\r\n\t1. 90% of girls fully vaccinated with HPV vaccine by age 15 years.
\r\n\t2. 70% of women are screened with a high-performance test by 35 years and again by 45 years
\r\n\t3. 90% of women identified with cervical disease receive treatment (90% of women with precancer treated, and 90% of women with invasive cancer managed
\r\n\r\n\tThis book “glows in teal”, committing itself, to the noble task of elimination of HPV infections and related cancers. This book has, well experienced and dedicated scientists from all over the world, contributing chapters in the fields of Epidemiology of HPV; HPV Vaccination – Efficacy – acceptance, affordability and policies; Pathophysiology and carcinogenesis of HPV; Hi-Tech screening protocols, methodologies for HPV testing; Diagnosis and treatment of Pre cancers and invasive cancers due to HPV; Prevention and control of Papillomaviridae infections and related Cancers of Cervix, Vagina, Vulva, Penis, Anus and Oropharynx.
\r\n\r\n\tWe, firmly hope that the knowledge shared in this book would immensely contribute to the global goal of elimination of Papillomavidae and related cancers, and serve as a beacon of “teal light” symbolizing cancer eradication, from the lighthouse of Scientific wisdom and Social welfare, The InTech publishers."
",isbn:null,printIsbn:"979-953-307-X-X",pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"b7612146e5bd35247afd8bb1b6913be8",bookSignature:"Dr. Rajamanickam Rajkumar",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11370.jpg",keywords:"Incidence, Prevalence, Determinants, Awareness, Transmission, Pathophysiology, Oncogenesis, Host Cell Changes, DNA Alterations, HPV Screening, HPV Vaccination, Types of Vaccines",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 3rd 2021",dateEndSecondStepPublish:"November 11th 2021",dateEndThirdStepPublish:"January 10th 2022",dateEndFourthStepPublish:"March 31st 2022",dateEndFifthStepPublish:"May 30th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"8 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Professor Dr. Rajamanickam Rajkumar, is a Champion for the cause of Cervical Cancer Elimination HPV Research, in rural India, from 2000, in collaboration with the IARC/WHO, The Ohio State University Medical Center -USA, and The Society for Colposcopy and Cervical Pathology Singapore.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"120109",title:"Dr.",name:"Rajamanickam",middleName:null,surname:"Rajkumar",slug:"rajamanickam-rajkumar",fullName:"Rajamanickam Rajkumar",profilePictureURL:"https://mts.intechopen.com/storage/users/120109/images/system/120109.png",biography:"Rajamanickam Rajkumar is an international frontline scientist in cervical cancer and HPV prevention with a Ph.D. in Cancer Epidemiology. 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Introduction
Patients with end-stage renal disease are at high risk of developing cardiovascular events. In addition to the major traditional risk factors for cardiovascular disease (ie, advanced age, hypertension, diabetes mellitus, dyslipidemia, and smoking), recent studies suggest that chronic kidney disease is an independent risk factor [1]. Several groups have reported that coronary artery disease severity and lesion complexity are associated with a decrease in the estimated glomerular filtration rate [2,3]. Recent epidemiological studies and clinical trials have demonstrated that chronic kidney disease is associated with increased mortality rate in patients with cardiovascular disease [4,5]. Notwithstanding the deep deleterious effects chronic renal disease itself plays in endothelial and medial arterial wall, renal failure leads to both significant increases in morbidity and decreases in life survival, particularly in hemodialysis patients, who represent the most severe and advanced expression of renal disease.
The mechanisms that underlie the association between renal dysfunction and coronary artery disease have not been elucidated fully. Previous studies have shown that renal dysfunction is associated with low-grade inflammation and activation of the sympathetic nervous system and of the renin-angiotensin aldosterone system [6-8]. Other factors such as calcium-phosphate disbalance, oxidative stress, hyperglycemia, advanced glycosylated end-products, and abnormal apolipoprotein levels also were shown, among others, to promote renal dysfunction [9,10]. As such, these factors could also contribute to the pathogenesis of atherosclerosis.
