IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\n
By listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
All three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n
"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
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"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
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In conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n
“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\n
We invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\n
Feel free to share this news on social media and help us mark this memorable moment!
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\n
By listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
All three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n
"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n
"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\n
In conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n
“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\n
We invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\n
Feel free to share this news on social media and help us mark this memorable moment!
\n\n
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"10891",leadTitle:null,fullTitle:"Leishmaniasis - General Aspects of a Stigmatized Disease",title:"Leishmaniasis",subtitle:"General Aspects of a Stigmatized Disease",reviewType:"peer-reviewed",abstract:"Leishmaniasis is a major global health challenge, affecting approximately 12 million of the poorest people in 100 countries. It is a deforming and fatal disease in the visceral form. Therapies for leishmaniasis are numerically restricted, basically consisting of the administration of miltefosine, pentavalent antimonials, amphotericin B, or pentamidine. This is an important vulnerability against therapy efficiency that must be overcome by the scientific community. This book discusses important aspects of the disease, such as treatment, epidemiology, and molecular and cell biology. The information contained herein is important for young researchers as they seek to develop safe and effective treatments for this neglected tropical disease.",isbn:"978-1-83968-082-3",printIsbn:"978-1-83968-081-6",pdfIsbn:"978-1-83968-092-2",doi:"10.5772/intechopen.95200",price:119,priceEur:129,priceUsd:155,slug:"leishmaniasis-general-aspects-of-a-stigmatized-disease",numberOfPages:256,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"e2123440fdf88dfa14b4713a1a8ba58a",bookSignature:"Leonardo de Azevedo Calderonon",publishedDate:"April 13th 2022",coverURL:"https://cdn.intechopen.com/books/images_new/10891.jpg",numberOfDownloads:1193,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:0,numberOfDimensionsCitationsByBook:0,hasAltmetrics:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 5th 2021",dateEndSecondStepPublish:"June 2nd 2021",dateEndThirdStepPublish:"August 1st 2021",dateEndFourthStepPublish:"October 20th 2021",dateEndFifthStepPublish:"December 19th 2021",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"177382",title:"Dr.",name:"Leonardo de Azevedo",middleName:null,surname:"Calderon",slug:"leonardo-de-azevedo-calderon",fullName:"Leonardo de Azevedo Calderon",profilePictureURL:"https://mts.intechopen.com/storage/users/177382/images/system/177382.jpg",biography:"Leonardo de Azevedo Calderon obtained a bachelor\\'s degree and a doctorate in Biological Sciences from the University of Brasília (UnB), Brazil, in 2000 and 2004, respectively. He is a researcher in public health at the Oswaldo Cruz Foundation, lecturer in the Medicine Department, Federal University of Rondônia, Brazil, and head of the Center for the Study of Biomolecules Applied to Health. He has experience in the fields of biochemistry, molecular biophysics, and bioinformatics, working mainly in the prospection and development of new chemical entities with potentially useful activities in future therapies for leishmaniasis and malaria.",institutionString:"Oswaldo Cruz Foundation",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Oswaldo Cruz Foundation",institutionURL:null,country:{name:"Brazil"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1046",title:"Infectious Diseases",slug:"infectious-diseases"}],chapters:[{id:"80467",title:"Leishmaniasis: Molecular Aspects of Parasite Dimorphic Forms Life Cycle",doi:"10.5772/intechopen.102370",slug:"leishmaniasis-molecular-aspects-of-parasite-dimorphic-forms-life-cycle",totalDownloads:76,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"According to WHO, Leishmaniasis is a complex neglected disease caused by a protozoa parasite from over 20 Leishmania species transmitted by more than 90 sandfly species, showing three main forms: visceral, cutaneous, and mucocutaneous. The efficient prevention and control of leishmaniasis are very difficult to achieve, depending on the combination of different intervention strategies, usually resulting in failure. Additionally, the correct diagnostics require the combination of clinical signs with laboratory tests, and only a few therapeutical options are available for patients. To improve this scenario, greater efforts in research for control and treatment are needed. For this purpose, the study and understanding of the life cycle of Leishmania are mandatory for all researchers who intend to dedicate their careers to the different aspects of this important disease. In order to support beginning researchers in the study of leishmaniasis, we propose in this review an update in the current knowledge about the major molecular aspects involved in the development of dimorphic forms of Leishmania parasites that replicate in the gut of sandflies (promastigotes) and in mammalian cells (amastigotes) and the relationship with host’s immune system.",signatures:"Natanael Endrew Souto Maior Torres Bonfim, Ana Lígia Barbour Scott and Leonardo de Azevedo Calderon",downloadPdfUrl:"/chapter/pdf-download/80467",previewPdfUrl:"/chapter/pdf-preview/80467",authors:[{id:"177382",title:"Dr.",name:"Leonardo de Azevedo",surname:"Calderon",slug:"leonardo-de-azevedo-calderon",fullName:"Leonardo de Azevedo Calderon"},{id:"465571",title:"Dr.",name:"Natanael",surname:"Endrew Souto Maior Torres Bonfim",slug:"natanael-endrew-souto-maior-torres-bonfim",fullName:"Natanael Endrew Souto Maior Torres Bonfim"},{id:"465572",title:"Dr.",name:"Ana",surname:"Lígia Barbour Scott",slug:"ana-ligia-barbour-scott",fullName:"Ana Lígia Barbour Scott"}],corrections:null},{id:"79372",title:"Protective and Pathogenic Immune Responses to Cutaneous Leishmaniasis",doi:"10.5772/intechopen.101160",slug:"protective-and-pathogenic-immune-responses-to-cutaneous-leishmaniasis",totalDownloads:85,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Leishmania (Kinetoplastida: Trypanosomatidae) parasites are known to cause a broad spectrum of clinical diseases in humans, collectively known as the leishmaniases. Cutaneous leishmaniasis is the most common clinical presentation with varying degrees of severity largely driven by host immune responses, specifically the interplay between innate and adaptive immune response. The establishment of a T lymphocyte driven cell-mediated immune response, leading to activated phagocytic cells, leading to Leishmania parasite killing and control of infection. Alternatively, the Leishmania parasite manipulates the host immune system, enabling parasite proliferation and clinical disease. Here we review how the cumulative interactions of different aspects of the host immune response determines disease outcome, severity, and immunity to re-infection.",signatures:"Elina Panahi, Danielle I. Stanisic, Christopher S. Peacock and Lara J. Herrero",downloadPdfUrl:"/chapter/pdf-download/79372",previewPdfUrl:"/chapter/pdf-preview/79372",authors:[{id:"80655",title:"Dr.",name:"Lara J.",surname:"Herrero",slug:"lara-j.-herrero",fullName:"Lara J. Herrero"},{id:"436057",title:"Ms.",name:"Elina",surname:"Panahi",slug:"elina-panahi",fullName:"Elina Panahi"},{id:"436058",title:"Dr.",name:"Christopher S.",surname:"Peacock",slug:"christopher-s.-peacock",fullName:"Christopher S. Peacock"},{id:"436059",title:"Dr.",name:"Danielle I.",surname:"Stanisic",slug:"danielle-i.-stanisic",fullName:"Danielle I. Stanisic"}],corrections:null},{id:"79300",title:"Extracellular Vesicles Released by Leishmania: Impact on Disease Development and Immune System Cells",doi:"10.5772/intechopen.101151",slug:"extracellular-vesicles-released-by-em-leishmania-em-impact-on-disease-development-and-immune-system-",totalDownloads:143,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Leishmania spp. release extracellular vesicles (EVs) containing parasite molecules, including several antigens and virulence factors. These EVs can interact with the host cells, such as immune cells, contributing to the parasite–host relationship. Studies have demonstrated that Leishmania-EVs can promote infection in experimental models and modulate the immune response. Although the immunomodulatory effect has been demonstrated, Leishmania-EVs can deliver parasite antigens and therefore have the potential for use as a new diagnostic tool and development of new therapeutic and vaccine approaches. This review aims to bring significant advances in the field of extracellular vesicles and Leishmania, focusing on their role in the cells of the immune system.",signatures:"Rogéria Cristina Zauli, Andrey Sladkevicius Vidal, Talita Vieira Dupin, Aline Correia Costa de Morais, Wagner Luiz Batista and Patricia Xander",downloadPdfUrl:"/chapter/pdf-download/79300",previewPdfUrl:"/chapter/pdf-preview/79300",authors:[{id:"421426",title:"Prof.",name:"Patricia",surname:"Xander",slug:"patricia-xander",fullName:"Patricia Xander"},{id:"421431",title:"Ms.",name:"Andrey",surname:"Sladkevicius Vidal",slug:"andrey-sladkevicius-vidal",fullName:"Andrey Sladkevicius Vidal"},{id:"421432",title:"Ms.",name:"Talita",surname:"Vieira Dupin",slug:"talita-vieira-dupin",fullName:"Talita Vieira Dupin"},{id:"421433",title:"Ms.",name:"Aline",surname:"Correia Costa de Morais",slug:"aline-correia-costa-de-morais",fullName:"Aline Correia Costa de Morais"},{id:"421434",title:"MSc.",name:"Rogéria Cristina",surname:"Zauli",slug:"rogeria-cristina-zauli",fullName:"Rogéria Cristina Zauli"},{id:"421435",title:"Prof.",name:"Wagner",surname:"Luiz Batista",slug:"wagner-luiz-batista",fullName:"Wagner Luiz Batista"}],corrections:null},{id:"79348",title:"Treatment of Leishmaniasis",doi:"10.5772/intechopen.101145",slug:"treatment-of-leishmaniasis",totalDownloads:58,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Treatment of Leishmaniasis is always not satisfactory despite advancement all these years. This chapter will discuss the standard treatment options like Amphotericin, oral miltefosine, topical paromycin, add more details about newer emerging drugs and alternative therapies, surgical treatment modalities for resistant cases. Will discuss few information regarding vaccines. Special precautions to be taken while travelling to endemic areas will be discussed. Management protocol for mucocutaneous and visceral type will be highlighted. Side-effects of drugs used in the treatment of Leishmaniasis will be discussed in short and measures to monitor these side effects will be discussed. Long term monitoring of relapse will also be discussed.",signatures:"R. Sivayogana, Aishwarya Krishnakumar, S. Kumaravel, Rajesh Rajagopal and P. Ravikanth",downloadPdfUrl:"/chapter/pdf-download/79348",previewPdfUrl:"/chapter/pdf-preview/79348",authors:[{id:"419522",title:"Assistant Prof.",name:"R.",surname:"Sivayogana",slug:"r.-sivayogana",fullName:"R. Sivayogana"},{id:"429065",title:"Dr.",name:"Aishwarya",surname:"Krishnakumar",slug:"aishwarya-krishnakumar",fullName:"Aishwarya Krishnakumar"},{id:"440470",title:"Dr.",name:"S.",surname:"Kumaravel",slug:"s.-kumaravel",fullName:"S. Kumaravel"},{id:"455626",title:"Associate Prof.",name:"Rajesh",surname:"Rajagopal",slug:"rajesh-rajagopal",fullName:"Rajesh Rajagopal"},{id:"455627",title:"Dr.",name:"P.",surname:"Ravikanth",slug:"p.-ravikanth",fullName:"P. Ravikanth"}],corrections:null},{id:"79223",title:"Visceral Leishmaniasis: Asymptomatic Facts",doi:"10.5772/intechopen.101109",slug:"visceral-leishmaniasis-asymptomatic-facts",totalDownloads:127,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Visceral Leishmaniasis (VL) caused by protozoan parasite Leishmania is a vector borne disease and infection is limited not to human but also to animals worldwide. For infection identification and prevalence in both Leishmania endemic and nonendemic regions, several serological and genetic techniques are used. Although diagnostic techniques and clinical symptoms can establish illness status, it is extremely difficult to diagnose infection in the absence of symptoms. Asymptomatic are healthy people who have an infection but are unaware of it. The epidemiology of asymptomatic Leishmaniasis is critical for its eradication. Only a small percentage of infected people are clinically suspected of having VL, as the majority of them may not show any symptoms and remain asymptomatic. Some asymptomatic infections may go away after a while, or they may linger for years, or they may develop to illness with clinical signs. Asymptomatic infection varies per endemic location, but almost all of them point to this hidden category of parasite infection. It is now critical to understand many factors such as diagnostic markers, genetic markers, and immunological markers along with different risk factors. All of these criteria, as well as some innovative techniques to diagnosing and controlling asymptomatic leishmaniasis, will be covered in this chapter. The main focus will be on asymptomatic condition of Indian Visceral Leishmaniasis, which is caused by Leishmania donovani and spreads via female sand fly P. argentipes biting. The numerous criteria that play a role in asymptomatic to symptomatic conversion in a specific time period will also be discussed in this chapter.",signatures:"Medhavi Sudarshan and Sumit Sharan",downloadPdfUrl:"/chapter/pdf-download/79223",previewPdfUrl:"/chapter/pdf-preview/79223",authors:[{id:"335269",title:"Assistant Prof.",name:"Medhavi",surname:"Sudarshan",slug:"medhavi-sudarshan",fullName:"Medhavi Sudarshan"},{id:"440228",title:"Dr.",name:"Sumit",surname:"Sharan",slug:"sumit-sharan",fullName:"Sumit Sharan"}],corrections:null},{id:"80815",title:"Geographical Distribution of Cutaneous Leishmaniasis and Pathogenesis",doi:"10.5772/intechopen.101841",slug:"geographical-distribution-of-cutaneous-leishmaniasis-and-pathogenesis",totalDownloads:68,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Leishmaniasis is still considered to be a global health problem, which spreads in most countries in the world. Leishmania is an intracellular obligate protistan parasite that causes different clinical symptoms in infected humans and other animals. There are clinically different types of the disease including: visceral, cutaneous or muco-cutaneous leishmaniasis. Approximately, two million new infections occurring annually; 0.7 to 1.2 million cases are recorded with cutaneous leishmaniasis and 200,000–400,000 cases return for visceral leishmaniasis. However, Cutaneous leishmaniasis considers one of uncontrolled wobbling endemic diseases, especially in Iraq, which occurs at the skin to cause a dermal lesion. Usually, the lesion is spontaneously healed to leave a colorless depressed scar and permanent immunity.",signatures:"Mohammed Hassan Flaih",downloadPdfUrl:"/chapter/pdf-download/80815",previewPdfUrl:"/chapter/pdf-preview/80815",authors:[{id:"419546",title:"Dr.",name:"Mohammed",surname:"Hassan Flaih",slug:"mohammed-hassan-flaih",fullName:"Mohammed Hassan Flaih"}],corrections:null},{id:"79230",title:"Geopolitical and Geospatial Conflicts Affecting Cutaneous Leishmaniasis: Iraqi Cases, 2014-2015",doi:"10.5772/intechopen.101147",slug:"geopolitical-and-geospatial-conflicts-affecting-cutaneous-leishmaniasis-iraqi-cases-2014-2015",totalDownloads:46,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"In Iraq, increment of cutaneous leishmaniasis (CL) was reported, a zoonotic type caused by Leishmania major and an anthroponotic type caused by Leishmania tropica. This is attributed to environmental changes, irregular construction, increased waste, and stray dogs in the cities. Internal displacement, poverty, and malnutrition play a role in the occurrence of disease. Iraq has been exposed to wars, civil war, widespread violence, and terrorism, Internal displacement of population, unlawful housing, shortage of municipal services, and accumulation of garbage have been increasing in the cities since 2003. Reports from Iraqi MOH documented an increase in the rate of CL. Eventually, case investigation, vector, and reservoir controls were suspended. Geopolitical conflicts and geospatial health deterioration contributed to an increase in various dominant reservoir species in these areas, particularly for ZCL, and the activity of the sand flies. A sudden sharp increase in CL cases was observed during 2003–2015. In conclusion, ongoing crises exposed Iraq to deterioration, collapse, and destruction of health system infrastructure and uncontrolled urbanization, all of which can act as risk factors for Leishmaniasis.",signatures:"Karim Abdulkadim Muftin Al Zadawi",downloadPdfUrl:"/chapter/pdf-download/79230",previewPdfUrl:"/chapter/pdf-preview/79230",authors:[{id:"419629",title:"Dr.",name:"Karim",surname:"Abdulkadim Muftin Al Zadawi",slug:"karim-abdulkadim-muftin-al-zadawi",fullName:"Karim Abdulkadim Muftin Al Zadawi"}],corrections:null},{id:"79857",title:"Use of Cell Biology to Identify Cellular Targets in Drug Development Process against Leishmania Sp.",doi:"10.5772/intechopen.101662",slug:"use-of-cell-biology-to-identify-cellular-targets-in-drug-development-process-against-em-leishmania-e",totalDownloads:136,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Leishmaniasis is one of the most important neglected tropical diseases. The chemotherapy for its treatment uses very toxic compounds with a low efficacy rate. Thus, there is an urgent need to develop new chemotherapeutic agents to help countries control this devasting disease. In drug development, different approaches can be used to identify potential cellular targets that allow us to understand better the cell biology of eukaryotic cells. Several groups are dedicated to studying new molecules, searching for promising candidates against Leishmania. Different techniques have been used to characterize the cell biology, biochemistry, and molecular biology alterations induced by the treatments, trying to understand the mechanisms of action. The main goal of this chapter is to describe an overview of the literature exploring the several studies published about the chemotherapy of anti-Leishmania concerning the mechanisms of action of different classes of molecules or therapeutic alternatives.",signatures:"Gabrielle dos Santos da Silva e Miranda, Joseane Lima Prado Godinho, Sara Teixeira de Macedo-Silva, Brunno Renato Farias Verçoza, Alisson Amaral da Rocha, Milena Barenco Pires de Abreu Sodré, Victor Feliciano dos Santos Ramos and Juliany Cola Fernandes Rodrigues",downloadPdfUrl:"/chapter/pdf-download/79857",previewPdfUrl:"/chapter/pdf-preview/79857",authors:[{id:"420224",title:"Associate Prof.",name:"Juliany",surname:"Cola Fernandes Rodrigues",slug:"juliany-cola-fernandes-rodrigues",fullName:"Juliany Cola Fernandes Rodrigues"},{id:"420943",title:"Ms.",name:"Gabrielle",surname:"dos Santos da Silva e Miranda",slug:"gabrielle-dos-santos-da-silva-e-miranda",fullName:"Gabrielle dos Santos da Silva e Miranda"},{id:"420944",title:"Dr.",name:"Brunno Renato",surname:"Farias Verçoza",slug:"brunno-renato-farias-vercoza",fullName:"Brunno Renato Farias