"B9",body:'Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S, et al. Focus update on the echocardiographic assessment of aortic valve stenosis: EAE/ASE recommendations for clinical practice. European Heart Journal Cardiovascular Imaging. 2017;18:254-275\n'},{id:"B10",body:'Rafique AM, Biner S, Ray I, Forrester JS, Tolstrup K, Siegel RJ. Metanalysis of prognostic value of stress testing in patients with asymptomatic severe aortic stenosis. The American Journal of Cardiology. 2009;104:972-977\n'},{id:"B11",body:'Marechaux S, Hachicha Z, Bellouin A, Dumesnil JG, Meimoun P, Pasquet A, et al. Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. European Heart Journal. 2010;31:1390-1397\n'},{id:"B12",body:'Steadman CD, Ray S, Ng LL, McCann GP. Natriuretic peptides in common valvular heart disease. Journal of the American College of Cardiology. 2010;55:2034-2048\n'},{id:"B13",body:'Bergler-Klein J, Klaar U, Heger M, Rosenhek R, Mundigler G, Gabriel H, et al. Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis. Circulation. 2004;109:2302-2308\n'},{id:"B14",body:'Monin JL, Lancellotti P, Monchi M, Lim P, Weiss E, Piérard L, et al. Risk score for predicting outcome in patients with asymptomatic aortic stenosis. Circulation. 2009;120:69-75\n'},{id:"B15",body:'Lancellotti P, Moonen M, Magne J, O’Connor K, Cosyns B, Attena E, et al. Prognostic effect of long-axis left ventricular dysfunction and B-type natriuretic peptide levels in asymptomatic aortic stenosis. The American Journal of Cardiology. 2010;105:383-388\n'},{id:"B16",body:'Musa TA et al. Myocardial scar and mortality in severe aortic stenosis: Data from the BSCMR Valve Consortium. Circulation. 2018;138:1935. DOI: 10.1161/CIRCULATIONAHA.117.032839\n'},{id:"B17",body:'Leal O, Bustamante J, Cánovas S, Pinto A. New therapeutic approaches to conventional surgery for aortic stenosis in high-risk patients. In: Aikawa E, editor. 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Vascular complications after transcatheter aortic valve replacement: Insights from the PARTNER (Placement of AoRTic TraNscathetER valve) trial. Journal of the American College of Cardiology. 2012;60:1043-1052\n'},{id:"B46",body:'Martin B, Leon MB, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. The New England Journal of Medicine. 2016;374:1609-1620. DOI: 10.1056/NEJMoa1514616\n'},{id:"B47",body:'Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. The New England Journal of Medicine. 2017;376:1321-1331\n'},{id:"B48",body:'Arora S, Vavalle JP. Transcatheter aortic valve replacement in intermediate and low risk patients-clinical evidence. Annals of Cardiothoracic Surgery. 2017;6(5):493-497. DOI: 10.21037/acs.2017.07.01\n'},{id:"B49",body:'Escutia-Cuevas HH, Merino-Rajme JA, Alcántara-Meléndez MA, et al. TAVI in intermediate-risk patients: A review in purpose of a case. Revista Mexicana de Cardiología. 2018;29(2):102-111\n'},{id:"B50",body:'Makkar RR, Fontana G, Jilaihawi H, et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. The New England Journal of Medicine. 2015;373:2015-2024. DOI: 10.1056/NEJMoa1509233\n'},{id:"B51",body:'Hoffmann CT, Heiner JA, Nguyen TC. Review of minimal access versus transcatheter aortic valve replacement for patients with severe aortic stenosis. Annals of Cardiothoracic Surgery. 2017;6(5):498-503. DOI: 10.21037/acs.2017.09.02\n'},{id:"B52",body:'Manolis AS. Transcatheter aortic valve implantation economics: A grisly reality. Annals of Cardiothoracic Surgery. 2017;6(5):516-523. DOI: 10.21037/acs.2017.07.02\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Omer Leal",address:"omerleal82@gmail.com",affiliation:'
Department of Cardiovascular Surgery, Policlínica de Gipuzkoa, Spain
Department of Cardiovascular Surgery, Hospital Clínico Universitario de Valladolid, Spain
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UK Research and Innovation (former Research Councils UK (RCUK) - including AHRC, BBSRC, ESRC, EPSRC, MRC, NERC, STFC.) Processing charges for books/book chapters can be covered through RCUK block grants which are allocated to most universities in the UK, which then handle the OA publication funding requests. It is at the discretion of the university whether it will approve the request.)