As renal function deteriorates at early stages, the different organ systems start to experience subtle alterations. These initial disturbances that develop at the molecular level, encompass mainly chronic inflammatory pathways mediated by cytokines secreted by leukocytes and uremic retention toxins. In turn, and with different degrees of clinical and biochemical manifestations, the many culprits interact and cause systemic impacts. The most important, albeit not the one, harmful effect is evident at the cardiovascular level. This is due to the fact that the endothelium is a direct target of plasmatic toxins, free radicals and altered synthesized molecules, abnormal platelets, short-live erythrocytes and malfunctioning leukocytes, hyperglycemia, dyslipidemia and hypertension. The damaged endothelium interacts with both the plasmatic and cellular constituents of blood and the inner vessel wall cells, particularly smooth muscle cells, circulating monocytes and tissular macrophages and fibroblasts. The direct consequences are vascular thrombosis, calcification and lipid deposition, and tissue hypoxia. Although these mentioned vascular alterations exist in all organ systems, the central nervous system, the heart and the kidneys are the most important clinically involved organs. This situation finds its most critical exponent when kidney function reaches stage 5 and uremia is present [11]. At this stage, renal replacement therapy is mandatory. Among the therapeutic options, hemodialysis, peritoneal dialysis and kidney transplantation are available. These options are far from ideal, albeit transplantation offers the best results. With respect to the dialysis procedures, hemodialysis is the most frequent modality employed worldwide to treat end-stage renal disease. Among the factors that add morbidity and mortality to hemodialysis individuals are -as mentioned- comorbid conditions as diabetes mellitus, hypertension, aging, endocrine and electrolyte derangements, oxidative stress, volume overload, hyporexia and nutrient losses during the dialysis process, dialysis devices and vascular access-blood interactions, the predisposition to infections, and water quality. All these main factors will definitively result in a vicious cycle in which protein energy wasting, malnutrition, uremic toxins retention, inflammation, and a hypercatabolic state with grim and most frequently irreversible consequences harmfully interact. Cardiovascular disease, malnourishment and inflammation are the main roads that can merge or independently lead to premature death, the reality dialysis patients still face nowadays [11,12].
As mentioned before, many clinical, nutritional, and biochemical parameters may be indicating a chronic inflammatory state in these individuals. Conventional and non-traditional risk factors and metabolic alterations observed in the uremic milieu may contribute to the excessive risk of cardiovascular disease [12]. Both Framingham and the so called non-traditional risk factors as inflammation, endothelial dysfunction, sympathetic activation, protein-energy wasting, oxidative stress, vascular calcification, and volume overload may play relevant roles in the development of vascular disease in dialysis patients [13-15]. However, it has recently demonstrated that the addition of multimarker scores (including markers of inflammation and volume overload) to conventional risk factors resulted only in small increases in the ability to grade risk, at least in the general population [16,17].
An important factor in hemodialysis that is linked to survival is residual renal function, clinically assessed as the amount of daily urinary output. Many factors conspire against this important variable: Lifetime on dialysis, aging, the etiologies of end-stage renal disease and higher degrees of ultrafiltration. However, proteinuria, an important marker of progression of renal disease that is associated in time with decreased renal function and oliguria, is not assessed routinely in hemodialysis.
The aim of the present chapter is to consider remnant proteinuria as an active marker of inflammation and cardiovascular disease, and also as a cause of decrease of residual renal function and urinary output in hemodialysis. Although not yet assessed, it is reasonable to presume that also in hemodialysis patients, proteinuria should be associated with increased cardiovascular events, inflammatory processes and decreased life survival.
2. Residual renal function in dialysis
In recent years, there has been a greater focus on residual renal function of patients on chronic dialysis therapy. Although residual renal function is often used to indicate remaining glomerular filtration rate, it also reflects remaining endocrine functions such as erythropoietin production [18], calcium, phosphorus and vitamin D homeostasis [19,20], volume control, and removal of “middle molecules” or low molecular weight proteins [21,22]. It is assumed by some authors that an estimated urine volume < 200 ml/24 h should be considered as a cut-off to consider loss of residual renal function. However, several of the significant associations with residual renal function loss have generated testable hypotheses regarding potential therapies that may preserve renal function among dialysis patients that may be independent of the urinary volume, even at less than 200 ml daily. Renal replacement function is clinically important in that it can account for major differences in dialysis requirements, since it contributes to measures of adequacy, both Kt/V urea and creatinine clearance [23,24]. As mentioned before, residual renal function has also been shown to be associated with mortality. Analysis of the CANUSA study [25] has shown that every 0.5 ml/min higher glomerular filtration rate was associated with a 9% lower risk of death in subjects with renal disease but not still in dialysis [26]. It has been shown that clinically important and statistically significant decreases in nutritional parameters occur with residual renal function loss [25]. Furthermore, it has been demonstrated that small increments in it may account for major differences in quality of life [27,28]. It is therefore very important to determine and understand the predictors of loss of residual renal function in the dialysis patient. The importance of identifying factors that protect and preserve renal function has been recognized among patients with chronic renal failure and pre-end-stage renal disease (stages 3 and 4). Control of blood pressure, angiotensin-converting enzyme inhibition, decreasing proteinuria, dietary modification, avoidance of nephrotoxins, and glucose control have all been considered integral parts of the pre-stage 5 care [29]. However, few studies have comprehensively evaluated whether these or other factors are important in preserving residual renal function after initiation of dialysis. Also on a clinical level, evaluating and monitoring factors that preserve it in patients who have just started dialysis has not received the same level of care as among the chronic renal failure population. It is also probable that subjects with stage 5D (under dialysis) may be treated differently than stage 5 subjects not still in dialysis: In stage 5 not in dialysis, individuals may be under pharmacologic regimes to control proteinuria, that may be left aside when dialysis is started, or the beneficial effects of which are not carefully assessed or even considered.