Verçoza"},{id:"420945",title:"Mr.",name:"Alisson",surname:"Amaral Da Rocha",slug:"alisson-amaral-da-rocha",fullName:"Alisson Amaral Da Rocha"},{id:"421145",title:"Dr.",name:"Joseane",surname:"Lima Prado Godinho",slug:"joseane-lima-prado-godinho",fullName:"Joseane Lima Prado Godinho"},{id:"421148",title:"Dr.",name:"Sara",surname:"Teixeira de Macedo-Silva",slug:"sara-teixeira-de-macedo-silva",fullName:"Sara Teixeira de Macedo-Silva"},{id:"421152",title:"Ms.",name:"Milena",surname:"Barenco Pires De Abreu Sodré",slug:"milena-barenco-pires-de-abreu-sodre",fullName:"Milena Barenco Pires De Abreu Sodré"},{id:"421153",title:"Mr.",name:"Victor",surname:"Feliciano Dos Santos Ramos",slug:"victor-feliciano-dos-santos-ramos",fullName:"Victor Feliciano Dos Santos Ramos"}],corrections:null},{id:"79559",title:"Toward New Antileishmanial Compounds: Molecular Targets for Leishmaniasis Treatment",doi:"10.5772/intechopen.101132",slug:"toward-new-antileishmanial-compounds-molecular-targets-for-leishmaniasis-treatment",totalDownloads:118,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The leishmaniases are a group of diseases caused by protozoan parasites—Leishmania sp. Leishmaniasis is classified among the 20 neglected diseases by WHO. Although the disease has been known for more than 120 years, the number of drugs used for the treatment is still limited to 5–6. The first-line drugs against leishmaniasis are pentavalent antimonials, which were introduced to the treatment 70 years ago—despite all their side effects. Molecular targets are becoming increasingly important for efficacy and selectivity in postgenomic drug research studies. In this chapter, we have discussed potential therapeutic targets of antileishmanial drug discovery such as pteridine reductase (PTR1), trypanothione reductase (TR), N-myristoyltransferase (NMT), trypanothione synthetase (TryS), IU-nucleoside hydrolase, and topoisomerases, enzymes and their inhibitors reported in the literature.",signatures:"Huseyin Istanbullu and Gulsah Bayraktar",downloadPdfUrl:"/chapter/pdf-download/79559",previewPdfUrl:"/chapter/pdf-preview/79559",authors:[{id:"419167",title:"Assistant Prof.",name:"Huseyin",surname:"Istanbullu",slug:"huseyin-istanbullu",fullName:"Huseyin Istanbullu"},{id:"435370",title:"Dr.",name:"Gulsah",surname:"Bayraktar",slug:"gulsah-bayraktar",fullName:"Gulsah Bayraktar"}],corrections:null},{id:"79649",title:"microRNAs: Are They Important in the Development of Resistance in Leishmaniasis?",doi:"10.5772/intechopen.101514",slug:"micrornas-are-they-important-in-the-development-of-resistance-in-leishmaniasis-",totalDownloads:176,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Leishmaniasis is an infectious and parasitic disease of great importance in public health. Numerous studies indicate that biochemical and molecular mechanisms are factors that contribute to the emergence of antileishmanial drug resistance. Currently, miRNAs have been identified as targets for the invasion of pathogens to control the immune response and imply resistance to treatments. Considering the alarming growth in drug resistance, new possibilities for controlling leishmaniasis have been emerging. Natural compounds originating from medicinal plants are being increasingly explored as promising antileishmanial alternatives. The chapter aims to provide a brief review on mechanisms of action associated with traditional agents used to treat leishmaniasis, focusing mainly on molecular bases associated with the resistance of Leishmania spp. to current drugs and identifying the possible miRNAs involved in this process. In addition, we seek to describe some of the promising plant molecules that can be used as potential antileishmanial agents and their possible mechanisms of action.",signatures:"Sandra Alves de Araújo, Tatiane Aranha da Penha-Silva, Jaqueline Diniz Pinho, Marcelo de Souza Andrade and Ana Lucia Abreu-Silva",downloadPdfUrl:"/chapter/pdf-download/79649",previewPdfUrl:"/chapter/pdf-preview/79649",authors:[{id:"223173",title:"Dr.",name:"Ana Lucia",surname:"Abreu-Silva",slug:"ana-lucia-abreu-silva",fullName:"Ana Lucia Abreu-Silva"},{id:"233684",title:"Dr.",name:"Tatiane",surname:"Aranha da Penha-Silva",slug:"tatiane-aranha-da-penha-silva",fullName:"Tatiane Aranha da Penha-Silva"},{id:"421473",title:"MSc.",name:"Sandra",surname:"Alves de Araújo",slug:"sandra-alves-de-araujo",fullName:"Sandra Alves de Araújo"},{id:"428524",title:"Dr.",name:"Jaqueline",surname:"Diniz Pinho",slug:"jaqueline-diniz-pinho",fullName:"Jaqueline Diniz Pinho"},{id:"428526",title:"Dr.",name:"Marcelo",surname:"de Souza Andrade",slug:"marcelo-de-souza-andrade",fullName:"Marcelo de Souza Andrade"}],corrections:null},{id:"79718",title:"Molecular Informatics of Trypanothione Reductase of Leishmania major Reveals Novel Chromen-2-One Analogues as Potential Leishmanicides",doi:"10.5772/intechopen.100594",slug:"molecular-informatics-of-trypanothione-reductase-of-em-leishmania-major-em-reveals-novel-chromen-2-o",totalDownloads:135,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Trypanothione reductase (TR), a flavoprotein oxidoreductase is an important therapeutic target for leishmaniasis. Ligand-based pharmacophore modelling and molecular docking were used to predict selective inhibitors against TR. Homology modelling was employed to generate a three-dimensional structure of Leishmania major trypanothione reductase (LmTR). A pharmacophore model used to screen a natural compound library generated 42 hits, which were docked against the LmTR protein. Compounds with lower binding energies were evaluated via in silico pharmacological profiling and bioactivity. Four compounds emerged as potential leads comprising Karatavicinol (7-[(2E,6E,10S)-10,11-dihydroxy-3,7,11-trimethyldodeca-2,6-dienoxy]chromen-2-one), Marmin (7-[(E,6R)-6,7-dihydroxy-3,7-dimethyloct-2-enoxy]chromen-2-one), Colladonin (7-[[(4aS)-6-hydroxy-5,5,8a-trimethyl-2-methylidene-3,4,4a,6,7,8-hexahydro-1H-naphthalen-1-yl]methoxy]chromen-2-one), and Pectachol (7-[(6-hydroxy-5,5,8a-trimethyl-2-methylidene-3,4,4a,6,7,8-hexahydro-1H-naphthalen-1-yl)methoxy]-6,8-dimethoxychromen-2-one) with good binding energies of −9.4, −9.3, 8.8, and −8.5 kcal/mol, respectively. These compounds bound effectively to the FAD domain of the protein with some critical residues including Asp35, Thr51, Lys61, Tyr198, and Asp327. Furthermore, molecular dynamics simulations and molecular mechanics Poisson-Boltzmann surface area (MMPBSA) computations corroborated their strong binding. The compounds were also predicted to possess anti-leishmanial activity. The molecules serves as templates for the design of potential drug candidates and can be evaluated in vitro with optimistic results in producing plausible attenuating infectivity in macrophages.",signatures:"Samuel K. Kwofie, Gabriel B. Kwarko, Emmanuel Broni, Michael B. Adinortey and Michael D. Wilson",downloadPdfUrl:"/chapter/pdf-download/79718",previewPdfUrl:"/chapter/pdf-preview/79718",authors:[{id:"419961",title:"Dr.",name:"Samuel K.",surname:"Kwofie",slug:"samuel-k.-kwofie",fullName:"Samuel K. Kwofie"},{id:"429019",title:"Mr.",name:"Gabriel B.",surname:"Kwarko",slug:"gabriel-b.-kwarko",fullName:"Gabriel B. Kwarko"},{id:"429020",title:"Dr.",name:"Emmanuel",surname:"Broni",slug:"emmanuel-broni",fullName:"Emmanuel Broni"},{id:"429021",title:"Prof.",name:"Michael B.",surname:"Adinortey",slug:"michael-b.-adinortey",fullName:"Michael B. Adinortey"},{id:"429022",title:"Prof.",name:"Michael D.",surname:"Wilson",slug:"michael-d.-wilson",fullName:"Michael D. Wilson"}],corrections:null},{id:"80026",title:"Plant-Based Alternative Treatment for Leishmaniasis: A Neglected Tropical Disease",doi:"10.5772/intechopen.101958",slug:"plant-based-alternative-treatment-for-leishmaniasis-a-neglected-tropical-disease",totalDownloads:29,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Leishmaniasis is a third most important vector born disease caused by intracellular parasite belongs to genus Leishmania. The leishmaniasis is prevalent in 102 countries/areas worldwide. Approximately, it effected 350 million people worldwide. Leishmaniasis effects developing and undeveloped countries globally. Antileishmanial drugs (pentavalent antimonials, stibogluconate, miltefosine, paramycin, and amphotericin) are most vital tool for curing leishmaniasis. However, none of these drugs is free from side effect including cost, toxicity, drug resistance, administration route, and prolong time, these disadvantages are main obstacle in the Leishmania infection eradication. Considering the increasing cases of leishmaniasis and drug resistance there is an urgent need for an effective and novel approach against leishmaniasis. Therefore, many researchers have tried to develop new medicines for the treatment of Leishmania infection. In the course of new therapies identification, plant based compounds were found to be an alternative that can be either used directly or with structural modifications. Several plants have been known for ages to be the source of phytochemicals with high values of medicines. These phytochemicals have been extracted by various techniques and have shown efficacy for the curing of several diseases. This chapter study explain various applications based on green approaches drugs for the treatment of leishmaniasis.",signatures:"Nargis Shaheen, Chaitenya Verma and Naveeda Akhter Qureshi",downloadPdfUrl:"/chapter/pdf-download/80026",previewPdfUrl:"/chapter/pdf-preview/80026",authors:[{id:"224439",title:"Dr.",name:"Naveeda",surname:"Akhter Qureshi",slug:"naveeda-akhter-qureshi",fullName:"Naveeda Akhter Qureshi"},{id:"420059",title:"Dr.",name:"Nargis",surname:"Shaheen",slug:"nargis-shaheen",fullName:"Nargis Shaheen"},{id:"420980",title:"Dr.",name:"Chaitenya",surname:"Verma",slug:"chaitenya-verma",fullName:"Chaitenya Verma"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"2327",title:"Chromatography",subtitle:"The Most Versatile Method of Chemical Analysis",isOpenForSubmission:!1,hash:"730549acc4ff27929bb106ba63661172",slug:"chromatography-the-most-versatile-method-of-chemical-analysis",bookSignature:"Leonardo de Azevedo Calderon",coverURL:"https://cdn.intechopen.com/books/images_new/2327.jpg",editedByType:"Edited by",editors:[{id:"177382",title:"Dr.",name:"Leonardo de Azevedo",surname:"Calderon",slug:"leonardo-de-azevedo-calderon",fullName:"Leonardo de Azevedo Calderon"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"825",title:"Current Topics in Tropical Medicine",subtitle:null,isOpenForSubmission:!1,hash:"ef65e8eb7a2ada65f2bc939aa73009e3",slug:"current-topics-in-tropical-medicine",bookSignature:"Alfonso J. 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In the first part of the second section, rainfall erosivity is estimated on the basis of pluviograph records and cumulative rainfall depths by means of empirical equations and machine learning methods. In the second part of the second section, a physically-based, hydrodynamic, finite element model is described for the computation of surface runoff and channel flows. In the first part of the third section, the soil erosion risk is assessed in two different basins. In the second part of the third section, the soil erosion risk management in a basin is evaluated, and the delimitation of the areas requiring priority planning is achieved.",isbn:"978-1-78985-196-0",printIsbn:"978-1-78985-195-3",pdfIsbn:"978-1-78985-581-4",doi:"10.5772/intechopen.74884",price:119,priceEur:129,priceUsd:155,slug:"soil-erosion-rainfall-erosivity-and-risk-assessment",numberOfPages:134,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"055d0c17144224427913ec894a6aa82a",bookSignature:"Vlassios Hrissanthou and Konstantinos Kaffas",publishedDate:"December 18th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/7300.jpg",keywords:null,numberOfDownloads:5519,numberOfWosCitations:11,numberOfCrossrefCitations:8,numberOfDimensionsCitations:14,numberOfTotalCitations:33,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 15th 2018",dateEndSecondStepPublish:"March 8th 2018",dateEndThirdStepPublish:"May 7th 2018",dateEndFourthStepPublish:"July 26th 2018",dateEndFifthStepPublish:"September 24th 2018",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"4 years",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"37707",title:"Prof.",name:"Vlassios",middleName:null,surname:"Hrissanthou",slug:"vlassios-hrissanthou",fullName:"Vlassios Hrissanthou",profilePictureURL:"https://mts.intechopen.com/storage/users/37707/images/system/37707.png",biography:"Dr.-Ing. Vlassios Hrissanthou is an Emeritus Professor at the Civil Engineering Department of Democritus University of Thrace (DUTH), Xanthi, Greece. He studied Civil Engineering at the Aristotle University of Thessaloniki (AUTH), Greece, obtaining the diploma of Civil Engineer in 1972. He then undertook postgraduate and doctoral studies on Hydrology and Hydraulic Structures at the University of Karlsruhe (KIT), Germany. Subsequently, he completed a postdoctoral study on Hydraulics and Hydraulic Structures at the University of the Armed Forces Munich (UniBw München), Germany. His teaching work includes the following graduate and postgraduate study courses: Fluid Mechanics, Hydraulics, Engineering Hydrology, River Engineering, Hydropower Engineering, Water Resources Management, Open Channel Hydraulics, Hydrology of Groundwater, Advanced Engineering Hydrology, Sediment Transport, Reservoir Design, Time Series Analysis, Selected Chapters of Hydropower Engineering, and Hydraulics of Stratified Flows. He has supervised a plethora of diploma, postgraduate and doctoral dissertations. He has participated as principal investigator in several competitive international, german and greek research projects, dealing amongst others with soil erosion and sediment transport. Professor Hrissanthou is the author and co-author of 48 publications in scientific journals, 88 publications in conference proceedings, as well as 12 publications in book chapters in English, Greek and German. Finally, he has reviewed numerous publications for 49 international scientific journals.",institutionString:"Democritus University of Thrace",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"5",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Democritus University of Thrace",institutionURL:null,country:{name:"Greece"}}}],coeditorOne:{id:"200942",title:"Dr.",name:"Konstantinos",middleName:null,surname:"Kaffas",slug:"konstantinos-kaffas",fullName:"Konstantinos Kaffas",profilePictureURL:"https://mts.intechopen.com/storage/users/200942/images/system/200942.png",biography:"Dr.-Ing. Konstantinos Kaffas is a researcher at the Civil Engineering Department of Democritus University of Thrace (DUTH), Xanthi, Greece and a member of the Greek Chamber of Civil Engineers since 2008. He received his diploma in Environmental Engineering from DUTH, in 2007. Subsequently he pursued postgraduate studies (M.Sc.) in Hydraulic Engineering and Water Resources Management Works. Since May 2017, he holds a Ph.D. in the field of hydromorphological modeling at the basin scale. His scientific interests and expertise include soil erosion, sediment transport, hydrological and hydraulic modeling, river basin management and flood risk assessment. During the last years, he has co-authored 6 publications in international scientific journals, 3 international conferences and 1 book chapter, and has also reviewed several publications. Dr. Kaffas is giving lectures on courses such as Advanced Engineering Hydrology, Sediment Transport, and Reservoir Design, in DUTH, since 2014. He has working experience in Civil/Environmental Engineering and has participated in the completion of several Environmental Impact Assessments.",institutionString:"Free University of Bozen-Bolzano",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Free University of Bozen-Bolzano",institutionURL:null,country:{name:"Italy"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"676",title:"Soil Degradation",slug:"soil-degradation"}],chapters:[{id:"69684",title:"Introductory Chapter: Soil Erosion at a Glance",slug:"introductory-chapter-soil-erosion-at-a-glance",totalDownloads:985,totalCrossrefCites:2,authors:[{id:"37707",title:"Prof.",name:"Vlassios",surname:"Hrissanthou",slug:"vlassios-hrissanthou",fullName:"Vlassios Hrissanthou"},{id:"200942",title:"Dr.",name:"Konstantinos",surname:"Kaffas",slug:"konstantinos-kaffas",fullName:"Konstantinos Kaffas"}]},{id:"66807",title:"Rainfall Erosivity and Its Estimation: Conventional and Machine Learning Methods",slug:"rainfall-erosivity-and-its-estimation-conventional-and-machine-learning-methods",totalDownloads:1300,totalCrossrefCites:6,authors:[{id:"23439",title:"Dr.",name:"Epaminondas",surname:"Sidiropoulos",slug:"epaminondas-sidiropoulos",fullName:"Epaminondas Sidiropoulos"},{id:"287846",title:"Dr.",name:"Konstantinos",surname:"Vantas",slug:"konstantinos-vantas",fullName:"Konstantinos Vantas"},{id:"287847",title:"Dr.",name:"Chris",surname:"Evangelides",slug:"chris-evangelides",fullName:"Chris Evangelides"}]},{id:"62965",title:"Simulation of Surface Runoff and Channel Flows Using a 2D Numerical Model",slug:"simulation-of-surface-runoff-and-channel-flows-using-a-2d-numerical-model",totalDownloads:1379,totalCrossrefCites:0,authors:[{id:"26297",title:"Dr.",name:"Yafei",surname:"Jia",slug:"yafei-jia",fullName:"Yafei Jia"}]},{id:"69110",title:"Evaluating Differences of Erosion Patterns in Natural and Anthropogenic Basins through Scenario Testing: A Case Study of the Claise, France and Nahr Ibrahim, Lebanon",slug:"evaluating-differences-of-erosion-patterns-in-natural-and-anthropogenic-basins-through-scenario-test",totalDownloads:976,totalCrossrefCites:0,authors:[{id:"308327",title:"Prof.",name:"Rachid",surname:"Nedjai",slug:"rachid-nedjai",fullName:"Rachid Nedjai"},{id:"308884",title:"Mr.",name:"Mario",surname:"Al Sayah",slug:"mario-al-sayah",fullName:"Mario Al Sayah"},{id:"308885",title:"Prof.",name:"Chadi",surname:"Abdallah",slug:"chadi-abdallah",fullName:"Chadi Abdallah"},{id:"308887",title:"Dr.",name:"Michel",surname:"Khouri",slug:"michel-khouri",fullName:"Michel Khouri"},{id:"308888",title:"Prof.",name:"Talal",surname:"Darwish",slug:"talal-darwish",fullName:"Talal Darwish"},{id:"308889",title:"Mr.",name:"François",surname:"Pinet",slug:"francois-pinet",fullName:"François Pinet"}]},{id:"69983",title:"Spatial Analysis of the Erosive Hazard of Soils and Natural Risks of Reservoir Siltation",slug:"spatial-analysis-of-the-erosive-hazard-of-soils-and-natural-risks-of-reservoir-siltation",totalDownloads:879,totalCrossrefCites:0,authors:[{id:"249619",title:"Dr.",name:"Rabii",surname:"El Gaatib",slug:"rabii-el-gaatib",fullName:"Rabii El Gaatib"}]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"177730",firstName:"Edi",lastName:"Lipovic",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/177730/images/4741_n.jpg",email:"edi@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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1. Introduction
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Beef and lamb, are a food category with positive and negative nutritional attributes. Ruminant meats are major sources for many bioactive compounds including iron, zinc and B vitamins. However they are associated with nutrients and nutritional profiles that are considered negative including high levels of saturated fatty acids (SFA) and cholesterol. It is well know that the low PUFA/SFA and high n-6/n-3 ratio of meats contribute to the imbalance in the in the fatty acid intake of today consumers [1]. Consumers are becoming more aware of the relationships between diet and health and this has increased consumer interest in the nutritional value of foods. Nutritionist advisers recommended a higher intake of polyunsaturated fatty acids (PUFA), especially n-3 PUFA at the expense of n-6 PUFA.