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After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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Climate change occurs as a result of an imbalance between incoming and outgoing radiation in the atmosphere. The global mean temperatures may increase up to 5.4°C by 2100. Climate change is mainly caused by humans, especially through increased greenhouse gas emissions. Climate change is recognized as a serious threat to ecosystem, biodiversity, and health. It is associated with alterations in the physical environment of the planet Earth. Climate change affects life around the globe. It impacts plants and animals, with consequences for the survival of the species. In humans, climate change has multiple deleterious consequences. Climate change creates water and food insecurity, increased morbidity/mortality, and population movement. Vulnerable populations (e.g., children, elderly, indigenous, and poor) are disproportionately affected. Personalized adaptation to the consequences of climate change and preventive measures are key challenges for the society. Policymakers must implement the appropriate strategies, especially in the vulnerable populations.",book:{id:"9664",slug:"environmental-issues-and-sustainable-development",title:"Environmental Issues and Sustainable Development",fullTitle:"Environmental Issues and Sustainable Development"},signatures:"Hassan M. Heshmati",authors:[{id:"313921",title:"Dr.",name:"Hassan M.",middleName:null,surname:"Heshmati",slug:"hassan-m.-heshmati",fullName:"Hassan M. 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As a result, the optimal formula is obtained with 300 g of mycorrhizal and rhizobium strains + 500 g of black soil + 200 g of potato peel crust, which has an effective antagonistic capacity of 100% in pea cultivation, 90% in the barley, and 85% in the potato, besides that it achieves a biotisation in the cultivation of peas of 95%, in the barley 100% and in the potato 90%.",book:{id:"11177",title:"Biomass, Biorefineries and Bioeconomy",coverURL:"https://cdn.intechopen.com/books/images_new/11177.jpg"},signatures:"Henry Juan Javier Ninahuaman and Grimaldo Quispe Santivañez"},{id:"82542",title:"Effects of Veld Degradation on Biomass Production in the Arable Lands of South Africa",slug:"effects-of-veld-degradation-on-biomass-production-in-the-arable-lands-of-south-africa",totalDownloads:14,totalDimensionsCites:0,doi:"10.5772/intechopen.102605",abstract:"This paper reviews the impacts of veld degradation on species diversity, veld ecological condition. The major focus of this review is to assess the major critical factors that contributeto veld degradation. It is imperative to revitalize information on the effects of veld degradation in the South African pastoral farming systems. Current studies have indicated the limited research gaps that identify the adverse effects of veld degradation on species composition and biomass production. Grazing behavior in different grazing patterns has not been clear. Finally, this review will assist farmers, policymakers, and pastoralists to broaden their knowledge on policy development, and appropriate the veld management practices, coping measures of veld degradation, particularly those from resource-poor communities. Whereby, livestock production is the focus for food security and poverty alleviation. However, the use of legumes intercropped with temperate grass species can improve animal performance and herbage production during critical periods. The review further evaluates the veld management practices and their ability in providing adequate foliar cover with the use of the edible perennial grass plant that ensures long-term sustainable production with maximum economic returns during critical grazing seasons.",book:{id:"11177",title:"Biomass, Biorefineries and Bioeconomy",coverURL:"https://cdn.intechopen.com/books/images_new/11177.jpg"},signatures:"Nkosikhona Madolo and Francis B. Lewu"},{id:"82330",title:"Advances in Bioenergy Production Using Fast Pyrolysis and Hydrothermal Processing",slug:"advances-in-bioenergy-production-using-fast-pyrolysis-and-hydrothermal-processing",totalDownloads:7,totalDimensionsCites:0,doi:"10.5772/intechopen.105185",abstract:"This chapter provides an overview of current efforts and advances as well as environmental and economic aspects of fast pyrolysis and hydrothermal processing, which are potential technologies for bioenergy production, mainly bio-oil and syngas. Biomass is presently the primary bioenergy resource in the world. The chapter presents a brief discussion of sources and compositions of biomass. Biomass is converted to various products using thermochemical conversions. Pyrolysis is a thermochemical process that converts biomass into carbon-rich solid residue, condensable vapors, and non-condensable gases in the absence of oxygen. It is a promising technology for converting biomass into renewable biofuels with environmental and economic advantages. Pyrolysis processes are classified