Several authors have observed that preservation of residual renal function is prolonged with peritoneal dialysis compared to hemodialysis [30-32]. Others have noted a more rapid decline in renal function among patients on automated peritoneal dialysis versus continuous ambulatory peritoneal dialysis [33]. For hemodialysis patients, there has been debate in the literature about whether the type of dialyzer membrane has an effect on remnant renal function. Some have suggested that biocompatible membranes preserve renal function for a longer time period [34-36]. Cause of end-stage renal disease, level of blood pressure, rate and profile of fluid removal, contrast materials as iodide and gadolinium, and also various medications have all been implicated as having an effect on renal function [29,37,38]. However, the current knowledge about the factors that preserve renal function in end-stage renal disease is still very limited. Daily urinary volume recollection may be cumbersome and imprecise, but has proved to be a useful measure of residual renal function. It is interesting that patients are more likely to have the outcome variable, urine volume, reported if they are on peritoneal dialysis or if they are female. It has been recognized that residual renal function is important in continous ambulatory peritoneal dialysis due to its contribution to small solute clearance, and more attention may be paid to monitoring it in this population. The reason for the gender difference is not clear. Several studies about the progression of chronic renal disease have reported that the decline in renal function is either linear or exponential [29,39]. Thus, it is assumed that longer follow- up and lower levels of renal function at the start of dialysis would be associated with a greater likelihood of loss of residual renal function. It is therefore necessary to control for these factors when evaluating the effect of other potential predictors. Duration of time on dialysis is indeed a significant predictor of renal function loss in the overall population and among the peritoneal dialysis population, but, interestingly, not among the hemodialysis population. Among the peritoneal dialysis patients, there is an increasing risk of loss of residual renal function over time, suggesting that time on dialysis is an important variable. Likewise, higher estimated glomerular filtration rates at dialysis initiation is associated with lower risk of loss of residual renal function at follow-up among peritoneal dialysis-treated patients but not among hemodialysis-treated patients.
Increasing age may not be associated with residual renal function loss. This is consistent with data from the Modification of Diet in Renal Disease (MDRD) study [29], in which age was not an independent predictor of progression of renal disease among patients with chronic renal failure. Female gender independently predicted renal function loss loss in the overall analysis and in the analysis limited to peritoneal dialysis patients. This gender effect could not be explained by differences in body mass index, mean arterial pressure, albumin, estrogen use, or menopausal status because the effect remained despite controlling for these variables [40]. However, other studies have shown the opposite, in which a slower rate of progression of renal function decline was reported in females with chronic renal failure [41-44]. Data from the MDRD study indicated a slower mean glomerular filtration rate decline in women compared to men with chronic renal failure. However, gender differences were reduced and no longer significant after controlling for baseline proteinuria, mean arterial pressure, and HDL cholesterol [29]. Non-white race was associated with residual renal function loss in the overall analysis; however, this effect was found to be limited to peritoneal dialysis patients only. This was true of both blacks and the category “other non-white race.” These relationships were independent of cause of renal disease and blood pressure at dialysis initiation, and also could not be explained by reported differences in pre-dialysis care. African-Americans are known to have a faster rate of progression of renal failure in the chronic renal failure population [29,45]. This analysis suggests that, at least among peritoneal dialysis-treated patients, this race effect may persist after dialysis initiation. The presence of diabetes predicts renal function loss particularly in both dialysis populations. Diabetic patients with hypertension and proteinuria have been shown to have an increased rate of loss of renal function in the chronic renal failure community. A history of congestive heart failure may also predict renal function loss, likely due to decreased blood flow to the compromised kidney. However, this statement has not been assessed properly in hemodialysis patients.