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The nutritional beef and lamb profile could be further improved by addition of potentially health promoting nutrients. There are many references of improved fatty acid composition in grass fed beef. Besides the beneficial effects of n-3 fatty acids on human health one fatty acid that has drawn significant attention for its potential health benefits in the last two decades is conjugated linoleic acid (CLA). Conjugated linoleic acids (CLA) are implicated as anti-carcinogenic, anti-atherosclerosis, and anti-inflammatory agents in a variety of experimental model systems. It has been shown that in ruminants grazing have potential beneficial effects on PUFA/SFA and n-6/n-3 ratios, increasing the PUFA and CLA content and decreasing the SFA concentration of beef [2].
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The total CLA content of beef varies from 0.17 to 1.35% of fat [3]. This wide range is related to the type feed, breed differences, and management strategies used to raise cattle [3, 4]. Grazing beef steers on pasture or increasing the amounts of forage (grass or legumes hay) in the diet has been shown to increase the CLA content in the fat of cattle. Also, supplementing high-grain diets of beef cattle with oils (e.g., soybean oil, linseed oil, sunflower oil) may increase the CLA content of beef [3, 5].
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There has been an increased interest in the substitution of animal fat sources with vegetable oils in animal nutrition. Vegetable oils have been attributed with reducing the level of saturation in monogastric animal tissues due to their unsaturated fatty acid concentration when compared with animal fat. In ruminants, dietary lipids were undergo two important transformations in the rumen. The initial transformation is the hydrolysis of the ester bond by microbial lipases. This initial step is a pre requisite for the second transformation, the biohydrogenation of unsaturated fatty acids [6, 7].
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Several factors influence the CLA content of beef as breed, sex, seasonal variation, type of muscle, production practices but diet plays the most important role. Dietary CLA from beef can be increased by manipulation of animal diets. CLA concentration in beef can be influenced by dietary containing oils or oilseeds high in PUFA, usually linoleic or linolenic fatty acids.These dietary practices can increase CLA concentrations up to 3 fold [5, 8]. Moreover, trans-11 18:1 (vaccenic acid,VA) is the precursor of cis-9,trans-11 18:2 ( rumenic acid, RA) is the major CLA isomer in animal and humans and, therefore, it might be considered as a fatty acid with beneficial properties.
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Soybean oil is one of the few plant sources providing ample amounts of both essential fatty acids 18:2 n-6 and 18:3 n-3. The fatty acid content of soy foods is often unrecognized by health professionals, perhaps because there is so much focus on soy proteins. Soybeans are used in cattle, poultry and pigs diets and could be a more important source of 18:3 n-3 for animal nutrition and also increase 18:3 n-3 and its fatty acids metabolites in meats. Genomics, specifically marker assisted plant breeding combined with recombinant DNA technology, provided powerful means for modifying the composition of oilseeds to improve their nutritional value and provide the functional properties required for various food oils [9].
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Thus, the manipulation of the fatty acid composition in ruminant meat to reduce SFA content and the n-6/n-3 ratio whilst, simultaneously increasing the PUFA and CLA contents, is the major importance in meat research. The supplementation of ruminant diets with PUFA rich lipids is the most effective approach to decrease saturated FA and promote the enrichment of CLA and n-3 PUFA.
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2. CLA structure, biosynthesis and potential beneficial effects on human health
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The CLA acronym refers to a group of positional and geometric isomers of linoleic acid, in which the double bands are conjugated. At least twenty four different CLA isomers have been reported as occurring naturally in food, especially from ruminant origin [10]. Isomerisation and incomplete hydrogenation of PUFA in the rumen produce several of octadecenoic, octadecadienoic and octadecatrienoic isomeric fatty acids [11] and, at least some of them, have powerful biological properties. The formation of conjugated dienes in the rumen during biohydrogenation of lipids in feed was observed previously, however, the anticarcinogenic effect of beef extracts was first observed and later identified [12, 13, 14].
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The dominant CLA in ruminant meats is the cis-9, trans-11 isomer (RA) which has being identified as possessing a range of health promoting biological properties including antitumoral and anticarcinogenic activities [15]. The rumenic acid is mostly produced in tissues by delta 9 desaturation of trans-11 18:1, (VA) and by ruminal biohydrogenation of dietary PUFA. The higher deposition of CLA in the neutral lipid fraction, 88% of total CLA relatively to phospholipid fraction, has been reported [16].The majority of the main natural isomer cis-9,trans-11 CLA does not originate directly from the rumen. Instead, only small amounts of CLA escape the rumen and trans-18:1 isomers are the main biohydrogenation intermediates available. El absorbed trans-11 18:1 is desaturated in the tissues by ∆9-desaturase to form RA [17]. Stearoyl-CoA (SCD) is a rate-limiting enzyme responsible for the conversion of SFA into monounsaturated fatty acids (MUFA). This enzyme, located in the endoplasmic reticulum, inserts a double band between carbons 9 and 10 into SFA and affects the fatty acid composition of membrane phospholipids, triglycerides and cholesterol esters [18]. SCD is also a key enzyme in the endogenous production of the cis-9,trans-11 isomer of conjugated linoleic acid (CLA). Trans octadecenoates (trans 18:1) are the major intermediates formed during rumen biohydrogenation of C18 PUFA. High trans-10 18:1 have been observed in tissues of concentrated-fed ruminants, whereas vaccenic acid is consistently associated with forage feeding [11, 19]. Evidence is accumulating that different trans 18:1 isomers have differential effects on plasma LDL cholesterol. Trans-9 and trans-10 18:1 are more powerful in increasing plasma LDL cholesterol than trans-11 18:1 [20]. Comparison of antiproliferative activities of different CLA isomers present in beef on a set of human tumour cells demonstrates that all CLA isomers possess antiproliferative properties. It appears that important to determine the variations of the distribution of CLA isomers in beef since these proportions could influence the biological properties of bioformed CLA [21].
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3. Factors influencing CLA concentrations on beef lipids
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Amounts of CLA in beef vary mainly with feeding conditions, nature and quality of forages, proportions between forage and concentrate, oil-seed supplementations, but also with intrinsic factors such as breed and sex and age of animals [22].
Breed or genotype and production system are determinant factors of the fatty acid composition of the ruminant meats. Breed affects the fat content of meat and fat content itself is a factor determining fatty acid composition. Genetic variability relates to differences between breeds or lines, variation due to the crossing of breeds and variation between animals within breeds reported that it can be difficult to assess the real contribution of genetics to variation in the CLA content.
Conjugated linoleic acid (CLA) concentrations on beef according to breed, sex and age\n.a b Indicates a significant differences (at least p < 0.05) between breed, sex or age reported within each respective study. Abbreviations LD: Longissimus dorsi ; SM: Semimembranosus ; LL Longissimus lumborum; LT Longissimus thoracis; Sub: Subcutaneous fat. \n
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Significant between-breed differences in CLA content were observed in both muscle and subcutaneous adipose tissue of five breeds of cattle with the highest values in Longhorn and with the lowest in Hereford [23]. German Holstein bulls accumulated a higher amount of CLA compared with German Simmental bulls [24]. CLA percentages were affected by breed with the low values for Angus beef compared with Charolais x Angus and Holstein Argentine steers [25]. The content of trans -10 C18:1 isomer tended to be higher in Limousin compared to Tudanca meat when expressed as mg/100g of meat, and the difference was only significant when expressed in terms of relative percent. The higher level of trans-10 C18:1 was consistent with the greater consumption of concentrate by Limousin calves [26]. Within a similar production system the age/weight, gender and crossbreeding practices have minor effects on muscle FA composition but Mertolenga-PDO veal has higher total CLA contents that PDO beef and PGI veal [ 27]. On the contrary the cis-9, trans-11 CLA levels among steers of Nguni, Bonsmara and Angus breeds raised on natural pasture were similar [28]. Similar results were found comparing the CLA content of Limousin and Aberdeen Angus beef [29].
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Sex and age differences in muscle FA contents are often be explained by the degree of fatness and associated changes in the triacylglycerol/phospholipid ratio [30]. Sex-dependent differences in the FA composition of muscle an adipose tissue from cattle slaughtered at different ages were demonstrated [31]. Concentration CLA in meat beef not affected by castration [32].
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3.2. Type muscle and anatomical location (Table 2)
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Little work has been conducted to assess the effects of slaughter season and muscle type on meat CLA profile. The type of muscles strongly influenced proportions of total CLA and of all CLA isomers classes in intramuscular fatty acids (Table 2). CLA is mainly associated to the triacylglycerol fraction which is linked to the fat content of tissues [21]. VA and CLA percentages were lower in lean muscle than subcutaneous fat or marbling [33]. The CLA content of steaks differs depending on the location of the fat, CLA level was almost doubled in outer subcutaneous fat compared to lean muscle [34]. There was significant differences in the concentration of CLA among depot sites through-out a bovine carcass. The brisket contained a higher concentration of cis-9, trans-11 CLA but no significant differences in the concentrations of trans-10, cis-12 CLA among the locations [35].
No differences between dietary grass silage and red clover silage were detected on CLA content of LD muscle of dairy cull cows [36]. Total CLA content was lower (p< 0.05) in intensively produced beef than in Carnalentejana-PDO meat, which did not show significant differences (p<0.05) when the slaughter season was compared. Furthermore Longissimus thoracis (LT) muscle had a higher (p<0.001) total CLA content relative to Longissimus dorsi (LD) muscle. In addition no significant differences (p<0.05) regarding specific CLA content were observed when slaughter season, production system and muscle type were analyzed [37]. Significant interactions between the slaughter season and muscle type were obtained for several fatty acid and CLA isomers and for total lipid and CLA. Mirandesa –PDO veal showed seasonal differences in the levels of CLA isomers but the CLA content was affected by much more influence by the muscle type [38]. The variation of CLA milk fat content during pasture season might be related to the alfa-linolenic/linoleic acid ratio in the pasture. The ratio in the average pasture sample decreased from 4.36 in May to 1.97 in August, and subsequently it increased to 3.14 in September, thus close to that at the beginning of pasture season. Thus the seasonal variation of the ratio in pasture were directly proportional to the corresponding content of CLA in ewe milk fat [39].
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\n\t\t\t\t\t\t\t\tCLA \n\t\t\t\t\t\t\t
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\n\t\t\t\t\t\t\t\tMuscle and adipose tissue location \n\t\t\t\t\t\t\t
Conjugated linoleic acid (CLA) concentrations on beef according to muscle and adipose tissue location, season and grass composition \n\t\t\t\t\t\ta b Indicates a significant differences (at least p<0.05) between anatomical location, season or pasture type reported within each respective study. Abbreviations LD: Longissimus dorsi ; SM: Semimembranosus ; LL Longissimus lumborum; LT Longissimus thoracis\n\t\t\t\t\t\t
A direct linear relation between grass percentage in cattle diet and meat CLA content has been described by [2] although the mechanism remains controversial. They suggested that grass in the diet enhances the growth of ruminal bacterium Butyrivibrio fibrisolvens which convert 18:2 n-6 into cis-9, trans-11 CLA isomer through the action of a linoleic acid isomerase. Others [40] proposed that the increased content of CLA in animals fed forage- based diets is associated with an increase in trans-11 18:1, which is the substrate of stearoyl-CoA desaturase in tissues. It is generally accepted that the concentrations of CLA can be increased in beef by increasing the forage to concentrate ratio, and by feeding fresh grass instead of grass silage [4, 22] (Table 3). Beef contains both of the bioactive CLA isomers, namely, cis-9, trans-11 and trans-10, cis-12. Many reports demonstrated that cis-9, trans 11 CLA is a major fatty acid in tissue and little or no trans-10, cis 12 CLA was detected [ 5,41]. High trans-10 18:1 have been observed in tissues of concentrated-fed ruminants, whereas vaccenic acid is consistently associated with forage feeding [11, 19]. Significantly higher contents of trans-18:1 were found in animals fed on concentrate diets relative to the pasture diet. This is mainly due to the trans-6, trans-8, trans-9 and trans-10 isomers, since the trans-11 and trans-12 18:1 remains unaffected by the dietary treatments. The feeding systems, pasture only, pasture feeding followed by 2 or 4 months of finishing on concentrate, and concentrate only, had a major impact on the concentration of CLA isomers from bull LD muscles. Beef fat from pasture-fed animals had a higher nutritional quality relative to that from concentrate-fed bulls and the feeding regimen had a major impact on the CLA isomeric distribution of beef affecting 10 of 14 CLA isomers. The CLA isomeric profile showed a clear predominance of the cis-9, trans-11 isomer for all diets [42]. The grass silage diets increased the proportions of trans-11 18:1 and cis-9, trans-11 18:2. Feeding a high forage diet may therefore have increased the rate of appearance of trans-11 18:1 in the rumen, providing more substrate for the endogenous production and deposition of CLA in bovine tissues [43]. This hypothesis is consistent with an increase of trans-11 18:1 concentration with no effect on cis-9, trans-11 in duodenal content of Hereford steers fed increasing levels of grass hay [44]. The relative flow of PUFA through the major biohydrogenation pathways, trans-10 or trans-11, 18:1, can be judged by the 11t-/10t- 18:1 ratio with a higher ratio denoting an improvement in its healthfulness to its human consumers [45]. Backfat composition was compared in steers fed either a control (barley grain based) diet or diets containing increasing levels of corn or wheat derived dried distillers’grains with solubles (DDGS). Back fat from control and wheat derived DDGS fed steers had lower levels of trans-18:1 and a higher 11trans/10 trans 18:1 ratio compared to back fat from corn derived DDGS fed steers [45]. The explanation might be found in ruminal biohydrogenation pathway of LA and ALA. Most of the cis-9, trans-11 CLA isomer present in tissues derive from endogenous desaturation of trans-11, 18:1, which originates during biohydrogenation of 18:2 n-6 and 18:3 n-3. The CLA concentrations in three different muscles of pasture- or feedlot-finished cattle were greater from pasture-finished than from cattle feedlot-finished [46]. The absolute cis-9, trans-11 CLA was about twice as high in Asturiana de la montaña (AV) and Asturiana del Valle (AV) animals than in other AV genotypes, probably due to the much higher fat content of the AM and AV animals [47]. This effect was also found in other studied were cis-9, trans-11 content variation was influenced by the total lipid content, and hence with variation in the neutral lipid fraction [48]. A linear correlation between VA and cis-9, trans-11 CLA was observed in several studies [8] and in other studied no significant correlation was found [49]. Breed or genotype effects could act by enhancing or inhibiting the ∆9-desaturase activity. The major isomers in beef fed a high barley diet is trans-10, 18:1 rather than trans-11, 18:1. In feedlot finished beef fed a diet containing 73% barley was found 2.13 % of trans-10 18:1 and only 0.77% of trans-11 18:1 in subcutaneous fat [19, 50]. Feeding ruminants diets with high levels of barley (low fiber, high starch) reduces rumen pH, alters the bacterial flora and causes a shift in the biohydrogenation pathway towards producing trans-10 18:1 instead of trans-11 18:1 [51]. Subcutaneous fat is quite sensitive to changes in diet and rumen function. This is due to adipose tissue having a high proportion of neutral lipids which accumulate greater levels of PUFA biohydrogenation products relative to polar lipids [24]. In addition, subcutaneous fat is easily accessible, inexpensive and levels of trans-18:1 have been reported to be linearly related to those found in muscle [52]. Vaccenic acid made up the greatest concentration of total trans fats in grass-fed beef, whereas CLA accounted for approximately 15% of the total trans fats [53].