based on their operating conditions and desired products. Two thermochemical processes, fast pyrolysis and hydrothermal processing are reviewed. Fast pyrolysis produces a higher quantity and quality of bio-oil and syngas than slow and intermediate pyrolysis processes. Hydrothermal processing converts wet biomass into carbonaceous biofuel. The ability to produce higher-value bioenergy by these pyrolysis technologies depends on the feedstock and operating condition of the pyrolysis processes. This chapter will present the most promising features of fast pyrolysis and hydrothermal processing along with their optimal pyrolysis conditions in maximizing the production of biofuels.",book:{id:"11177",title:"Biomass, Biorefineries and Bioeconomy",coverURL:"https://cdn.intechopen.com/books/images_new/11177.jpg"},signatures:"Meegalla R. Chandraratne and Asfaw Gezae Daful"},{id:"81162",title:"Economic Assessment of Biomass Based Power Generation",slug:"economic-assessment-of-biomass-based-power-generation",totalDownloads:14,totalDimensionsCites:0,doi:"10.5772/intechopen.103692",abstract:"Biomass based power generation systems can play a significant role to alleviate energy crisis and reduce fossil fuel dependency in the countries that possess abundance of agricultural and forest biomass resources. Particularly the countries to go for biomass energy in a large scale must know power and energy potential for biomass based commercial production with proper economic assessment of the possibilities. In-depth knowledge is must to assess the profitability and sustainability of the projects. Profitability measures how the investment in the project can be secured to have an ensured surplus to be shared by the stake holders and sustainability ensures the long-term existence in the business with a positive trend of gaining market share day by day or simply to be in the business. This chapter will present the details of the economic assessment of biomass- based energy projects in terms of net present value (NPV), internal rate of return (IRR), discounted payback period (DPB), and cost of energy. The economic profitability measure is a must before advancing to a venture whether it is self-financed or loan financed. So, it is hoped that readers of the chapter should develop a proper evaluation capability and know how to analyze the biomass-based energy projects.",book:{id:"11177",title:"Biomass, Biorefineries and Bioeconomy",coverURL:"https://cdn.intechopen.com/books/images_new/11177.jpg"},signatures:"A.B.M. Abdul Malek"},{id:"80542",title:"Comparative Analysis of Biodiesel Production from Different Potential Feedstocks in the Philippines",slug:"comparative-analysis-of-biodiesel-production-from-different-potential-feedstocks-in-the-philippines",totalDownloads:31,totalDimensionsCites:0,doi:"10.5772/intechopen.102724",abstract:"In response to the worsening crisis on energy security and climate change, the Philippine Biofuels Law (Republic Act 9367) was enacted which mandates the blending of biodiesel to petroleum diesel sold in the country. Primarily, feedstock and pricing concerns led to stagnant growth of the Philippine biodiesel industry. Hence, viability of different potential biodiesel feedstocks such as coconut, oil palm, and soybean (first generation), jatropha and used cooking oil (second generation), and microalgae (third generation) was assessed through extensive research and developments. Among these sources, oil palm is regarded as the best complementary feedstock to coconut due to its high biodiesel productivity of 376 million liters per year. Oil palm biodiesel production in the Philippines was also found to have a low carbon footprint of 1.80 kg CO2e per liter and a GHG reduction potential of 42%, which corresponds to a GHG savings of about 1.05 million metric tons CO2e per year for a 5% blending mandate in 2025. Additionally, a low biodiesel selling price of about Php 33.26 per liter can be achieved from using this feedstock for biodiesel production. Hence, use of a low cost and readily available feedstock coupled with established processing technologies and pricing mechanisms will help boost the biodiesel industry in the Philippines.",book:{id:"11177",title:"Biomass, Biorefineries and Bioeconomy",coverURL:"https://cdn.intechopen.com/books/images_new/11177.jpg"},signatures:"Rona Joyce B. Landoy, Rex B. Demafelis, Bernadette T. Magadia and Anna Elaine D. Matanguihan"},{id:"80493",title:"Conventional and Unconventional Transformation of Cocoa Pod Husks into Value-Added Products",slug:"conventional-and-unconventional-transformation-of-cocoa-pod-husks-into-value-added-products",totalDownloads:42,totalDimensionsCites:0,doi:"10.5772/intechopen.102606",abstract:"The drive for a sustainable society and a circular economy has motivated researchers around the globe to turn to the transformation of renewable raw materials like biomass into value-added products that are akin or superior to their fossil counterparts. Among these biomass raw materials, cocoa pod husks (CPH) which is the non-edible