Several comparative studies of peritoneal dialysis and hemodialysis mortality have shown that the relative mortality risk favors peritoneal dialysis to the greatest degree early after end-stage renal disease start and the relative mortality risk increases for peritoneal dialysis with time on dialysis [46-49]. One reason that peritoneal dialysis may offer this early advantage may be the greater preservation of residual renal function. Higher postdialysis blood pressure at baseline appears to correlate with a lower risk of renal function loss loss in the hemodialysis-only population but may be an insignificant predictor in the peritoneal dialysis subjects. Several studies have observed a relationship of higher mortality associated with low predialysis blood pressure [50-52]. A similar phenomenon may exist for residual renal function. Previous studies have shown that use of cellulose dialyzer membranes among hemodialysis patients hastens residual renal function loss [34,36] due to blood and cellulose dialysis membrane interactions, which may induce potentially nephrotoxic inflammatory mediators [53].
Comparing peritoneal dialysis patients to hemodialysis patients using biocompatible membranes revealed that peritoneal dialysis patients are still significantly less likely to lose residual renal function than hemodialysis patients. Preservation of residual renal function is an important goal. In addition to identifying demographic groups at risk, it is also important to identify other potentially modifiable factors as calcium and phosphorus metabolism, blood pressure, hyperglycemia, PTH and vitamin D levels, dose of erythropoietin, use of iron, and therapies (dialysis modality, angiotensin converting enzyme inhibitors or angiotensin receptor blockers, calcium channel blockers, statins and aspirin) that are involved in residual renal function. There appear to be substantial differences in both the actual loss of residual renal function and the contributing risk factors among peritoneal dialysis compared to hemodialysis patients. Additional prospective studies, ideally clinical trials, are necessary to determine whether these possible interventions are efficacious. Proteinuria has not been assessed in any of both modalities as a marker of progression of residual renal function loss, and as a cause of cardiovascular disease and inflammation [40].
In peritoneal dialysis, the best means for assessing adequacy remain ill defined [54]. The concept of adequate dialysis should include some defined level of solute removal, adequate fluid removal to achieve normal volume homeostasis and blood pressure control, maintenance of adequate nutrition, normal acid–base balance, normal mineral metabolism, minimal anemia, normal lipid metabolism, and prevention of atherosclerosis. Small solute clearance has traditionally been an integral part of the overall definition of peritoneal dialysis adequacy; most other measures appear to parallel solute removal. The importance of small solute clearance in peritoneal dialysis has been confirmed by a variety of studies [55,56], most notably CANUSA, which showed that Kt/V and corrected creatinine clearance independently predict patient survival. All these studies have been confounded by residual renal function. Solute removal by peritoneal dialysis may not be clinically equivalent to an equal quantitated solute removal by residual renal function. For example, the increased fractional secretion of creatinine during declining glomerular filtration rate can be extremely misleading if other solutes do not show a fractional increase in excretion. Conversely, the increased secretion of organic solutes during chronic renal failure may far exceed the diffusive losses of the same solute during peritoneal dialysis. Hence, the relative effects of renal versus peritoneal clearance on survival remain to be elucidated. There is consensus that residual renal function has a major impact on the ability to achieve small solute clearance targets [57]. Residual renal function contributes to approximately 25% of total Kt/V and 40% of total weekly creatinine clearance. This numerical contribution is even greater for high and middle molecular weight solutes. As residual renal function deteriorates, failure to compensate for this loss will result in an increasing frequency of inadequate dialysis. Even with increasing dialysis prescription, as many as 40% of continuous ambulatory peritoneal dialysis patients fail to meet the target [58,59]. Small changes in residual renal function with time on peritoneal dialysis may account for major differences in quality of life and dialysis outcome. Data from the CANUSA study showed that the overall outcome was worse for patients who lost their residual renal function [60,61]. The adverse impact of loss of residual renal function on outcome in peritoneal dialysis patients could be due partly to loss of residual diuresis and difficulty in managing fluid status, hypertension, and left ventricular hypertrophy, all of which contribute to cardiovascular mortality [62].