Conjugated linoleic acid (CLA) concentrations on beef under dietary grass or concentrate \n\t\t\t\t\t\ta b Indicates a significant differences (at least p<0.05) between dietary grass or concentrate reported within each respective study. Abbreviations LD: Longissimus dorsi ; Longissimus thoracis ; ST: Semitendinosus
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3.5. Oil supplementation (Tables 4 & 5)
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The most common method of enhancing the CLA and VA content of ruminant meat and dairy products is to provide the animal with additional dietary unsaturated fatty acids, usually from plants oils such as soybean oil (SBO), for use as substrates for ruminal biohydrogenation [4]. Steers fed a corn-based diet supplemented with SBO may enhance TVA without impacting CLA, while reducing the MUFA content of lean beef [54]. Both oilseed and free oils affect CLA content in a similar manner. Free plant oils with high PUFA concentrations are normally not included in ruminant diets as high levels of dietary fat disturb the rumen environment and inhibit microbial activity. The main sources of supplementary fatty acids in ruminant rations are plant oils and oilseeds, fish oils, marine algae and fat supplements. Since dietary inclusion of fatty acids must be restricted to avoid impairment of rumen function, the capacity to manipulate the fatty acid composition by use of ruminally available fatty acids is limited [55]. Many researchers have found higher CLA content in muscle lipids by supplementing with different oils. However, some studies reported no significant differences in CLA content due to oil supplementations. The differences in responses to plant oils were probably due to variations in stage of growth of cattle, levels of oil supplementation, levels of oil in total ration and amount of linoleic acid in oils. Researchers have successfully increased CLA content by supplementation of different oils [4,48,56]. Others [3] supplementing with 4% SBO to diets did not affect the CLA. Similar to [41] who reported that feeding 5% SBO no affected CLA but increased trans10-cis-12 CLA. The addition of different vegetable oils to the bulls diet (soybean or linseed, either protected or not protected from rumen digestion) increased the CLA content, with an average CLA value of 0.72 %. The increase of CLA was also due to the addition of oils presenting large quantities of its precursor LA in diets with unprotected soybean and linseed oils [57]. Diets containing silage and concentrate or sugarcane and sunflower seeds fed Canchim- breed animals, produce an improvement in CLA levels (0.73g/100g vs. 0.34g/100) [58]. Rapeseed oil and whole rapeseed do not seem to have positive effects. Of the three studied none showed increased CLA concentrations in the LDi after supplementation with 6% rapeseed oil [41]. Soybean oil (SBO) has been used as a source de LA throughout the finishing period to promote greater CLA accretion in lean tissues with equivocal results [56, 41]. and where CLA accretion was increased with SBO addition, growth performance was reduced [56]. Fed steers with 5% of soybean oil in a finishing experiment for 102 days had no effects in meat cis-9, trans, 11 CLA [41]. In a study with steers, supplementation of 4% soybean oil to a finishing diet based on concentrate and forage (80:20) resulted in a depression of the CLA deposition in muscle tissues (2.5 vs. 3.1 mg/g FAME) compared to the same diet without soybean oil On the other hand, comparing 4% with 8% added soybean oil in a 60:40 concentrate : forage diet showed a numerical increase of the CLA content with the higher soybean supplementation (2.8/3.1 mg/g FAME) [59]. The inclusion of sunflower oil in the diets (80% barley, 20% barley silage) of finishing cattle at 0%, 3%, or 6% increased the CLA content of the beef by 75% when cattle were fed 6% sunflower oil [4]. Although supplementation with oil or oil seeds increased CLA content in muscle, the inclusion of linoleic acid –rich oil or oilseeds such as safflower or sunflower, in the diet of ruminants appears to be the most effective [60]. Supplementation of cattle with a blend of oils rich in n-3 PUFA and linoleic acid results in a synergistic accumulation of ruminal and tissue concentrations of TVA [61]. VA is the substrate for ∆9 –desaturase- catalyzed de novo tissue tissue synthesis of cis-9 trans-11 isomer of CLA. However, despite increases in its substrate, muscle tissue concentrations of cis-9, trans-11 CLA have not increased by using this strategy [62]. Inclusion of extruded linseed in the diet of Limousin and Charolais cattle, increase CLA [63]. The importance of the contribution of TVA to total CLA intake is further reinforced by a French study [64] in which a huge 233% increase of VA was shown, along with 117% increase of RA, which was caused by adding extruded linseeds into the animal fodder. Several authors reported that diets containing proportionally high levels of linolenic acid, such as fresh grass, grass silage, and concentrates containing linseed, resulted in increased deposition of the cis-9, trans-11 CLA isomer in muscle [65]. The biohydrogenation by rumen microorganism does not include the cis-9, trans-11 CLA isomer as an intermediate. The trans-11 18:1 is the common intermediate during the biohydrogenation of dietary linoleic acid and linolenic acid to stearic acid [6]. Since only a relatively small percentage the cis-9, trans-11 CLA isomer, formed in the rumen, is available for deposition on the muscles, the major source of this isomer in muscle results from the endogenous synthesis involving ∆ 9 desaturase and vaccenic acid [17].. Hereford steers cannulated in the proximal duodenum were used to evaluated the effects of forage and sunflower oil level on ruminal biohydrogenation and conjugated linoleic acid. Flow of trans-10 18:1 decreased linearly as dietary forage level increased whereas trans -11 18:1 flow to the duodenum increased linearly with increased dietary forage. Dietary forage or sunflower oil levels did not alter the outflow of cis-9, trans-11 CLA [44]. Linseed supplementation was an efficient way to increase CLA proportion in beef (+22% to 36%) but was highly modulated by the nature of the basal diet, and by intrinsic factors as breed, age/sex, type of muscle, since these ones could modulate CLA proportions in beef from 24% to 47% [21]. Soybean oil, which is rich in linoleic acid, has been found in several studied [66,67,] to be more efficient than linseed oil, which is rich in linolenic acid, in increasing the CLA content of milk. In beef cattle the addition of 3% and 6% sunflower oil to a barley based finishing diet results in increased CLA content in LD muscle: 2.0 vs 2.6 vs. 3.5 mg/g lipid for control, 3%,, and 6% sunflower oil, respectively. A more substantial increase in the CLA concentration was found when sunflower oil was added to both the growing and finishing diet of beef cattle.[68,69]. 4.3, 6,3 and 9.1 mg CLA / g FAME in LD muscle lipids of heifers, were found, after supplementing the feed with 0, 55, and 110 g sunflower oil per kg of the diet for 142 days before slaughter [48]. Supplementation of a high forage fattening diet with either soybean oil or extruded full fat soybeans at a level of 33g added oil per kg of diet DM resulted in a 280-410 % increase in the concentration of CLA in the intramuscular and subcutaneous lipid depots of fattening Friesian bull calves The content of VA in both lipid depots were also increased about three-fold by this oil supplementation [70].
Trans-11 and trans 10 C18:1 isomer proportions on beef under different conditions. \n\t\t\t\t\t\ta b Indicates a significant differences (at least p<0.05) between trans-10 C18:1 and trans-11 C18:1 reported within each respective study. ”na” indicates that the value was not reported in the original study. Abbreviations LD: Longissimus dorsi ; LL Longissimus lumborum LT: Longissimus thoracis.
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4. Factors influencing CLA concentrations on lamb lipids
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In lamb production, more than other species, each country or region has its own specific weight/age and type of carcass criteria, depending on the culture and the customs of the people. Many factors including breed, gender, age/body weight, fatness, depot site, environmental condition, diet and rearing management influence lamb fat deposition and composition. Further studied are needed to understand how animal circadian rhythms, diurnal rumination patterns and daily changes in herbage chemical composition could affect lamb fatty composition [71].
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4.1. Production system (Tables 6 & 8)
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No differences were detected in the muscle CLA/ trans-11 18:1 index of herbage or concentrate –fed lambs but the supplementation of tanino produced strong effects on the accumulation of fatty acids which are involved in the biohydrogenation pathway [72]. During two years (Y1 and Y2) lambs were under four diets. Only silage both pre and post weaning (SS), only silage until weaning, silage plus concentrate thereafter (SC), silage plus concentrate both pre and post weaning (CC) and silage plus concentrate before weaning, only silage after (CS). Treatment differences for trans-11 18:1 were presented only in Y1, with muscle from the lamb fed silage before weaning having the highest levels. The same groups has the highest levels of cis-9, trans 11 CLA in Y1. Similar in Y2 the group SS has the highest CLA level, while the CC group has the lowest [73]. The feeding strategy around parturition influence the CLA and VA content of lamb meat. Pre-partum grazing, regardless of post-partum feeding, can improve the fatty acid composition, increasing the CLA content in lamb meat [74]. The meat of lambs slaughtered at Christmas has a higher CLA content than those reared in winter (slaughtered at Easter) as a result of the traditional feeding system which provided that lambs born and reared in autumn receive milk from ewes permanently pastured while those reared in winter are suckled by ewes permanently stall-fed [75]. The grazing on T.subterraneum as monoculture, associated with L. multiflorum in the proportion T/L=66/33 incremented cis-9,trans-,11 CLA of L. dorsi muscle of lambs [76]. The meat fatty acid profile was affected by the grazing management: compared to a morning-grazing or to a whole day-grazing management. Allowing lambs to gaze in the afternoon resulted in a meat fatty acid profile richer in CLA. In particular, in the 4hPM meat there is a greater proportion of those fatty acids arising from ruminal biohydrogenation, among them the CLA [71].
Conjugated linoleic acid (CLA) concentrations on lamb meat according to concentrate, pasture, muscle type and season.\n\t\t\t\t\t\ta b Indicates a significant differences (at least p<0.05) between values reported within each respective study. Abbreviations LD: Longissimus dorsi ; ST: Semitendinosus ; LL Longissimus lumborum; ; LT: Longissimus toracsis; SM: Semimembranosus.
Several strategies have been tested in recent years to improve CLA isomers in meat of intensively–reared lambs, keep indoors and fed high-concentrate diets rich linoleic acid and poor in linolenic. Incorporating linseed rich, in linolenic acid, the proportion of trans-11, 18:1 and cis-9, trans-11 18:2 were higher in the muscle and in the adipose tissues of linseed –fed lambs than in control lambs [77]. This increased is in contrast to results of [78] but in agreement with [79]. Discrepancias between these studies may due to differences in the level of intake the linoleic and linolenic acids or the different level of ∆9- desaturase inhibition as it has been shown that ∆9 desaturase is inhibited by PUFA with increasing inhibition as the degree of fatty acid unsaturation increases. Fed lambs from weaning to slaughter with diets that contained 5% supplemental from high oleic acid safflower or normal safflower increased the meat cis-9,trans,11 CLA compared with the control group [80] In lambs inclusion of 8% of soybean oil to a lucerne hay-based diet resulted in an intramuscular (M. Longissimus thoracis ) CLA content of 23.7 compared with 5.5 mg/g FAME in the control group [81]. Feeding soybean and linseed oils to lambs pre and post weaning did not increase CLA content of muscle, whereas post weaning oil supplementation minimally increased CLA concentration in subcutaneous fat [82]. Conflicting results have been reported on altering FA content of meat supplementing ruminant diets with lipid sources high in linoleic and linolenic acids. Some research suggests supplementing CLA, linoleic or linolenic acids in high concentrate fed to lambs can increase CLA content in muscle [ 83], whereas supplementation of linoleic in finishing diets fed to cattle had no effects on CLA in adipose or muscle tissue [3,41]. Feeding lipid sources rich in linoleic and linolenic increases the cis-9,trans-11 18:2 content of ruminant meats [21,81, 83,84]. However, feeding linseed oil, rich in linolenic acid, seems to be less effective in the increases of cis-9, trans-11 18:2 in muscle than sunflower oil, rich in linoleic acid [45,48]. Seems to be that a blend of sunflower and linseed oils may be a good approach to obtain an enrichment in CLA in lamb meat. Maximun CLA concentrations (42.9 mg/100 g fresh lamb tissue ) was observed with 100% of sunflower, decreasing linearly at 78% by sunflower oil with linseed oil replacement [86]. A consistent significant increase in CLA content in lamb tissues was observed with dietary supplementation with 6% of safflower oil. The CLA concentration in several lamb tissues was increased by more than 200% [39]. These results indicated that supplementation of lamb feedlot diets with a source of LA was a successful method of increasing CLA content of tissues. Merino Branco ram lambs initially fed with concentrate showed a lower proportions of cis-9,trans-11 18:2 CLA (0.98% vs. 1.38% of total fatty acids) than lambs initially fed with Lucerne. Initial diet did not compromise the response to the CLA promoting diet (dehydrated lucerne plus 10% soybean oil) and the proportion of cis-9,trans-11 C18:2 CLA in intramuscular fat increased with the duration of time on the CLA-promoting diet (1.02% vs. 1.34% of total fatty acids) [87]. Supplementation of oilseed with different levels of oleic (rapeseed), linoleic (sunflower and safflower seeds), and linolenic acid (linseed) on trans-11 18:1 and CLA isomers on ewe different tissues showed that the percentage of trans-11 C18:1 averaged around 4.56 % of total fatty acids for all supplements and tissues [88]. Increasing dietary forage and soybean oil did not change the sheep mixed ruminal microbes concentration of vaccenic acid but increased rumenic acid [89].
Conjugated linoleic acid (CLA) concentrations on lamb meat according to dietary oil.\n\t\t\t\t\t\ta b Indicates a significant differences (at least p<0.05) between valus reported within each respective study. Abbreviations LD: Longissimus dorsi ; LL Longissimus lumborum; LT Longissimus thoracis
Conjugated linoleic acid (CLA) isomer proportionson lamb under different condicions. \n\t\t\t\t\t\ta b Indicates a significant differences (at least p<0.05) between values reported within each respective study. ”na” indicates that the value was not reported in the original study. Abbreviations LD: Longissimus dorsi ; LM: Semimembranosus; Sub: Subcutaneous
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5. Conclusions
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Several factors influence the CLA content of ruminant meats as breed, sex, seasonal variation, type of muscle, production practices but diet plays the most important role. CLA concentration in beef and lamb can be influenced by dietary containing oils or oilseeds high in PUFA, usually linoleic or linolenic fatty acids. The supplementation of ruminant diets with PUFA rich lipids is the most effective approach to decrease saturated FA and promote the enrichment of CLA and n-3 PUFA. The differences in responses to plant oils were probably due to variations in stage of growth of animals, levels of oil supplementation, levels of oil in total ration and amount of linoleic acid in oils. Thus, the manipulation of the fatty acid composition in ruminant meat to reduce SFA content and the n-6/n-3 ratio whilst, simultaneously increasing the PUFA and CLA contents, is the major importance in meat research.