portion of cocoa (ca. 70–75% weight of the while cocoa fruit) remains a promising bio-resource raw material for the production high-value added chemicals but yet largely underexploited. Currently, the most popular applications of CPH involves its use as low-value application products such as animal feed, raw material for soap making, and activated carbon. However, the rich source of lignocellulosic content, pectin, and phenolic compounds of CPH means it could be used as raw materials for the production industrially relevant platform chemicals with high potential in the agrochemicals, pharmaceutical, and food industries, if efficient transformations routes are developed by scientists. In this chapter, we will shed light on some of the works related to the transformation of CPH into various value-added products. An economic evaluation of the transformation of cocoa pod husk into relevant chemicals and products is also discussed.",book:{id:"11177",title:"Biomass, Biorefineries and Bioeconomy",coverURL:"https://cdn.intechopen.com/books/images_new/11177.jpg"},signatures:"Martina Francisca Baidoo, Nana Yaw Asiedu, Lawrence Darkwah, David Arhin-Dodoo, Jun Zhao, Francois Jerome and Prince Nana Amaniampong"}],onlineFirstChaptersTotal:17},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:18,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:9,numberOfPublishedChapters:139,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:122,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:21,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. 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He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. 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Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:{name:"Association for Computing Machinery",country:{name:"United States of America"}}},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:"Manufacturing and Technology Integrated Campus – SENAI CIMATEC",institution:null},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:'"Politechnica" University Timişoara',institution:null},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"426586",title:"Dr.",name:"Oladunni A.",middleName:null,surname:"Daramola",slug:"oladunni-a.-daramola",fullName:"Oladunni A. Daramola",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Federal University of Technology",country:{name:"Nigeria"}}},{id:"357014",title:"Prof.",name:"Leon",middleName:null,surname:"Bobrowski",slug:"leon-bobrowski",fullName:"Leon Bobrowski",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Bialystok University of Technology",country:{name:"Poland"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"354126",title:"Dr.",name:"Setiawan",middleName:null,surname:"Hadi",slug:"setiawan-hadi",fullName:"Setiawan Hadi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Padjadjaran University",country:{name:"Indonesia"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"332603",title:"Prof.",name:"Kumar S.",middleName:null,surname:"Ray",slug:"kumar-s.-ray",fullName:"Kumar S. Ray",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Statistical Institute",country:{name:"India"}}},{id:"415409",title:"Prof.",name:"Maghsoud",middleName:null,surname:"Amiri",slug:"maghsoud-amiri",fullName:"Maghsoud Amiri",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Allameh Tabataba'i University",country:{name:"Iran"}}},{id:"357085",title:"Mr.",name:"P. Mohan",middleName:null,surname:"Anand",slug:"p.-mohan-anand",fullName:"P. Mohan Anand",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356696",title:"Ph.D. Student",name:"P.V.",middleName:null,surname:"Sai Charan",slug:"p.v.-sai-charan",fullName:"P.V. Sai Charan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"357086",title:"Prof.",name:"Sandeep K.",middleName:null,surname:"Shukla",slug:"sandeep-k.-shukla",fullName:"Sandeep K. Shukla",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}}]}},subseries:{item:{id:"22",type:"subseries",title:"Applied Intelligence",keywords:"Machine Learning, Intelligence Algorithms, Data Science, Artificial Intelligence, Applications on Applied Intelligence",scope:"This field is the key in the current industrial revolution (Industry 4.0), where the new models and developments are based on the knowledge generation on applied intelligence. The motor of the society is the industry and the research of this topic has to be empowered in order to increase and improve the quality of our lives.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/22.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11418,editor:{id:"27170",title:"Prof.",name:"Carlos",middleName:"M.",surname:"Travieso-Gonzalez",slug:"carlos-travieso-gonzalez",fullName:"Carlos Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Carlos M. Travieso-González received his MSc degree in Telecommunication Engineering at Polytechnic University of Catalonia (UPC), Spain in 1997, and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. 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