Residual renal function has also been shown to have a greater influence on dietary protein intake and nutritional status than peritoneal clearance [63-65]. Following the initial observation of Rottembourg et al., a number of studies have shown that the decline in residual renal function is more protracted in patients on peritoneal dialysis than those on hemodialysis [31,66-69]. However, the changes in residual renal function with time are not uniform in all patients. The issue of which factors affect preservation of residual renal function in patients with chronic renal failure once dialysis is started has received very little attention [70-74]. There appears to be a gradual deterioration of residual glomerular filtration rate with time on peritoneal dilaysis, with 33% of patients developing anuria at a mean of 20 months after the start of dialysis, according to Singal et al data [75]. In that study, on comparison between patients in the highest and lowest quartiles of slope for residual glomerular filtration rate, male gender, presence of diabetes, higher grades of left ventricular dysfunction, and glomerular filtration rate higher 24-hour urine protein excretion corresponded with faster decline of residual renal function. Singal et al could not show a good correlation between the decline of urine volume and renal glomerular filtration rate. Urine volume was well maintained until 30 months after start of peritoneal dialysis. This was in contrast to previous studies, where the decline in creatinine clearance and urine volume in individual patients was significantly correlated [76]. A number of studies have shown that residual renal function is better preserved in peritoneal dialysis patients than in those on hemodialysis. However, all these comparisons were made between hemodialysis using conventional bioincompatible membranes and peritoneal dialysis. The advent of newer dialytic techniques such as automated peritoneal dialysis and biocompatible hemodialysis membranes may alter this relationship. It has also been suggested that peritoneal dialysis patients with rapidly falling residual renal function depart from therapy at a high rate, leaving those with better preservation of residual renal function on peritoneal dialysis after many months [77]. Previous studies have not clearly defined the factors that affect the rate of residual renal function loss in patients on dialysis. In hemodialysis patients, Iest et al. reported that the mean rate of decline of residual renal function was unaffected by weight, gender, age, hypertension status or medications, and by the original disease [78]. Lutes et al. also reported in 32 peritoneal dialysis patients no influence of age, diabetes, mean arterial pressure, peritonitis rate, and initial creatinine clearance at the start of peritoneal dialysis, on the rate of residual renal function loss [70]. Davies et al. looked at the half-life of loss of residual renal function in 303 patients started on peritoneal dialysis between 1990 and 1997 [32]. Patients with interstitial nephritis, renovascular disease and hypertensive nephrosclerosis had slower decline of residual renal function. Comorbid conditions did not influence rate of loss of residual renal function. Moist et al. studied predictors of loss of residual renal function in new dialysis patients [40]. As partially mentioned before, increasing age, female gender, and nonwhite race predicted faster loss, whereas peritoneal dialysis and use of angiotensin converting enzyme inhibitors and calcium channel blockers was associated with slower loss of residual renal function. However, the primary outcome variable was urine volume, not residual glomerular filtration rate, in that study. Singal et al evaluated the risk factors assumed to be associated with residual glomerular filtration rate [75]. There was no effect of age, race, or primary renal disease on the rate of decline of residual renal function. Presence of diabetes as a cause of renal disease or as a comorbidity was significantly associated with the rate of decline. Presence of peripheral vascular disease and higher degrees of left ventricular dysfunction on echocardiography may have a significant effect in patients in upper and lower quartiles of slope of residual glomerular filtration rate. Considering the 105 patients with diabetes, 38% had peripheral vascular disease and left ventricular dysfunction of grades I to IV in 60%, 13%, 15%, and 12% of patients respectively; compared to 137 patients with no diabetes where 12% had peripheral vascular disease and left ventricular dysfunction of grades I to IV in 77%, 13%, 7%, and 3% respectively. Similarly, 24-hour urinary protein excretion may also be associated with diabetic nephropathy as a cause of end-stage renal disease.
Therefore, residual renal function may contribute significantly to total solute clearance and fluid balance in patients on continuous peritoneal dialysis. Changes in residual renal function with time are not uniform in all patients. Faster decline of residual renal function corresponds with male gender, large body mass index, presence of diabetes mellitus, higher grades of congestive heart failure and higher 24-hour proteinuria. Higher rates of peritonitis and use of antibiotics for the treatment of peritonitis are also associated independently with faster decline of residual renal function. Whether the type of peritoneal dialysis and use of larger dialysate volume are associated with faster decline of residual renal function remains speculative [75]. In summary, loss of residual renal function and urinary output is an important risk factor of morbidity and mortality in dialysis patients. In predialysis patients, proteinuria is clearly associated with renal and cardiovascular disease progression. However, the link between proteinuria and residual renal function in dialysis is to be discussed next.