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\n\t\n',keywords:null,chapterPDFUrl:"https://cdn.intechopen.com/pdfs/40841.pdf",chapterXML:"https://mts.intechopen.com/source/xml/40841.xml",downloadPdfUrl:"/chapter/pdf-download/40841",previewPdfUrl:"/chapter/pdf-preview/40841",totalDownloads:2241,totalViews:292,totalCrossrefCites:2,totalDimensionsCites:6,totalAltmetricsMentions:0,impactScore:2,impactScorePercentile:79,impactScoreQuartile:4,hasAltmetrics:0,dateSubmitted:"March 23rd 2012",dateReviewed:"August 22nd 2012",datePrePublished:null,datePublished:"February 20th 2013",dateFinished:"November 8th 2012",readingETA:"0",abstract:null,reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/40841",risUrl:"/chapter/ris/40841",book:{id:"3244",slug:"soybean-bio-active-compounds"},signatures:"Pilar Teresa Garcia and Jorge J. Casal",authors:[{id:"33493",title:"Dr.",name:"Pilar Teresa",middleName:null,surname:"Garcia",fullName:"Pilar Teresa Garcia",slug:"pilar-teresa-garcia",email:"pitegarcia@yahoo.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"National Agricultural Technology Institute",institutionURL:null,country:{name:"Argentina"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. CLA structure, biosynthesis and potential beneficial effects on human health",level:"1"},{id:"sec_3",title:"3. Factors influencing CLA concentrations on beef lipids",level:"1"},{id:"sec_3_2",title:"3.1. Breed, sex and age (Table 1)",level:"2"},{id:"sec_4_2",title:"3.2. Type muscle and anatomical location (Table 2)",level:"2"},{id:"sec_5_2",title:"3.3. Season and pasture type (Table 2)",level:"2"},{id:"sec_6_2",title:"3.4. Grass vs. concentrate (Tables 3 & 5)",level:"2"},{id:"sec_7_2",title:"3.5. Oil supplementation (Tables 4 & 5)",level:"2"},{id:"sec_9",title:"4. Factors influencing CLA concentrations on lamb lipids",level:"1"},{id:"sec_9_2",title:"4.1. Production system (Tables 6 & 8)",level:"2"},{id:"sec_10_2",title:"4.2. Oil supplementation (Tables 7& 8). ",level:"2"},{id:"sec_12",title:"5. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRusso\n\t\t\t\t\t\t\tG. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2009\n\t\t\t\t\tDietary n-6 and n-3 polyunsaturated fatty acids: From biochemical to chemical implications in cardiovascular prevention. Biochemical Pharmacolog 77\n\t\t\t\t\t937\n\t\t\t\t\t946\n\t\t\t\t\n\t\t\t'},{id:"B2",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFrench\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tStanton\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLawless\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tO`\n\t\t\t\t\t\t\tRiordan. 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P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJoos\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPiper\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2010\n\t\t\t\t\tEffectof sampling fat location and cooking on fatty acid composition of beef steaks.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t84\n\t\t\t\t\t86\n\t\t\t\t\t92\n\t\t\t\t\n\t\t\t'},{id:"B34",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPestana\n\t\t\t\t\t\t\tJ. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCosta\n\t\t\t\t\t\t\tA. S. H.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlves\n\t\t\t\t\t\t\tS. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMartins\n\t\t\t\t\t\t\tS. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlfaia\n\t\t\t\t\t\t\tC. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2012\n\t\t\t\t\tSeasonal changes and muscle type effect on the nutritional quality of intramuscular fat in Mirandesa-PDO veal\n\t\t\t\t\tMeat Science\n\t\t\t\t\t90\n\t\t\t\t\t819\n\t\t\t\t\t827\n\t\t\t\t\n\t\t\t'},{id:"B35",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTurk\n\t\t\t\t\t\t\tS. N.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSmith\n\t\t\t\t\t\t\tS. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2009\n\t\t\t\t\tCarcass fatty acid mapping.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t81\n\t\t\t\t\t658\n\t\t\t\t\t663\n\t\t\t\t\n\t\t\t'},{id:"B36",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLee\n\t\t\t\t\t\t\tM. R. F.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEvans\n\t\t\t\t\t\t\tP. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNute\n\t\t\t\t\t\t\tG. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRichardson\n\t\t\t\t\t\t\tR. I.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tScollan\n\t\t\t\t\t\t\tN. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2009\n\t\t\t\t\tA comparison between red clover silage and grass silage feeding on fatty acid composition, meat stability and sensory quality of the M. Longissimus muscle of dairy cull cows.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t81\n\t\t\t\t\t738\n\t\t\t\t\t744\n\t\t\t\t\n\t\t\t'},{id:"B37",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlfaia\n\t\t\t\t\t\t\tC. M. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRibeiro\n\t\t\t\t\t\t\tV. S. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLourenco\n\t\t\t\t\t\t\tM. R. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tQuaresma\n\t\t\t\t\t\t\tM. A. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMartins\n\t\t\t\t\t\t\tS. I. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPortugal\n\t\t\t\t\t\t\tA. P. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t2006\n\t\t\t\t\tFatty acid composition, conjugated linoleic acid isomers and cholesterol in beef from crossbred bullocks intensively produced and from Alentejana purebred bullocks reared according to Carnalentejana-PDO specifications\n\t\t\t\t\tMeat Science\n\t\t\t\t\t72\n\t\t\t\t\t425\n\t\t\t\t\t436\n\t\t\t\t\n\t\t\t'},{id:"B38",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlfaia\n\t\t\t\t\t\t\tC. P. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCastro\n\t\t\t\t\t\t\tM. L. F.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMartins\n\t\t\t\t\t\t\tS. I. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPortugal\n\t\t\t\t\t\t\tA. P. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlves\n\t\t\t\t\t\t\tS. P. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFontes\n\t\t\t\t\t\t\tC. M. G. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t2007\n\t\t\t\t\tInfluence of slaughter season and muscle type on fatty acid composition, conjugated linoleic acid isomeric distribution and nutritional quality of intramuscular in Arouquesa-PDO veal.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t76\n\t\t\t\t\t787\n\t\t\t\t\t795\n\t\t\t\t\n\t\t\t'},{id:"B39",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMel’uchova\n\t\t\t\t\t\t\tB.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBlasko\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKubinec\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGorova\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2008\n\t\t\t\t\tSeasonal variations in fatty acid composition of pasture forage plant and CLA content in ewe milk fat.\n\t\t\t\t\tSmall Ruminant Research\n\t\t\t\t\t78\n\t\t\t\t\t56\n\t\t\t\t\t65\n\t\t\t\t\n\t\t\t'},{id:"B40",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDaniel\n\t\t\t\t\t\t\tZ. C. T. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWynn\n\t\t\t\t\t\t\tR. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSalter\n\t\t\t\t\t\t\tA. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tButtery\n\t\t\t\t\t\t\tP. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2004\n\t\t\t\t\t Differing effects of forage and concentrate diets on the oleic acid and the conjugated linoleic acid content of sheep tissues.\n\t\t\t\t\tJournal of Animal Science\n\t\t\t\t\t82\n\t\t\t\t\t747\n\t\t\t\t\t758\n\t\t\t\t\n\t\t\t'},{id:"B41",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBeaulieu\n\t\t\t\t\t\t\tA. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDrackley\n\t\t\t\t\t\t\tJ. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMerchen\n\t\t\t\t\t\t\tN. 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A. .\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002\n\t\t\t\t\tFatty acid profile of milk and rumen digesta from cows fed fish oil, extruded soybean or their blend.\n\t\t\t\t\t Journal Dairy Science.\n\t\t\t\t\t85\n\t\t\t\t\t2266\n\t\t\t\t\t2276\n\t\t\t\t\n\t\t\t'},{id:"B62",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKenny\n\t\t\t\t\t\t\tD. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKelly\n\t\t\t\t\t\t\tJ. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMonahan\n\t\t\t\t\t\t\tF. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMoloney\n\t\t\t\t\t\t\tA. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2007\n\t\t\t\t\tEffect of dietary fish and soya oil on muscle fatty acid concentrations and oxidative lipid stability in beef cattle.\n\t\t\t\t\tJournal Animal Science\n\t\t\t\t\t85\n\t\t\t\t\t1\n\t\t\t\t\t911\n\t\t\t\t\n\t\t\t'},{id:"B63",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBarton\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMarounek\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKudrna\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBures\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tZahradkova\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2007\n\t\t\t\t\tGrowth performance and fatty acid profiles of intramuscular and subcutaneous fat from Limousin and Charolais heifers fed extruded linseed\n\t\t\t\t\tMeat Science\n\t\t\t\t\t76\n\t\t\t\t\t517\n\t\t\t\t\t523\n\t\t\t\t\n\t\t\t'},{id:"B64",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWeill\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSchmitt\n\t\t\t\t\t\t\tB. 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G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChesneau\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDaniel\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSafraou\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLegrand\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002\n\t\t\t\t\tEffects of introducing linseed oil in livestock diet on blood fatty acid composition of consumers of animal products.\n\t\t\t\t\tAnnals of Nutrition and Metabolism\n\t\t\t\t\t46\n\t\t\t\t\t182\n\t\t\t\t\t191\n\t\t\t\t\n\t\t\t'},{id:"B65",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDannenberger\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNuernberg\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNuernberg\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tScollan\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSteinhart\n\t\t\t\t\t\t\tH. y.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEnder\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2005\n\t\t\t\t\tEffect of pasture vs. concentrate diet on CLA isomers distribution in different tissue lipids of beef cattle.\n\t\t\t\t\tLipids\n\t\t\t\t\t40\n\t\t\t\t\t589\n\t\t\t\t\t598\n\t\t\t\t\n\t\t\t'},{id:"B66",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDhiman\n\t\t\t\t\t\t\tT. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSatter\n\t\t\t\t\t\t\tL. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPariza\n\t\t\t\t\t\t\tM. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGalli\n\t\t\t\t\t\t\tM. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlbright\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTolosa\n\t\t\t\t\t\t\tM. X. .\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2000\n\t\t\t\t\tConjugated linoleic acid (CLA) content of milk from cows offered diets rich in linoleic and linolenic acid.\n\t\t\t\t\tJournal Dairy Science\n\t\t\t\t\t83\n\t\t\t\t\t1016\n\t\t\t\t\t1027\n\t\t\t\t\n\t\t\t'},{id:"B67",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChouinard\n\t\t\t\t\t\t\tP. Y.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCorneau\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tButler\n\t\t\t\t\t\t\tW. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChilliard\n\t\t\t\t\t\t\tY.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDrackley\n\t\t\t\t\t\t\tJ. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBauman\n\t\t\t\t\t\t\tD. E. .\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2001\n\t\t\t\t\tEffect of dietary lipid source on conjugated linolei acid concentrations in milk fat. Journal Dairy Science 84\n\t\t\t\t\t680\n\t\t\t\t\t690\n\t\t\t\t\n\t\t\t'},{id:"B68",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMir\n\t\t\t\t\t\t\tP. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMir\n\t\t\t\t\t\t\tZ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKuber\n\t\t\t\t\t\t\tP. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGasking\n\t\t\t\t\t\t\tC. T.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMartin\n\t\t\t\t\t\t\tE. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDodson\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tElias\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCalles\n\t\t\t\t\t\t\tJ. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJohnson\n\t\t\t\t\t\t\tK. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBusboom\n\t\t\t\t\t\t\tJ. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWood\n\t\t\t\t\t\t\tA. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPittenger\n\t\t\t\t\t\t\tG. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tReeves\n\t\t\t\t\t\t\tJ. J. .\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002\n\t\t\t\t\tGrowth, carcass characteristics, muscle conjugated linoleic acid (CLA) content, and response to intravenous glucose challenge in high percentage Wagyu, Wagyu x Limousin, and Limousin steers fed sunflower oil-containing diets.\n\t\t\t\t\tJournal Animal Science\n\t\t\t\t\t80\n\t\t\t\t\t2996\n\t\t\t\t\t3004\n\t\t\t\t\n\t\t\t'},{id:"B69",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMir\n\t\t\t\t\t\t\tP. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMc Allister\n\t\t\t\t\t\t\tT. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tZaman\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJones\n\t\t\t\t\t\t\tS. D. 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I.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLuciano\n\t\t\t\t\t\t\tg.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tScerra\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCaparra\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFoti\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t2012\n\t\t\t\t\tEffect of morning vs. afternoon on intramuscular fatty acid composition in lamb.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t90\n\t\t\t\t\t93\n\t\t\t\t\t98\n\t\t\t\t\n\t\t\t'},{id:"B72",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVasta\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPriolo\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tScerra\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHallet\n\t\t\t\t\t\t\tK. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWood\n\t\t\t\t\t\t\tJ. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDoran\n\t\t\t\t\t\t\tO.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2009\n\t\t\t\t\tΔ9 desaturase protein expression and fatty acid composition of longissimus dorsi muscle in lamb fed green herbage or concentrate with or without added tannins.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t82\n\t\t\t\t\t357\n\t\t\t\t\t364\n\t\t\t\t\n\t\t\t'},{id:"B73",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBernes\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTurner\n\t\t\t\t\t\t\tT.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPickova\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2012\n\t\t\t\t\tSheep fed only silage supplement with concentrates. 2. Effects on lamb performance and fatty acid profile of ewe milk and lamb meat.\n\t\t\t\t\tSmall Ruminant Research\n\t\t\t\t\t102\n\t\t\t\t\t114\n\t\t\t\t\t124\n\t\t\t\t\n\t\t\t'},{id:"B74",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJoy\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRipoll\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMolino\n\t\t\t\t\t\t\tF.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDervishi\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlvarez\n\t\t\t\t\t\t\tRodriguez. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2012\n\t\t\t\t\tInfluence of the type of forage supplied to ewes in pre- and post-partum periods on the meat fatty acid of suckling lambs.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t90\n\t\t\t\t\t775\n\t\t\t\t\t782\n\t\t\t\t\n\t\t\t'},{id:"B75",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMazzone\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGiammarco\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVignola\n\t\t\t\t\t\t\tG.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSardi\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLambertini\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2010\n\t\t\t\t\tEffects of rearing season on carcass and meat quality of suckling Apennine light lambs. \n\t\t\t\t\tMeat Science\n\t\t\t\t\t86\n\t\t\t\t\t474\n\t\t\t\t\t478\n\t\t\t\t\n\t\t\t'},{id:"B76",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChiofalo\n\t\t\t\t\t\t\tB.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSimonella\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDi Grigoli\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLiotta\n\t\t\t\t\t\t\tL.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFrenda\n\t\t\t\t\t\t\tA. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLo\n\t\t\t\t\t\t\tPresti. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBonanno\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChiofalo\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2010\n\t\t\t\t\tChemical and acidic compostion of Longissimus dorsi of Comisana lambs fed with Trifolium subterraneum and Lolium multiflorum.\n\t\t\t\t\tSmall Ruminant Research\n\t\t\t\t\t88\n\t\t\t\t\t89\n\t\t\t\t\t96\n\t\t\t\t\n\t\t\t'},{id:"B77",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBerthelot\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBas\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSchmidely\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2010\n\t\t\t\t\tUtilization of extruded linseed to modify fatty acid composition of intensively-reared lamb meat: Effect of associated cereals (wheat vs. corn) and linoleic acid content of the diet.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t84\n\t\t\t\t\t114\n\t\t\t\t\t124\n\t\t\t\t\n\t\t\t'},{id:"B78",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBas\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBerthelot\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPottier\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNormand\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2007\n\t\t\t\t\tEffect of linseed on fatty acid composition of muscles and adipose tissues of lamb with emphasis on trans fatty acids. Meat Science 77\n\t\t\t\t\t678\n\t\t\t\t\t688\n\t\t\t\t\n\t\t\t'},{id:"B79",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWachira\n\t\t\t\t\t\t\tA. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSinclair\n\t\t\t\t\t\t\tL. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWilkinson\n\t\t\t\t\t\t\tR. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEnser\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWood\n\t\t\t\t\t\t\tJ. D.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFisher\n\t\t\t\t\t\t\tA. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002\n\t\t\t\t\tEffects of dietary fat source and breed on the carcass composition, n-3 polyunsaturated fatty acid and conjugated linoleic acid content of sheep and adipose tissue. \n\t\t\t\t\tJournal of Nutrition\n\t\t\t\t\t88\n\t\t\t\t\t697\n\t\t\t\t\t709\n\t\t\t\t\n\t\t\t'},{id:"B80",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBolte\n\t\t\t\t\t\t\tM. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHess\n\t\t\t\t\t\t\tB. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMeans\n\t\t\t\t\t\t\tW. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMoss\n\t\t\t\t\t\t\tG. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRule\n\t\t\t\t\t\t\tD. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002\n\t\t\t\t\tFeeding lambs high-oleate or high-linoleate safflower seeds differentially influences carcass fatty acid composition.\n\t\t\t\t\tJournal Animal Science\n\t\t\t\t\t80\n\t\t\t\t\t609\n\t\t\t\t\t616\n\t\t\t\t\n\t\t\t'},{id:"B81",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSantos-Silva\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBessa\n\t\t\t\t\t\t\tR. J. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMendes\n\t\t\t\t\t\t\tI. 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P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFigueredo\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTexeira\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRodriguez\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJaneiro\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t2006\n\t\t\t\t\tDiscrimination of production system and origin of animal products using chemical markers\n\t\t\t\t\tIn Animal Products from the Mediterranean area. EAAP Publication\n\t\t\t\t\t119\n\t\t\t\t\t231\n\t\t\t\t\t240\n\t\t\t\t\tThe Netherland: Wageningen Academic Publishers.\n\t\t\t'},{id:"B85",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBessa\n\t\t\t\t\t\t\tR. J. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlves\n\t\t\t\t\t\t\tS. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJeronimo\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlfaia\n\t\t\t\t\t\t\tC. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPrates\n\t\t\t\t\t\t\tJ. A. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSantos-Silva\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2007\n\t\t\t\t\tEffect of lipid supplements on ruminal biohydrogenation intermediates and muscle fatty acids in lambs.\n\t\t\t\t\tEuropean Journal of Lipid Science Technology\n\t\t\t\t\t109\n\t\t\t\t\t868\n\t\t\t\t\t878\n\t\t\t\t\n\t\t\t'},{id:"B86",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJeronimo\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tAlves\n\t\t\t\t\t\t\tS. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPrates\n\t\t\t\t\t\t\tJ. A. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSantos-Silva\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBessa\n\t\t\t\t\t\t\tR. J. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2009\n\t\t\t\t\tEffect of dietary replacement of sunflower oil with linseed oil on intramuscular fatty acids of lamb meat\n\t\t\t\t\tMeat Science\n\t\t\t\t\t84\n\t\t\t\t\t499\n\t\t\t\t\t505\n\t\t\t\t\n\t\t\t'},{id:"B87",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBessa\n\t\t\t\t\t\t\tR. J. B.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLourenco\n\t\t\t\t\t\t\tM.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPortugal\n\t\t\t\t\t\t\tP. V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSantos-Silva\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2008\n\t\t\t\t\tEffects of previous diet and duration of soybean oil supplementation on light lamb carcass composition, meat quality and fatty acid composition.Meat Science 80\n\t\t\t\t\t1100\n\t\t\t\t\t1105\n\t\t\t\t\n\t\t\t'},{id:"B88",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPeng\n\t\t\t\t\t\t\tY. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBrown\n\t\t\t\t\t\t\tM. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWu\n\t\t\t\t\t\t\tJ. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLiu\n\t\t\t\t\t\t\tZ.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2010\n\t\t\t\t\tDifferent oilseed supplements alter fatty acid composition of different adipose tissues of adult ewes.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t85\n\t\t\t\t\t542\n\t\t\t\t\t549\n\t\t\t\t\n\t\t\t'},{id:"B89",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKucut\n\t\t\t\t\t\t\tO.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHess\n\t\t\t\t\t\t\tB. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRule\n\t\t\t\t\t\t\tD. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2008\n\t\t\t\t\tFatty acid composition of mixed ruminal microbes isolated from sheep supplemented with soybean oil.\n\t\t\t\t\t Research in Veterinary Science\n\t\t\t\t\t84\n\t\t\t\t\t213\n\t\t\t\t\t224\n\t\t\t\t\n\t\t\t'},{id:"B90",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRealini\n\t\t\t\t\t\t\tC. 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V.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMurray\n\t\t\t\t\t\t\tB. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMoloney\n\t\t\t\t\t\t\tA. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tTroy\n\t\t\t\t\t\t\tD.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBerian\n\t\t\t\t\t\t\tM. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2009\n\t\t\t\t\tThe effect of cooking on the fatty acid composition of Longissimus dorsi muscle from beef steers fed rations designed to increase the concentration of conjugated linoleic acid in tissue.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t81\n\t\t\t\t\t307\n\t\t\t\t\t312\n\t\t\t\t\n\t\t\t'},{id:"B94",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPavan\n\t\t\t\t\t\t\tE.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDuckett\n\t\t\t\t\t\t\tS. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2007\n\t\t\t\t\tCorn oil supplementation to steers grazing endophyte-free tall fescue. 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A.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2011\n\t\t\t\t\tEffects of vitamin E and flaxseed on rumen-derived fatty acid intermediates in beef intramuscular fat.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t88\n\t\t\t\t\t434\n\t\t\t\t\t440\n\t\t\t\t\n\t\t\t'},{id:"B96",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGarcia\n\t\t\t\t\t\t\tP. T.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCasal\n\t\t\t\t\t\t\tJ. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFianuchi\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMagaldi\n\t\t\t\t\t\t\tJ. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRodriguez\n\t\t\t\t\t\t\tF. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tNancucheo\n\t\t\t\t\t\t\tJ. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2008\n\t\t\t\t\tConjugated linolenic acid (CLA) and polyunsaturated fatty acids in muscle lipids of lamb from the Patagonian area of Argentina.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t79\n\t\t\t\t\t541\n\t\t\t\t\t548\n\t\t\t\t\n\t\t\t'},{id:"B97",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMir\n\t\t\t\t\t\t\tZ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRushfeldt\n\t\t\t\t\t\t\tM. I.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPaterson\n\t\t\t\t\t\t\tL. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWeselake\n\t\t\t\t\t\t\tP.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2000\n\t\t\t\t\tEffects of dietary supplementation with CLA or linoleic rich oil in the lamb content of lamb tissues.\n\t\t\t\t\tSmall Ruminant Research\n\t\t\t\t\t36\n\t\t\t\t\t25\n\t\t\t\t\t31\n\t\t\t\t\n\t\t\t'},{id:"B98",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKott\n\t\t\t\t\t\t\tR. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHatfield\n\t\t\t\t\t\t\tP. G.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBergman\n\t\t\t\t\t\t\tJ. W.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFlyn\n\t\t\t\t\t\t\tC. R.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tVan Wagoner\n\t\t\t\t\t\t\tH.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBoles\n\t\t\t\t\t\t\tJ. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003\n\t\t\t\t\tFeedlot performance, carcass composition, and muscle and fat CLA concentrations of lambs fed diets supplemented with safflower seeds.\n\t\t\t\t\tMeat Science\n\t\t\t\t\t49\n\t\t\t\t\t11\n\t\t\t\t\t17\n\t\t\t\t\n\t\t\t'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Pilar Teresa Garcia",address:"pgarcia@cnia.inta.gov.ar",affiliation:'
Area Bioquimica y Nutricion. Instituto Tecnologia de Alimentos. Centro de Investigacion en Agroindustria. Instituto Nacional Tecnologia Agropecuaria. INTA Castelar, CC77(B1708WAB) Moron, Pcia Buenos Aires, Argentina
'},{corresp:null,contributorFullName:"Jorge J. Casal",address:null,affiliation:'
Universidad de Moron. Facultad de Ciencias Agroalimentarias. Cabido 137. Moron , Pcia Buenos Aires, Argentina
'}],corrections:null},book:{id:"3244",type:"book",title:"Soybean",subtitle:"Bio-Active Compounds",fullTitle:"Soybean - Bio-Active Compounds",slug:"soybean-bio-active-compounds",publishedDate:"February 20th 2013",bookSignature:"Hany A. 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1. Introduction
Genitourinary fistulas are abnormal tracts between the genital and urinary tracts. Abnormal tracts connecting the urinary system to any structure of the pelvic floor [1], gastrointestinal tract and the skin are also regarded as urinary fistulas [2]. Obstetric fistula is an abnormal hole connecting the vagina to the bladder (VVF), the rectum (RVF), the ureter (UVF) or a combination of these which leads to uncontrollable leakage of urine or feces or both through the vagina, and resulted usually as a complication of difficult labor. Urinary fistulas are severe physical, social and psychological debilitating conditions [3]. It presents as a surprise, taking the patient and caring physician unawares. The commonest type, vesicovaginal fistula (VVF) is still very common in the rural areas especially in Northern Nigeria, [4] and Ethiopia [5]. Thus, this condition is basically a rural disease. Rural area is characterized by meager earnings, low education and poor infrastructure [6]. In the developing countries the attending healthcare worker may be a Traditional Birth Attendant (TBA), traditional healer, quack, midwife, medical officer, obstetrician and gynecologist, surgeon or urologist. In the context of this work, the rural practitioner is a qualified medical doctor practising in the rural area, and is available and accessible to those who suffer from genitourinary fistulas.