3. Proteinuria and chronic kidney disease
The incidence of end-stage renal disease is dramatically increasing worldwide [80]. Most patients with kidney problems visit their physicians in the late stages of the disease. Progression from mild to moderate kidney disease to end-stage renal disease may be halted or slowed when kidney damage is detected and appropriate treatment is started during the early stages. Kidney damage is frequently asymptomatic but can be suspected in the presence of proteinuria, hematuria, or a reduced glomerular filtration rate [81]. Due to increased awareness of people about chronic kidney disease and early detection and prevention programs implemented in developed countries, the incidence of end-stage renal disease has shown a small downward trend [82,83]. However the total number of individuals worldwide with chronic kidney disease is still high and estimated at 500,000,000 people [82-84].
Proteinuria is a major risk factor for renal disease progression [85-87]. Among the main causes that lead to dialysis, diabetes, hypertension and glomerular diseases account for more than 70% of the most frequent described etiologies in the adult population. All these entities display a marker of disease progression: Proteinuria. In this setting, proteinuria can be due to primary glomerulopathies, which is the third cause of end-stage renal disease in the adult population and an important cause of secondary hypertension, or could be the result of secondary glomerular damage due to primary hypertension, diabetes mellitus, hyperfiltration, metabolic syndrome, reduced renal mass, autoimmune or infectious diseases, vesicoureteral reflux, etc.
Proteinuria is another predictor of increased cardiovascular risk in the general population [88]. Numerous studies have shown that treating proteinuria in patients with diabetic or non-diabetic chronic kidney disease and proteinuria slows the progression of renal disease. It can also be stated that the greater the decrease in proteinuria, the greater the clinical benefit [89-91]. In addition to predicting kidney disease progression, proteinuria is a well-established risk marker for cardiovascular disease [86,92-94]. In chronic kidney disease individuals, reduction in proteinuria confers a significant decrease in cardiovascular events. For example, the RENAAL study showed that albuminuria is the most important factor in predicting the cardiovascular risk in patients with type 2 diabetic nephropathy, and at 6 months for every 50% reduction in albuminuria, a 18% reduction in cardiovascular risk and a 27% reduction in heart failure was reported16. It is evident that proteinuria presents an important predictive value in cardiac failure, both as a marker of future events and also as a therapeutic target. Patients with diabetic nephropathy and proteinuria greater than 3 g/g have a 2.7-fold higher risk for heart failure when compared with patients with low proteinuria (<1.5 g/g) [95]. A coexistent diagnosis of hypertension and diabetes increases the risk of adverse cardiovascular and renal outcomes. This increased risk extends to a diastolic blood pressure of 83 mmHg and a systolic of 127 mmHg [96,97]. Reduction of proteinuria by >30% within the first 6 to 12 months of treatment in patients with chronic kidney disease has also been shown to predict long-term renal and cardiovascular outcomes [86,88,98]. Moreover, the management of albuminuria in normotensive or hypertensive patients with diabetes may slow progression of diabetic nephropathy [99], and microalbuminuria itself, an early marker of kidney vascular dysfunction, is a strong prognostic indicator of mortality and cardiovascular disease in hypertension and diabetes mellitus [100,101]. Therefore, one of the main goals to slow the progression of renal disease is an adequate and not unusually aggressive control of blood pressure and the reduction of proteinuria to its lowest possible level [102]. Moreover, proteinuria has been shown to be the strongest predictor of cardiovascular outcomes, including hospitalization for heart failure. Extinguishing proteinuria by decreasing blood pressure, hyperfiltration states, sodium intake, and tight glycemia control are generally accepted potential strategies to reduce cardiovascular risk events [89]. Although the nature of the links between proteinuria and vascular disease may partly be due to endothelial dysfunction, persistent low-grade inflammation also plays a role. Indeed, inflammation is associated with both endothelial dysfunction and albuminuria [11,102-104].
4. Residual renal function and proteinuria
The past 20 years of research in nephrology have yielded substantial information on the mechanisms by which persisting dysfunction of an individual component cell in the glomerulus is generated and signaled to other glomerular cells and to the tubule. Spreading of disease is central to processes by which nephropathies of different types progress to end stage renal disease. Independent of the underlying causes, chronic proteinuric glomerulopathies have in common a sustained or permanent loss of selectivity of the glomerular barrier to protein filtration. Glomerular sclerosis is the progressive lesion beginning at the glomerular capillary wall, the site of abnormal filtration of plasma proteins. Injury is transmitted to the interstitium favoring the self-destruction of nephrons and eventually of the kidney. The underlying mechanisms of tubulointerstitial injury that are activated by ultrafiltered protein load of tubular epithelial cells continue during the entire process of the disease, which is accompanied by several clinical markers, as fluid and toxins retention, edema, hypertension, proteinuria, creeping creatinine and a continuous decrease in urinary output. It needs to be emphasized that this field is relevant to interpret clinical findings and to improve treatment of patients with non-diabetic or diabetic nephropathies.