The questions are, “will the integration of rural practitioners in the efforts towards elimination of obstetric fistulas reduce the prevalence and burden of the conditions?” What roles will the rural practitioner play in the treatment and management of genitourinary fistulas?
The true incidence of genitourinary fistulas in the developing countries is not known, [7] but some authors have put rates for VVF at 1–3 per 1000 deliveries [8], 3.5 per 1000 births [9] and 5–10 per 1000 deliveries [10]. In contrast VVF is no longer common in the developed countries as a result of improved obstetrics care; and results mainly as a complication of pelvic surgery, malignancy and radiotherapy [11].
This chapter will dwell on fistulas caused by trauma, including obstetric and iatrogenic, and its aim is to highlight the strategic position of rural practitioners in the prevention of genitourinary fistulas, the benefits that will be derived from their education and training on the subject matter, and to suggest a framework for their roles in the treatment and management of these conditions.
1.1 Objectives
The objectives of this work are to:
Rekindle attention to the burden of genitourinary fistulas in the rural areas.
Emphasize the importance of preventive strategies and stratify them for easy identification of roles and levels of participation by rural practitioners and specialized centers.
Empower the rural practitioner with information to identify and specify complex fistula varieties that require referral to specialized centers.
Prepare the rural practitioner to initiate informed early treatment and care for the genitourinary fistula patient.
Rekindle advocacy and solicit for regular fistula missions to reduce the prevalence and number in the waiting list.
Engage and train interested rural practitioners on effective preventive strategies and efficient fistula surgery, as they are more available and accessible to these rural fistula patients.
2. Etiology
2.1 Causes of genitourinary fistulas
Obstructed labor is the main cause of VVF in the rural areas accounting for between 56 and 97.88% in some series [4, 12, 13, 14, 15, 16].
Other causes of genitourinary fistulas in the developing world are well reported, [4, 5, 7, 9, 10, 12, 13, 14, 15, 16, 17], and shown on Table 1.
SN
Etiology
Type(s)
1
Obstetric Obstructed labor. Injury to the bladder during cesarean section. Uterine rupture into the bladder. Perineal tear during childbirth. Forceps lacerations
Etiology of genitourinary fistulas in rural practice.
Table 2 summaries the etiology of genitourinary fistulas encountered by the author in rural practice from January 2000 to December 2020. Two of the VVF cases were associated with big vesical calculi; one of them had also vesicocutaneous fistula. Urethrovaginal fistulas are not common as noted in Table 2. They were complications of vaginal hysterectomy and consequences of vaginal procedures by quacks and homeopaths.
SN
Etiology
Type(s) of Fistulas(s)
No. of cases
Remarks
1. a b c d e
Obstetrics Obstructed labor Cesarean section Uterine rupture into the bladder Perineal tear Forceps injury
Referred by medical officers, obstetrician and gynecologists, midwives or directed by relatives or friends. There were attempted repairs in 19. The RVFs occurred in association with VVF.
2 a b c
Post gynecologic surgery Abdominal hysterectomy Vaginal hysterectomy Myomectomy
UVF 6, VVF 4 VCF 2 VVF4, Ur VF 3, EVF 1 VVF 4
12 8 4
Referred or invited by gynecologists Referral from gynecologists.
3 a b c 4 a b
Pelvic and inguinal surgeries General surgery Urology Inguinal herniorrhaphy Complications of procedures by unqualified personnel Homeopaths Quacks
VCuF 2 RUF 1, VCuF 8 VCuF 7 VVF 2 VVF 2, UrVF 1
2 9 7 2 3
The fistulas from urology procedures arose from the wounds of suprapubic cystostomies that failed to close spontaneously after removal of catheter. Injury to bladder sliding with hernial sac. Treating cystocele Treating Uterovaginal Prolapse
4
Circumcision
Ur C F 12
12
Infants.
5
Fall From height
VRF 2, RUF 2
4
Fell astride sharp pointed object. All males
6 a b
Violence Gunshot Stab injury
RUF4, UrCF3, VEF2, VCuF 1: from base of bladder to upper left thigh. RUF 2
10 2
One patient was shot with locally made hand shotgun forcefully inserted in his anus by armed robbers One patient was pinned in a bent over position at the waist and stabbed through the anus with a dagger.
7 a b c d
Miscellaneous Retained gauze After vaginal surgery Occupational hazard Infection Foreign body in the urethra Total
VVF 1 RVF 1 UrCF 1 UrVF 1 142
1 1 1 1
Lady farmer fell onto a cassava stem stump while harvesting cassava root by uprooting method.
Table 2.
Genitourinary fistulas encountered by the author in rural practice.
Rectovaginal Fistulas and other urinary fistulas are less common. RVF resulted from trauma mostly, and when it occurred during obstructed labor, it was associated with VVF. Urethrocutaneous fistulas in infants resulting from circumcision mishaps were not rare. These procedures were performed by traditional health attendants, hospital attendants, nurses, midwives and medical officers. The surgical residents at the Federal Medical Center Owerri, Nigeria perform circumcision under the supervision of team consultants since 2000. The less commonly occurring vesicouterine fistula (VUF) and vesicocervical fistula are complications of difficult cesarean sections (CS) [16], and uterine rupture. When urinary fistula occurs as a complication of treatment the effect is devastating to the trained care giver even though the propensity for medicolegal litigation is very low in the rural areas. The patient often stays isolated, withdrawn, miserable and depressed. The husbands and relatives of patients in my experience have been supportive and cooperative in contrast to other reports especially from northern Nigeria [3, 4, 5, 6, 7, 8, 9, 10, 18].
2.1.1 Risk factors
The risk factors related to the development of urogenital fistulas in the rural areas that appear in the literature, [7, 12, 14, 16, 17, 18, 19, 20, 21, 22, 23] are enumerated in Table 3. Other factors especially in the developed world include periurethral bulking, Burch Culpo suspension, urethral diverticulum repair, and loop excision of the cervix [24, 25, 26, 27, 28]. Endometriosis, gynecologic cancer, pelvic irradiation, schistosomiasis, intrauterine device and neglected pessary have also been reported [12, 14].
Contributory factors to this burden are poor transport infrastructure, lack of skilled medical personnel and collapsed public healthcare delivery system [6]. Specialists in surgery and obstetrics and gynecology show little interest in fistula surgery, and rarely practice in rural areas. Bad roads prolong the time interval between onset of labor and arrival to hospital or make it impossible for the journey [7, 9].
In southern Nigeria many roads are not passable during the peak of rainy season: July–September. Brain drains affect developing countries seriously as their trained healthcare professionals relocate or emigrate to Europe, America, Canada, Saudi Arabia for greener pastures [29, 30]. In this situation, these hapless young pregnant women turn to the familiar, available and accessible traditional healers, quacks, traditional birth attendants and poorly trained midwives whom they can afford their services for obstetrics care.
2.2 Classification and pathogenesis of genitourinary fistulas
The anatomic classification of urinary fistulas has been mentioned in Table 2. Figure 1 shows them graphically.
Figure 1.
(A and B): Anatomic sites of Urinary fistulas. 1-Vesicovaginal fistula, 2-Rectovaginal fistula, 3-Vesicouterine fistula, 4-Ureterovaginal fistula, 5-Vesicocervical fistula, 6- Urethrovaginal fistula, 7- Vesicorectal fistula, 8- Enterovaginal fistula, 9-Rectouethral fistula, 10-Vesicorectal fistula, 11-Urethrocutaneous fistula, Vesicoenteric fistula is not shown.
The exact pathological mechanism in the formation of obstetric fistula is not clear. However, the compression of maternal soft tissues of bladder base, urethra, cervix vagina and rectum posteriorly, against the unyielding pubis and sacral spine during prolonged obstructed labor; with the resultant ischemia, epithelial necrosis and subsequent sloughing had been postulated as the pathophysiologic process in the formation of obstetric fistulas by many workers in the developing world [4, 5, 6, 7, 8, 9, 10, 14, 16, 20, 21, 22, 24].
Arrowsmith et al. described obstetric fistula formation within the spectrum of “obstructed labor injury complex” [20]. Urinary fistulas arising from surgical complications, wounding from accidents and stabbing are focal injuries [7]. Gunshots are more complex as they are associated with the phenomena of “tract cavitation and expansion” injuries [31]. Fistulas resulting from obstetric and high velocity gunshot injuries are larger. Ischemia, erosion and migration maybe responsible for the formation of fistulas by foreign bodies in the vagina, bladder, urethra or retained gauze during vaginal surgery.
3. Clinical features
3.1 Clinical presentation
Leakage of urine is the usual complaint. Discharge of feces from the vagina indicates rectovaginal fistula, alone or in association with VVF. The genitourinary fistulas are associated with offensive urine odor. There may be leakage of urine from the vagina, anus or through a hole in the skin depending on the type and location of the fistula. The patient may give a history of prolonged or obstructed labor prior to the leakage by 3 to 10 days in the case of VVF. History of assisted vaginal delivery, before the leakage may indicate VVF [17]. Cesarean section, hysterectomies or any other pelvic surgery may precede the urinary leakage by 10–14 days. VVF, UVF, VCF, VUF, VCuF and RUF may result from these obstetric and pelvic surgeries. The differential diagnoses of VVF include stress, urge and over flow incontinence. Pain is not usually associated with VVF, and urinary leakage in VVF may commence immediately after catheter is removed.
VVF may present many weeks after pelvic surgery. A 65 years old lady presented to the author with offensive vaginal discharge and urinary retention 10 weeks after vaginal hysterectomy by a gynecologist. It turned out to be VVF resulting from eroding infected gauge that migrated into the bladder and pointing at the tip of the urethra. The gauze probably used to pack away the bladder must have been forgotten in the wound during the surgery. The patient may present with with a referral letter indicating the definitive or provisional diagnosis. In developing countries difficult urinary fistulas are referred to the urologist or fistula centers. Frequency, urgency, dysuria, vaginal discharge, bleeding or pain during coitus may be present. There may be irritation, rash or dermatitis and whitish crystal formation on the skin surrounding the fistula, Figure 2.
History of accidentally falling astride a sharp object, stab, or gunshot injury and sustaining a penetrating injury in the perineum or suprapubic region may be elicited; leakage of urine from the anus may suggest VRF or RUF.
3.2 History
History from clinical presentation as noted above will guide the clinician towards the likely fistula he/she is dealing with.
3.3 Physical examination
A general examination should be performed noting nutritional state of the patient and comorbidities. In rural practice nutritional anemia is common and they need to be addressed to enhance wound healing.
3.4 Pelvic examination
Inspection of the perineum for sinuses, fistulas or associated tears; followed by digital bimanual and bivalve speculum examination which assist in identifying the fistula; and provides the opportunity to note the location, size, number and whether simple or complex. An idea about inflammation, fibrosis and pliability of tissue surrounding the fistula and that of the introitus and vagina are ascertained during the examinations. Stenosis and fibrosis of the introitus and vagina sometimes complicate VVF [7, 32].
Ongoing inflammation, infection and induration around the fistula are contraindications for immediate repair.
4. Assessment and diagnoses of genitourinary fistulas
4.1 Dye test in VVF management
Indications
Confirmation or identification of small and hidden fistulas that cannot be verified by direct vision examination.
To differentiate between VVF and UVF
Differentiate between urogenital fistula and urinary incontinence
Method
It can be performed in the treatment room or theater. Methylene blue or indigo carmine is mixed with sterile water and instilled into the urinary bladder under gravity without spillage. A sterile gauze or cotton ball is placed at the vault, mid and distal vagina. Patient is asked to walk about and return for inspection after 30 minutes.
Interpretations
If the gauze at the vault is wet and not stained, a ureterovaginal fistula is suspected.
If the gauze at the vault is stained, a high VVF is suspected
If the gauze at the mid vagina is stained a mid-vesicovaginal fistula is suspected
Staining at the most distal part of the gauze in the distal vagina near the introitus suggests urinary incontinence.
If the staining of the gauze at this distal vagina spares the most distal portion a urethrovaginal fistula is suspected.
In the case where UVF is strongly suspected the vagina is carefully cleaned and test is performed again with fresh gauze in the vagina and intravenous indigo carmine given. Blue staining of the proximal end of the gauze confirms UVF. An intravenous urogram can also be used to confirm it where it is available.
4.2 Cystoscopy
Ideally cystoscopy should be performed for patients presenting with VVF. However, in the setting of rural practice in developing countries of Africa, such necessary services are not always available. The author uses a hand-held battery-operated portable cystoscope, Figure 3, to scope urinary fistula patients whenever necessary in the rural setting. It is very cheap to operate. Apart from visualizing the fistula, it helps in assessing the location, and size, whether simple or complex, and location of the ureteric orifices in relation to the fistulas. This is important in planning and choosing the approach for the repair [2, 32].
Imaging may be needed, but most hospitals in rural practice lack imagine facilities. Patients who could afford contrast studies are referred to facilities that have them to access studies as intravenous urogram, with cystogram in UVF and VVF, retrograde urethrogram (RUG), Figure 4 and micturating cystourethrogram (MCUG) in RUF, urethrovaginal, urethrocutaneous, and vesicocutaneous fistulas; barium enema, vaginography in RVF, and contrast CT scan. Many of our patients are poor and cannot afford these tests. In the rare situation where the fistulas could not be identified with office procedures despite a suggestive history, Rony A Adam [32] described a process where the patient is given phenazopyridine. (Pyridium) and wear a series of gauze at home over a long period. The gauze balls are placed separately in different plastic bags and brought for inspection later. Patients are instructed on proper conduct of the test in order not to contaminate the gauze during insertion.
Figure 4.
Retrograde urethrogram showing a fistulous connection between bulbo-membranous urethra and rectum.
5. Prevention
Urinary fistulas especially obstetric when they occur is associated with misery and isolation, expensive and difficult to treat. Healthcare financing is low in many developing countries [33] and may not be able to accommodate the management of genitourinary fistulas. Nigeria is perceived to bear the world’s heaviest burden of obstetric fistulas, followed by Ethiopia, Uganda and Sudan [34]. In Nigeria, 12,000 fresh cases occur annually while 150,000 in the pool await repair [35]. Only 43% of births are attended to by skilled medical personnel in Nigeria [36]. Thus, some of these common genitourinary fistulas are avoidable. Hence some authors, National strategic Framework for Elimination of Obstetric Fistula in Nigeria, Fistula Foundation, and Professional groups recommended preventive strategies for genitourinary fistulas [34, 36]. The rural area is the veritable ground for it, and rural practice is one of the best channels to use.
Three perspectives can be recognized: primary, secondary and tertiary.
5.1 Primary prevention
The goal is to remove or stop the factors known to cause or contribute to urinary fistula formation. Health education and improvement on community health. Involve community healthcare stakeholders as traditional rulers, village heads, women, youth and religious leaders, teachers and traditional birth attendants, traditional healers and heads of healthcare facilities in this program. Emphasis should be to discourage girlchild marriage, early pregnancy, delivery at home or in the church, conducting labor for a long time before referring to a superior facility, and female genital organ mutilation. Educate the community to embrace the attitude to have deliveries in suitable and efficient healthcare facilities. Encourage the girlchild to go to school and be able to comprehend the dangers in early marriage and pregnancy. Government to upscale health and transportation infrastructures to ensure timely comprehensive emergency obstetric care to all women as is obtainable in developed countries where the condition is eradicated. Effective training of midwives to conduct safe vaginal deliveries, and medical doctors to conduct safe vaginal deliveries, cesarean sections, gynecologic and pelvic surgeries. Regular workshops for public and private primary healthcare staff to monitor and recognize prolonged labor for quick referral. Multidisciplinary team approach for anticipated difficult cases. It can be rewarding to invite an experienced specialist or expert to the local center. The author has been invited by gynecologists and medical officers to join their surgeries in more than 35 instances. Part time or visiting appointments can be offered to such experts.
5.2 Secondary prevention
The goal is to recognize and repair injuries caused to urinary and genital tracts during surgeries; and to offer early attention and treatment to genitourinary injuries from other causes. The use of appropriate suture material and size in the surgery on urinary tract; and safe surgical conduct. Improved operating light is very important. Many theaters in rural practice use improvised theater lamp [6]. The author uses LED head light gear, Figure 5 to augment whatever light that is available. It is pertinent for the pelvic surgeon to appreciate the applied anatomy of pelvic structures, and note that the trigone is situated at the anterior aspect of upper 1/3 of the vagina, and the cervical os is at the base of the trigone (inter ureteric ridge).
Figure 5.
Rechargeable LED operating headlight gear.
5.3 Tertiary prevention
Involves interventions geared towards prevention of complications from urinary fistulas. Treat infections, skin care, nutritional support, correction of nutritional deficiencies and anemia, social support and community reintegration to avert depression, abandonment and divorce. Advocacy for bilateral cooperation and collaboration to sponsor obstetric fistula repairs and training for more fistula surgeons. Repairs should be undertaken by skilled fistula surgeons. Nigeria|Fistula Foundation in her recent report stated that it has provided 9,464 fistula repair surgeries to Nigeria women since 2010 [36].
6. Treatment
6.1 Principles of fistula management
In addition to thorough evaluation of the genitourinary fistula patient, the following management principles are important. They should have adequate nutrition, successful treatment of infection, effective urinary drainage, removal or by pass of any distal obstruction and rule out any associated malignancy [2, 32, 37]. Adherence to the principles of surgical repair of urogenital fistulas is paramount to successful repair [2, 4, 5, 7, 8, 9, 10, 14, 32, 37]. These include optimal operating light, adequate exposure of the fistula, excision of devitalized and ischemic tissues, removal of foreign bodies from the fistula, careful dissection, keeping to anatomical plane between organ cavities, use of small sized delayed absorbable sutures on small automatic needles, water tight closure, use of well vascularized flaps for repair and support, multilayer closure, non-overlapping tension free suture lines, stenting of urinary tract, adequate drainage after repair, prevention and treatment of infection, and adequate hemostasis.
6.2 Treatment of vesicovaginal fistula
6.2.1 Conservative method
Conservative treatment though not popular may be attempted when patient presents early and while waiting for infection and inflammation to subside. The author has recorded success on a few cases that ranged from 0.5 cm – 1.5 cm, Table 4. Small fistulas with oblique tracts have been reported to be amenable to conservative management [2].
Cases of genitourinary fistulas treated with conservative method.
6.2.2 Surgical repair of VVF
VVF is commonly classified as vesicocervical, juxtacervical, midvaginal suburethral, VVFs [8]. Other classification methods exist [38, 39].
Fistula repairs should be undertaken by “tutored and trained fistula surgeon” who has passion to ameliorate the suffering of patients. Some medical officers belong to this group [38]. The best opportunity to achieve a successful repair is at the first attempt [2, 3, 4, 5, 6, 7, 8]. There should be no room for trial and error. The trainee surgeon should be assisted and monitored by experienced fistula surgeons. In rural surgery for VVF, the best outcomes do not often come from trained specialists as obstetrician and gynecologists; general surgeons, urologists and plastic surgeons.
Timing of repair
In rural practice, obstetric fistula is commonest. Patients arrive late [18–10]. In the case of those who arrive early, we allow 8–12 weeks. If the fistula was iatrogenic or resulted from any other focal injury, we close the fistula as soon as infection is controlled. Controversies surround the timing of repair of VVF [4, 8, 14, 37, 38].
Approach
Whoever is undertaking VVF repair must be familiar with both vaginal and abdominal approaches, techniques and maneuvers. One approach may not be suitable for every case [40]. Most surgeons in the developing world use the vaginal approach [4, 5, 6, 7, 8, 9, 12, 16, 37, 38].
6.2.2.1 Anesthesia
Anesthesia should be simple, safe and easy in rural practice. Heavy 0.5% Bupivacaine spinal and intravenous (iv) Ketamine anesthesia; conscious sedation with diazepam and pentazocine injections with local infiltration anesthesia of 1 or 2% lidocaine or lignocaine with or without adrenaline are commonly used. Sometimes iv Ketamine is used to supplement spinal anesthesia in lengthy surgical sessions. Ketamine is safe, 1–2 mg/kg for induction and 25–50 mg iv boluses in titrated doses [41]. Atropine 0.6 mg, diazepam 5 mg stat and given 30 minutes before the start of operation. Atropine prevents secretions and bradycardia, while diazepam prevents dysphoria and psychotomimetic effects during recovery. Bupivacaine spinal anesthesia may last up to 3 hours and is superior to 2% heavy lidocaine spinal anesthesia which may last for 90 minutes. Endotracheal intubation anesthesia is rarely used in rural practice [6].
6.2.2.2 Tools for VVF-repair
Tools for VVF repair is shown on Table 5. Two assistants are required in prone position. One will be holding up the posterior vaginal wall with a Sim’s speculum [37].
SN
Item
Average quantity required
1
Operating table with stirrup accessories
1
2
Size 3, 12 cm, Bard parker handle
2
3
Sizes 10, 11 and curved 12 surgical blades
2 each
4
Medium and large sim’s speculum
1 each
5
Short-blade Auvard (weighted) vaginal speculum
2
6
Long-blade Langenback retractors
2
7
Mosquito artery forceps: curved and straight
4 each
8
12 cm curved slender artery forceps with fine tips
4
9
Tissue forceps: Vulsellum, Allis
2 each
10
Curved 20 cm (McIndoe) light scissors
2
11
Straight stitch scissors
2
12
Standard needle holders
2
13
2- way foley catheters: sizes 16, 12, 10, 8
2 each
14
Methylene blue
1 bottle
15
Sterile water or normal saline
1, 000 mls
16
A small funnel for the catheter
1
17
Good suction machine with tubing
1
18
Sutures: 5/0 poliglecaprone (monocryl) or polyglyconate (Maxolon) or polydiaoxanone (PDS II); 4/0 polyglactin (vicryl) or polyglycolic acid (Dexon), 3/0 polyglactin .
6 each
19
Adrenaline 1: 1000
1 ampule
S20
2% lidocaine: plain and with Adrenaline
1 bottle each
21
Assistants
2
22
Scrub Nurse
1
Table 5.
Tools for VVF repair.
6.2.2.3 Preoperative counseling
It is done in the language she will understand when conservative management has failed. Expectations are discussed, especially that the repair may fail, but hope will not be lost. The need for catheterization for 2–3 weeks, length of hospital stays; possible post-operative frequency, urgency, urgency incontinence for some time after removal of catheter. Patient is counseled thoroughly on informed consent and reminded that challenges may warrant change of plans intraoperatively.
Choice of suture materials
Small size delayed absorbable sutures ranging from 5/0–4/0, monofilament and braided multifilament from 4/0 to 3/0 with 3/8 and 5/8 atraumatic needles are recommended, Table 5. This minimizes the amount of suture material in the wound and still provides adequate closure of wound edges [42].
6.2.2.4 Position for repair of VVF
This depends on the preference of the surgeon.
6.2.2.4.1 Prone position
Prone position is used in many fistula centers where skilled and experienced anesthetists will perform cuffed endotracheal intubation inhalation general anesthesia. The specifics of prone position are well illustrated in primary surgery volume one, edited by Maurice King et al. [37].
6.2.2.4.2 Lithotomy position
Exaggerated lithotomy position with slight head down position, buttocks just beyond the edge of the table.
6.2.2.5 Repairing technique of VVF
The principal steps are: dissecting out the fistula, mobilizing the vaginal skin from the bladder and precervical fascia, mobilization of precervical (pubovesical) fascia, if possible, attention to ureteric orifices, closure of bladder wall, doing a second layer with the precervical fascia over the first suture layer, placement of vascularized graft when indicated and closing the vaginal skin.
6.2.2.5.1 Steps in vaginal approach
After spinal anesthesia, antibiotic prophylaxis is given.
Exaggerated lithotomy position.
Skin preparation and draping.
Pass size 16, 2- way Foley catheter, inflate the balloon and connect to a urine bag.
Infiltrate the layer between the vaginal wall and bladder wall with adrenaline in normal saline 1:100,000. If patient is hypertensive, use plain normal saline. This facilitates dissection and reduces bleeding when the adrenaline-saline solution is used.
The fistula is dilated, and size 14 or 12, or 10 or 8, 2- way Foley catheter depending on the size of fistula is inserted into the fistula tract and the balloon inflated with 5 mls of sterile water.
Commensurate traction is applied distally on the catheter in the fistula to enhance access, purchase and exposure.
The vaginal skin is incised elliptically around the fistula. Using sharp dissection with knife and slander scissors, the vaginal skin is carefully dissected from the bladder wall for a distance of 0.5–1.5 cm, to allow for tension free closure eventually, Figure 6A. Some authors recommend 1 cm towards the cervix and 0.5 cm laterally [37].
Where possible separate the layer of tissue between the bladder and vagina (precervical fascia) from the bladder wall. This may be difficult in large and fibrotic fistulas. Use suture ligation with 5/0 polyglactin to control bleeding.
The fistula collar, Figure 6B, may or may not be excised depending on the size of the fistula. In large fistulas with repeated repair attempts, conservation is prudent. In the past some workers insist on total excision of fistulous tracts and fibrous tissue [43].
Size 20, 2- way Foley catheter is placed suprapubically for drainage.
Extra mucosal closure of the bladder is done, starting at each end and coming towards the center, with 5/0 poliglecaprone (Monocryl) on a 5/8 atraumatic needle, at 3–5 mm interval. Through – and - through bladder mucosal closure can be done with good result especially in large fibrotic fistulas [37], where tissues are not very pliable or bleeding mucosal edge [32]. The ureters can be avoided by conserving fistular collar in large fistulas and doing careful extra mucosal closure. In high fistulas near the cervix the bladder is usually closed transversely and in low fistulas near the urethra the first layer is sutured longitudinally [2, 32, 37]. There are no hard and fast rules about this, the bladder should be closed in the line of least tension [32].
The tightness of the repair is checked by instilling 200–300 mls of methylene blue normal saline solution into the bladder. More stitch is put at any leaking point, or the stitches removed, to start a fresh if the leakage is copious.
The precervical fascia is closed if possible or the first layer is imbricated by suturing the bladder muscularis layer together with 4/0 or 3/0 polyglactin 910, Figure 6C. The stitches of this layer are staggered between those of the first layer so that no stitch lies on top of each other.
If the fistular is large or significant dead space exists, a graft is indicated. The bladder peritoneum can be mobilized or a Martius fat pad transpositional flap is raised and placed over the closed fistula [2, 3].
The vaginal skin is closed perpendicular to the bladder closure line, if possible, otherwise close according to easy approximation of edges. Figure 6D.
Repeat cystoscopy with intravenous indigo carmine to assess ureteric patency if available.
Figure 6.
(a) Vaginal wall is dissected off the bladder wall. (b) Dissecting out fistula collar. (c) Closed precervical fascia. (d) Closed vaginal skin.
In Latzko technique, the fistulous tract is not excised. It is imbricated into the bladder with interrupted extra mucosal sutures on a small tapered needle [44]. The Latzko technique is versatile, simple and cost effective [45]. Many small and moderate sized vaults and high fistulas can be repaired with various versions of modified Latzko technique [46, 47].
The vaginal flap technique made popular by Zimmern et al. and Eilber et al., results in four-layer closure when the flap is used [48, 49]. It is well illustrated by Ganabathi K, Sirls L, Zimmern PE and Leach GC [50].
6.2.2.6 Abdominal approach in VVF repair
Extra peritoneal and intraperitoneal techniques of VVF repairs have been well discussed by Gabanathi K, et al. and Wein AJ et al. [51, 52].
7. Post-operative management of VVF repair
Presumptive intravenous antibiotics with 3rd generation cephalosporine in combination with metronidazole or tinidazole continued for 5 days is recommended, because of the peculiar setting of rural practice. Routine presumptive antibiotics regimen is not practiced in developed countries [32].
Efficient and effective bladder drainage. Urine bags should be emptied hourly and recorded in a chart [37]. Debate on method of catheter drainage is still on. Advocates of single urethral catheter as Collins CG et al., Trancer ML and Leng WW et al., found it effective [40, 52, 53]. Suprapubic catheter drainage alone is advocated by Blaivas JG et al. and, Carr and Webster [54, 55]. Both suprapubic and urethral catheters drainage were favored by Wein AJ et al., Eilber et al. and others [2, 32, 37, 49, 50, 51].
In transperitoneal technique, nil orally until bowel function returns.
Urethral catheter is removed when macroscopic hematuria has cleared, usually about the 3rd day in the case of double catheter drainage, and leave the suprapubic for three weeks.
The catheter is spigoted at day 18 and bladder training is commenced: release urine hourly for 3 hours, then 2 hourly for 6 hours and thereafter 3–4 hourly from day 20. If all is well, catheter is removed on day 21.
Patient is observed for 2 days for normal micturition and dryness. If she leaks urine, examination in the left lateral position is done, to ascertain whether urine is coming from the fistula or urethra.
If she is leaking from the urethra, discharge and reassess at 6 weeks. If she is leaking from the fistula, recommence bladder drainage for 21 days. If she does not close, remove catheter and recommence salt (Sitz) bath.
Counsel and work her up for future repair.
7.1 Adjuncts
Anticholinergics to control bladder spasms, oxybutinine 5 mg twice or three times daily; Tolterodine 2 mg twice daily, and solifenacin 5 mg daily are useful.
Loose vaginal gauze as wick drains and changed daily. Some authors use vaginal packs after abdominal approach [2], while others do not [32].
Estrogen may be given to enhance vaginal skin [2, 32, 50]. Estrogen is rarely used in rural practice.
7.1.1 Postoperative counseling
Sexual intercourse is forbidden for 3 months.
Subsequent pregnancies shall be delivered by cesarean section.
7.2 Failure of VVF repair
Failure after repair may result from.
host factors as presence of foreign body, tissue ischemia, infection, metabolic diseases as diabetes mellitus, peripheral vascular diseases and rarely malignancy.
Surgical technique as inexperience, inadequate excision of devitalized tissues and scar tissue, use of inappropriate suture materials and lack of adherence to detailed measures in the principles of surgical repair of vesicovaginal fistula.
8. Complex vesicovaginal fistula
These include:
Multiple vesicovaginal fistulas involving the urethra and intestine, associated with trauma of fall from heights, anterior posterior- compression fractures from road traffic accidents, and gun short injuries.
Giant Vesicovaginal fistulas of more than 5 cm in diameter. Those associated with partial or complete loss of urethra, stress incontinence, narrow vagina and small bladder capacity.
Those involving the cervix and lower uterine segments.
Those complex fistulas are referred to fistula units in tertiary institutions and fistula centers. Elsewhere the author has emphasized the importance of sustaining the 2- way referral system in the practice of medicine [6]. It supports a good rural surgical practice.
9. Rectovaginal fistulas (RVF)
9.1 Etiology and clinical presentation
This is an abnormal connection between the rectum and vagina. The etiology, pathogenesis, clinical presentation and diagnosis of RVF have been discussed in the preceding sections and highlighted on Tables 1 and 2. RVF can be classified as low, mid and high vaginal fistula. Low is from the vaginal opening to the hymenal ring, mid from the hymenal ring to the external cervical os, and high from the external cervical opening to the vault of the vagina (area of the cul-de-sac) [32].
9.2 Management
Conservative management may be tried. Some resulting from penetrating and stab wounds responds to antibiotics, salt bath and fluid diet. Defunctioning colostomy has been performed for some cases. Obstetric RVF will require surgical correction after treating infection and resolution of inflammation.
Time of repair: A waiting period of 3–6 months is allowed, and salt bath continues before repair.
9.2.1 Surgical repair of RVF
A defunctioning sigmoid colostomy may be done.
Assessment under anesthesia as soon as possible to ascertain the location, size and state of the fistula, presence of sloughs, and edema. If the fistula is above 8 cm from the fourchette refer to higher center for repair from above. For mid and low fistulas, repairs can be undertaken from below. If there is associated VVF, it should be repaired first [37].
9.2.1.1 Low fistula
Spinal anesthesia, prophylactic antibiotics, supine lithotomy position, aseptic technique, transperineal, transvaginal or transanal approach may be used [32, 37]. The tissue around the fistula is infiltrated with adrenalin-normal saline solution as in VVF. An incision along the anterior anal sphincter border or transverse along the posterior fourchette is deepened and dissected proximally separating the vaginal wall from the perineal body, anal sphincter, anal and rectal walls, developing a reasonable dissection of the rectovaginal space proximally, distally and laterally. The fistula is excised, homeostasis achieved, extraluminal closure of the rectum is done using interrupted 3/0 polyglactin and imbricated with seromuscular layer incorporating the internal anal sphincter using interrupted 2/0 polyglactin. Vaginal wall is closed with 3/0 polyglactin. The external anal sphincter if disrupted is repaired end-to-end with interrupted polyglactin O.
9.2.1.2 Mid fistula
The transvaginal approach is preferred. The principles and techniques are the same. The fistula tract is dissected and excised, wide dissection of the rectovaginal space is done, layered closure of the rectum avoiding the lumen, and interrupted vaginal wall closure with 3/0 delayed absorbable suture.
9.2.1.3 Postoperative care
Presumptive antibiotics for 5 days, since the wound is contaminated.
Pain is controlled with pentazocine injection 30 mg 4–6 hourly for about 72 hours.
Liquid diet for about 5 days, then low residue diet.
Stool softener as lactulose suspension, without inducing diarrhea.
Urethral catheter is left for 7 days.
10. Ureterovaginal fistula (UVF)
10.1 Etiology and clinical presentation
This is a pathological communication between the ureter and the vagina. Etiology includes surgical injuries especially hysterectomy [2, 56]. More cases of UVF are appearing in rural practice due to increasing rates of cesarean sections performed by unsupervised medical officers working alone. Other causes of UVF have been discussed by Payne CK and Raz S [56].
Vaginal urinary leakage after gynecologic or obstetric surgery is the commonest symptom. Urine may drain from incision wounds and wound drain. When urine collects in the abdomen or retroperitoneum, nonspecific symptoms of flank and abdominal pains, hiccups, fever, abdominal distension, ileus, localized fluctuance and tenderness may occur.