The opinion among nephrologists that proteinuria could be a marker only of injury largely has been challenged. The strong predictive value of proteinuria in chronic nephropathies now is firmly established. Baseline proteinuria was an independent predictor of renal outcome in patients with type 1 diabetes and nephropathy [105]. and in patients who did not have diabetes and entered the MDRD study [86]. In the Ramipril Efficacy In Nephropathy (REIN) trial [92], urinary protein excretion was the only baseline variable that correlated significantly with glomerular filtration rate decline and progression of non-diabetic chronic proteinuric nephropathies to end-stage renal disease. Similar evidence was provided recently in patients with type 2 diabetes and overt nephropathy [87]. Other studies corroborated these data and extended the predictive value of proteinuria to risks for overall or cardiovascular mortality [106,107]. Clinical trials consistently showed renoprotective effects of proteinuria reduction and led to the recognition that the antiproteinuric treatment is instrumental to maximize renoprotection [86,92,94,108]. The MDRD study revealed tight association between reduction of proteinuria and decrease in rate of glomerular filtration rate decline [86]. Protection that was achieved by lowering blood pressure depended on the extent of initial proteinuria. The renoprotection that was conferred by angiotensin-converting enzyme inhibition in the REIN study was mediated by the drug’s action of reducing urinary protein levels, to the extent that patients who were on ramipril had a better outcome paralleled by more reduction in proteinuria, whereas blood pressure was comparable to that of control subjects [92]. Angiotensin converting enzyme inhibitor–induced reduction in proteinuria was the strongest time-dependent covariate predicting slower progression to uremia. Finding that the rate of glomerular filtration rate decline correlated negatively with proteinuria reduction and positively with residual proteinuria provided further evidence for a pathogenetic role of proteinuria [109]. Likewise, trials in type 1 [94,110] and type 2 diabetes [111,112] documented that whenever proteinuria is decreased by treatments, progression to end-stage renal disease is reduced. As already mentioned, the Reduction of Endpoints in type 2 diabetes with the Angiotensin II Antagonist Losartan (RENAAL) study [111] in 1513 patients with type 2 diabetic nephropathy confirmed that more reduction in proteinuria by losartan invariably was associated with more renoprotection at comparable levels of blood pressure control. Beneficial cardiovascular effects of losartan also were driven by effects on urinary protein and largely depended on the amount of residual proteinuria. Similar results were found in the Irbesartan Diabetic Nephropathy Trial [112]. Finally, the Angiotensin-Converting-Enzyme Inhibition and Progression of Renal Disease study [113,114] confirmed that proteinuria is a strong risk factor for progression of chronic renal disease and that patients with more severe renal disease benefit most from angiotensin converting enzyme inhibitor therapy. Importantly, in no case from a was there a worsening in proteinuria that subsequently was associated with an improved outcome [115].
In progressive nephropathies, severe dysfunction of the glomerular capillary barrier to circulating proteins causes protein overload of tubular epithelial cells and intrarenal activation of complement that is responsible for spreading of injury to the tubulointerstitium. Drugs that block angiotensin II limit the abnormal passage of plasma proteins and are renoprotective. The podocyte is the primary site of antiproteinuric action through stabilization of podocyte–podocyte contacts and prevention of permselective dysfunction at the slit diaphragm. Although the abnormal passage of plasma proteins across the glomerular capillary wall is likely to be a factor that is responsible for further podocyte injury and progression to glomerulosclerosis [116], most of the available data highlight the mechanisms underlying proximal tubular cell activation and interstitial inflammation and fibrosis. The toxicity of albumin seems to be mediated by its initial endocytic uptake, although the importance of albumin itself versus protein-bound molecules in the induction of irreversible tubular damage is not clear. Other molecules, including ultrafiltered transferrin and immunoglobulins, and the intrarenal complement and ammonium interactions could play relevant roles. Developments in these areas yield further support to design protocols in which drugs against secondary pathways of injury should be tested in association with drugs that limit the abnormal passage of proteins across the glomerular capillary barrier [117]. This statement must be borne in mind when considering treatment of proteinuria as the patient enters dialysis, as the already triggered pathologic pathways are perpetuated.