10.2 Diagnosis
Confirmation of the leakage as urine. Oral phenazopyridine hydrochloride (pyridium) is given. Brown coloration of the leakage confirms it is urine. Intravenous indigo carmine can be used. Dye test as described under VVF can be done. Staining of the gauze at the vault confirms UVF. Intravenous urogram (IVU) and micturating cystourethrogram (MCUG) can also be used. The MCUG will diagnose a bladder fistula, confirm or rule out ureteric reflux; while IVU shows the excretion function of the kidneys, site of contrast extravasation, dilatation of upper tract and contrast in the vagina. A postvoid film is needed to assess for a distal fistula. Once the diagnosis is made or suspected, refer the patient to a urologist.
11. Vesicouterine fistula (VUF)
11.1 Etiology and clinical presentation
An abnormal communication between the uterus or cervix and the urinary bladder. It is uncommon. The commonest cause is lower segment cesarean section [2, 5, 57]. Other causes include myomectomy [17], vaginal operative delivery, induced abortion and, dilatation and curettage. Presentation is the classical “Youssef’s syndrome” of symptom complex: “menouria, cyclic hematuria associated with amenorrhea, secondary infertility and urinary continence” [58]. Diagnosis can be made by a combination of contrast cystogram with voiding cystogram and cystoscopy. Refer to a tertiary healthcare institution for multidisciplinary team management.
12. Urethrovaginal fistula (UrVF)
12.1 Etiology and clinical presentation
UrVF is an abnormal connection between the urethra and the vagina. The commonest cause in the developing world is obstructed labor followed by female genital mutilation as ‘GISHIRI CUT in Northern Nigeria [8, 15, 37]. In the developed world it occurs as a result of vaginal surgery for incontinence, anterior colporrhaphy, vaginal prolapse and urethral diverticulum [2]. It is often associated with VVF [37]. It presents as urinary leakage from the vagina. A small fistula may produce minimal discomfort, while a large one leaks copiously. Distal small fistulas may be asymptomatic.
12.2 Diagnosis
The diagnosis is made clinically and confirmed by urethrocystoscopy if available or by micturating cystourethrogram.
12.3 Treatment
Treatment is by surgical repair. However, some workers recommend that distal urethral fistulas can be observed or managed with an extended meatotomy [59].
12.3.1 Operative repair
Spinal anesthesia, lithotomy position, aseptic technique is used. Size 16 urethral catheter is passed. The tissue around the fistula is infiltrated with adrenalin normal saline solution 1:100, 000 or plain saline. The fistula tract is encircled with incision. The vaginal skin is dissected free from the urethra all-round the fistula to about 5 mm. An inverted ‘U’ shaped incision is marked out on the anterior wall of the vagina with the base at the proximal margin of the encircled fistula. The area within the incision is infiltrated with the adrenalin saline solution and dissected off the periurethral fascia as a vaginal wall flap, to a reasonable distance not less than 2 cm. The edges of the fistula are mobilized, reflected over the fistula but not excised. It is closed with interrupted 5/0 monocry (poliglecaprone) or vicryl in the line of least tension. The periurethral fascia is closed perpendicular to the first as a second layer when possible. A Martius flap is raised and tunneled to the repair as an additional layer. The anterior vaginal wall flap is advanced over the closure and sutured with 4/0 vicryl to the distal margin of the wound. This repair technique is well illustrated by Rovner ES, and Leach GE et al. [2, 60]. The repair of UrVF may be very difficult due to relative lack of connective tissues in the mid and distal urethra. Interposition tissue flap is often indicated. Multiple and complex urethrovaginal fistulas should be referred to higher centers for multidisciplinary team approach.
This is a rare connection between the lumen of small bowel and urinary bladder. The etiology in the rural areas include penetrating and gunshot injuries to the lower abdomen and pelvis; and iatrogenic trauma. In the developed world, it is caused by diverticulitis, malignancy, Grohn’s disease, trauma, foreign body and infection [2, 61].
Presenting symptoms include pneumaturia, fecaluria, debritic urine, lower urinary tract symptoms (LUTs), fever, chills, abdominal pain, hematuria, epididymitis, orchitis, and urine from the rectum [2, 61].
Once suspected, the patient should be referred to a higher center for multidisciplinary team management.
14. Enterovaginal fistula (EVF)
14.1 Etiology and clinical presentation
A rare abnormal connection between the small bowel and vagina. A complication of hysterectomy in the author’s experience, Table 2. Elsewhere cases arising from Crohn’s disease have been reported [62].
14.2 Treatment
Refer promptly and accordingly once diagnosed or suspected in rural practice.
15. Rectourethral fistula (RUF)
15.1 Etiology and clinical presentation
This distressing acquired abnormal communication between the urethra and rectum is seen in males. The author has encountered only seven cases in 28 years; 4 from gunshot Figure 7, two from stab injury and 1 iatrogenic endoscopic injury during endourology procedure, Table 2. Other causes in the literature are iatrogenic trauma during prostatectomy, cryotherapy, anorectal surgery, pelvic irradiation, urethral instrumentation, infection and Crohn’s disease [2, 63]. The symptoms may include fecaluria, hematuria, LUTs, fever, malaise, urinary tract infection (UTI), nausea and vomiting [64].
Figure 7.
Perineal gunshot injuries resulting in rectourethral fistula.
15.2 Diagnosis
Diagnosis is by history, physical examination, urine microscopy and culture; high index of suspicion; and confirmed by retrograde urethrogram (RUG) and MCUG. Urethrocystoscopy and sigmoidoscopy may visualize the fistula.
15.3 Treatment
15.3.1 Conservative
Some will heal on conservative management [63, 64]. The author managed the RUF that resulted from iatrogenic trauma during a Direct Vision Internal Urethrotomy (DVIU) procedure with urethral catheterization continuous bladder drainage for 3 weeks, low residue diet and appropriate antibiotics cover.
15.3.2 Surgical repair
Surgical repair of RUF is beyond the scope of rural practice. Single and staged repairs with or without urinary and fecal (defunctioning colostomy) diversions have been described involving transrectal, transanal and transperineal approaches [64, 65, 66, 67, 68, 69].
The York-Mason procedure is a transrectal approach requiring jack-knife prone position and skilled anesthesia. It has been found to be effective with low morbidity [70].
16. Vesicocutaneous fistula
16.1 Etiology and clinical presentation
An abnormal communication between the urinary bladder and the skin. The commonest variety is the type connecting the bladder and the skin of the lower abdomen or suprapubic region; Figure 2. This commonly follows prolonged or neglected suprapubic catheterization. Other sites encountered are perineum and upper thigh. Males are commonly affected. Other causes include gunshot and stab injuries, fall from heights and following pelvic surgery, Table 2.
It presents as urinary leakage through the skin.
16.2 Diagnosis
Diagnosis is clinical and confirmed by MCUG.
16.3 Treatment
16.3.1 Conservative
Removal or bypass of distal urethral obstruction will heal some.
16.3.2 Surgical treatment
Others will require surgical excision of fistulous tract, closure of urinary bladder in layers and wound closure may be primary or delayed depending on its state of cleanliness and contamination.
17. Urethrocutaneous fistula
17.1 Etiology and clinical presentation
This is an acquired connection between the urethra and skin. It commonly occurs on the penis, Figure 8.
Figure 8.
Urethrocutaneous fistula complicating male circumcision.
In rural practice, it results commonly as circumcision mishap [71]. There are reported cases following surgery of urethral stricture and diverticulum; and hypospadias repair [72]. Others include paraurethral abscess, gunshot wounds and chronic inflammatory disease.
17.2 Diagnosis
Diagnosis is clinical.
17.3 Treatment
There is no standardized surgical repair technique for this condition. Each case should be individualized and treated according to its merit. Urethrocutaneous fistulas should be referred to the urologist.
18. Role of the rural practitioner and future research
The roles of the rural practitioner have not been clearly defined in the treatment and management of the genitourinary fistula patient. The following roles are suggested from this study. They should:
participate in the three preventive strategies mentioned in Section 5, and should participate in the treatment of the fistula from the beginning.
Resuscitate and refer complex and recurrent fistulas promptly to centers with good fistula repair record. Sophisticated ones as UVF, VUF, VEF, EVF, RUF, vesicocutaneous and urethrocutaneous fistulas are beyond the scope of rural practice, and should be referred appropriately once the diagnoses are suspected.
They may undertake the repair of simple fistulas after undergoing adequate training and exposure.
It will be worthwhile to determine the degree of involvement of rural practitioners in the treatment and management of genitourinary fistulas at present, and the impact on the burden of the disease when they are fully integrated.
19. Conclusion
Genitourinary fistulas which occur often in rural practice embarrass the patient and practitioner. The dearth of skilled medical personnel and trained fistula surgeons in the rural areas, made worse by brain drain, poor transport, education and health infrastructures complicate the burden of genitourinary disease. Thus, the patient will be most grateful to the rural practitioner who promptly guides and refers her to a good fistula surgeon who repairs her fistula successfully. The rural clinician should participate effectively in the preventive strategies, initiate treatment and care as soon as fistula occurs, refer complex and sophisticated ones, and may undertake repair of simple fistulas after adequate training and exposure. Good skill, dedication with passion, attention to the principles of fistula management and surgical treatment will achieve high repair success rate. More efforts in training the rural medical practitioner in fistula surgery, education of the girlchild and the public, deployment of more resources to improve social welfare infrastructures, the treatment and rehabilitation of victims, and regular frequent fistula treatment missions will reduce the prevalence of this condition. It is believed that the realization of these objectives will reduce the burden of genitourinary fistulas.
\n',keywords:"Common, Genitourinary, Fistula, Rural, Practice",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/78204.pdf",chapterXML:"https://mts.intechopen.com/source/xml/78204.xml",downloadPdfUrl:"/chapter/pdf-download/78204",previewPdfUrl:"/chapter/pdf-preview/78204",totalDownloads:156,totalViews:0,totalCrossrefCites:0,dateSubmitted:null,dateReviewed:"June 28th 2021",datePrePublished:"August 23rd 2021",datePublished:"February 16th 2022",dateFinished:"August 23rd 2021",readingETA:"0",abstract:"Acquired genitourinary fistulas are common in rural practice. They are pathological communications between the urinary and genital tracts, or between either of the tracts and gastrointestinal tract or skin. Vesicovaginal fistula is the commonest and most devastating. They may result from prolonged and obstructed labor, injuries during obstetric, gynecologic, pelvic and urologic procedures, circumcision, fall from heights, road traffic accidents and female genital mutilation. They present as urinary leakage with characteristic odor. Diagnoses are mainly clinical and confirmed by dye tests, contrast radiography and endoscopy. Treatment is individualized according anatomic sites and etiology. Timing of repair is of essence; delayed repair for obstetric and early for focal injuries. Multidisciplinary team approach and cooperation is encouraged in the management of some of these cases. The sustenance of the 2 – way referral system is emphasized in cases beyond the scope of rural practice. Repairs when undertaken by skilled compassionate fistula surgeons with attention to principles of fistula management and surgical treatment, success rate can approach 90%. Interposition of vascularized grafts have improved success rate. The burden of this condition will be reduced through integration of rural practitioners in the preventive strategies of health education of the public and girlchild; improvement of healthcare, education and transportation infrastructures.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/78204",risUrl:"/chapter/ris/78204",signatures:"Chineme Michael Anyaeze",book:{id:"9810",type:"book",title:"Rural Health",subtitle:null,fullTitle:"Rural Health",slug:"rural-health",publishedDate:"February 16th 2022",bookSignature:"Umar Bacha",coverURL:"https://cdn.intechopen.com/books/images_new/9810.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83969-371-7",printIsbn:"978-1-83969-370-0",pdfIsbn:"978-1-83969-372-4",isAvailableForWebshopOrdering:!0,editors:[{id:"244265",title:"Dr.",name:"Umar",middleName:null,surname:"Bacha",slug:"umar-bacha",fullName:"Umar Bacha"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"344204",title:"Dr.",name:"Chineme Michael",middleName:null,surname:"Anyaeze",fullName:"Chineme Michael Anyaeze",slug:"chineme-michael-anyaeze",email:"chinemema85@gmail.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_1_2",title:"1.1 Objectives",level:"2"},{id:"sec_3",title:"2. Etiology",level:"1"},{id:"sec_3_2",title:"2.1 Causes of genitourinary fistulas",level:"2"},{id:"sec_3_3",title:"2.1.1 Risk factors",level:"3"},{id:"sec_5_2",title:"2.2 Classification and pathogenesis of genitourinary fistulas",level:"2"},{id:"sec_7",title:"3. Clinical features",level:"1"},{id:"sec_7_2",title:"3.1 Clinical presentation",level:"2"},{id:"sec_8_2",title:"3.2 History",level:"2"},{id:"sec_9_2",title:"3.3 Physical examination",level:"2"},{id:"sec_10_2",title:"3.4 Pelvic examination",level:"2"},{id:"sec_12",title:"4. Assessment and diagnoses of genitourinary fistulas",level:"1"},{id:"sec_12_2",title:"4.1 Dye test in VVF management",level:"2"},{id:"sec_13_2",title:"4.2 Cystoscopy",level:"2"},{id:"sec_14_2",title:"4.3 Imaging",level:"2"},{id:"sec_16",title:"5. Prevention",level:"1"},{id:"sec_16_2",title:"5.1 Primary prevention",level:"2"},{id:"sec_17_2",title:"5.2 Secondary prevention",level:"2"},{id:"sec_18_2",title:"5.3 Tertiary prevention",level:"2"},{id:"sec_20",title:"6. Treatment",level:"1"},{id:"sec_20_2",title:"6.1 Principles of fistula management",level:"2"},{id:"sec_21_2",title:"6.2 Treatment of vesicovaginal fistula",level:"2"},{id:"sec_21_3",title:"Table 3.",level:"3"},{id:"sec_22_3",title:"Table 5.",level:"3"},{id:"sec_22_4",title:"6.2.2.1 Anesthesia",level:"4"},{id:"sec_23_4",title:"Table 5.",level:"4"},{id:"sec_24_4",title:"6.2.2.3 Preoperative counseling",level:"4"},{id:"sec_25_4",title:"6.2.2.4 Position for repair of VVF",level:"4"},{id:"sec_25_5",title:"6.2.2.4.1 Prone position",level:"5"},{id:"sec_26_5",title:"6.2.2.4.2 Lithotomy position",level:"5"},{id:"sec_28_4",title:"6.2.2.5 Repairing technique of VVF",level:"4"},{id:"sec_28_5",title:"6.2.2.5.1 Steps in vaginal approach",level:"5"},{id:"sec_30_4",title:"6.2.2.6 Abdominal approach in VVF repair",level:"4"},{id:"sec_34",title:"7. Post-operative management of VVF repair",level:"1"},{id:"sec_34_2",title:"7.1 Adjuncts",level:"2"},{id:"sec_34_3",title:"7.1.1 Postoperative counseling",level:"3"},{id:"sec_36_2",title:"7.2 Failure of VVF repair",level:"2"},{id:"sec_38",title:"8. Complex vesicovaginal fistula",level:"1"},{id:"sec_39",title:"9. Rectovaginal fistulas (RVF)",level:"1"},{id:"sec_39_2",title:"9.1 Etiology and clinical presentation",level:"2"},{id:"sec_40_2",title:"9.2 Management",level:"2"},{id:"sec_40_3",title:"9.2.1 Surgical repair of RVF",level:"3"},{id:"sec_40_4",title:"9.2.1.1 Low fistula",level:"4"},{id:"sec_41_4",title:"9.2.1.2 Mid fistula",level:"4"},{id:"sec_42_4",title:"9.2.1.3 Postoperative care",level:"4"},{id:"sec_46",title:"10. Ureterovaginal fistula (UVF)",level:"1"},{id:"sec_46_2",title:"10.1 Etiology and clinical presentation",level:"2"},{id:"sec_47_2",title:"10.2 Diagnosis",level:"2"},{id:"sec_49",title:"11. Vesicouterine fistula (VUF)",level:"1"},{id:"sec_49_2",title:"11.1 Etiology and clinical presentation",level:"2"},{id:"sec_51",title:"12. Urethrovaginal fistula (UrVF)",level:"1"},{id:"sec_51_2",title:"12.1 Etiology and clinical presentation",level:"2"},{id:"sec_52_2",title:"12.2 Diagnosis",level:"2"},{id:"sec_53_2",title:"12.3 Treatment",level:"2"},{id:"sec_53_3",title:"12.3.1 Operative repair",level:"3"},{id:"sec_56",title:"13. Vesicointestinal (vesicoenteric) fistula (VEF)",level:"1"},{id:"sec_56_2",title:"13.1 Etiology and clinical presentation",level:"2"},{id:"sec_58",title:"14. Enterovaginal fistula (EVF)",level:"1"},{id:"sec_58_2",title:"14.1 Etiology and clinical presentation",level:"2"},{id:"sec_59_2",title:"14.2 Treatment",level:"2"},{id:"sec_61",title:"15. Rectourethral fistula (RUF)",level:"1"},{id:"sec_61_2",title:"15.1 Etiology and clinical presentation",level:"2"},{id:"sec_62_2",title:"15.2 Diagnosis",level:"2"},{id:"sec_63_2",title:"15.3 Treatment",level:"2"},{id:"sec_63_3",title:"15.3.1 Conservative",level:"3"},{id:"sec_64_3",title:"15.3.2 Surgical repair",level:"3"},{id:"sec_67",title:"16. Vesicocutaneous fistula",level:"1"},{id:"sec_67_2",title:"16.1 Etiology and clinical presentation",level:"2"},{id:"sec_68_2",title:"16.2 Diagnosis",level:"2"},{id:"sec_69_2",title:"16.3 Treatment",level:"2"},{id:"sec_69_3",title:"16.3.1 Conservative",level:"3"},{id:"sec_70_3",title:"16.3.2 Surgical treatment",level:"3"},{id:"sec_73",title:"17. Urethrocutaneous fistula",level:"1"},{id:"sec_73_2",title:"17.1 Etiology and clinical presentation",level:"2"},{id:"sec_74_2",title:"17.2 Diagnosis",level:"2"},{id:"sec_75_2",title:"17.3 Treatment",level:"2"},{id:"sec_77",title:"18. 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Department of Surgery, Federal Medical Centre Owerri, Nigeria
Surgery and Urology Unit, Six-C Specialist Clinic, Nigeria
Mater Misericordiae Hospital, Nigeria
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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. 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