In this regard, the pathophysiological process that leads to end-stage renal disease where proteinuria is a hallmark is crucial to be followed and treated. As long as urinary output is present, all the severely damaged nephron structures may be still abnormally working, as hypertension and proteinuria are two clinical evident markers of renal disease virtually present in the vast majority of dialysis individuals.
5. Hemodialysis: Is there a role of proteinuria as a marker of disease?
Noteworthy, despite this active attempt to reduce proteinuria in pre-dialysis patients to delay disease progression, proteinuria appears to be forgotten or even ignored by nephrologists once a patient enters dialysis. However, its existence may certainly continue conferring the well-known inflammatory, catabolic, fibrinolytic and toxic effects on the endothelium that has been exerting in the pre-dialysis period [104,118,119]. Our group determined that the higher degrees of proteinuria in chronic hemodialysis patients are associated with inflammatory and cardiovascular markers of disease [120]. These results may also be related to the nutritional status and mortality rates.
In chronic kidney disease patients, proteinuria is a common event, irrespective of cause, and virtually all patients with chronic kidney disease present variable degrees of proteinuria [121]. However, in dialysis patients, the prevalence of proteinuria is unknown. In the present study, proteinuria was present in 87% of the hemodialyzed population. Noteworthy, despite significantly differences in proteinuria among the three groups, these changes were not accompanied by significant alterations in albuminemia or in cholesterolemia. This phenomenon could be attributed to the similar nutritional status the three groups displayed and to the use of statins in virtually all patients. In patients with proteinuria > 3/day, the two main causes of end-stage renal disease were diabetes nephropathy and primary glomerulonephritis, although no significant differences in the amount the proteinuria could be observed between both subpopulations. However, there was a significant increase in diabetic patients with heavy proteinuria in comparison to the other two groups, and a relative increase in the diabetic population was observed as proteinuria augmented. Proteinuric levels did not correlate with body mass index, the type of vascular acceses, and could not be attributed to hypertension or to hemodynamic fluctuations, as Pro-Brain natriuretic peptide (Pro-BNP) measurements were not different among the groups. There was a significant difference in the ultrafiltration rates, but we could not associate it to any of the variables under consideration, particularly with Pro-BNP or adiponectin, between which important feedback regulations exist. Interestingly, as proteinuria worsened, a significant correlation developed between Troponin T, a cardiovascular biomarker, and C-Reactive Protein (CRP), an inflammatory marker. This interrelationship may suggest that proteinuria could interact as a covert and ignored culprit in the complex and chronic protein energy wasting syndrome dialysis patients live in, contributing to a higher risk of cardiovascular disease and inflammation as proteinuria rises.
In our own experience, in a one-year recruitment cross-sectional study where 265 chronic kidney disease patients were classified into the 5 stages according to K/DOQI guidelines, proteinuria was present in 204 subjects (76.98%) [122]. Interestingly, proteinuria significantly worsened as kidney function declined, and the highest rates of proteinuria were encountered in the most advanced stages of the cohort: Stage 3, 1.39±3.2 g/day (range: 0-21.6) in 80% of the 90 cases included vs stage 4, 1.87±0.99 g/day (range 0-5.1), which represented the 95% of the 37 individuals included in this group. In Stage 5D, proteinuria was present in 85% of the 60 patients included, and the mean level of proteinuria was 2.48±3.72 g/day (range 0-21.5). This level of proteinuria was significantly higher and different from stages 3 (p=0.001) and 4 (p=0.013). These findings underscore previous findings that demonstrated that proteinuria is associated with chronic kidney disease, that worsens renal function, and that it is highly prevalent in end-stage renal disease [89-91,121].
Cardiovascular disease in the main cause of death in the chronic population. However, cardiovascular disease can be the final pathophysiological pathway where many different entities may converge: Framingham factors, malnutrition, oxidative stress, calcium-phosphate metabolism, anemia, infections, inflammation. Although we have included many of the traditional Framingham risk factors in our study, only diabetes mellitus was significantly more frequent in patients with proteinuria > 3 g/day compared to the other groups. In chronic kidney disease, the main causes that lead to renal replacement therapies are diabetic nephropathy, hypertension and glomerulonephritis. In all these entities, cardiovascular disease is a major cause of morbidity and mortality, and proteinuria again plays a key role in these pathophysiological processes. In our study, higher degrees of proteinuria (> 3 g/day) significantly correlated with Troponin T and CRP, markers of cardiovascular stress and systemic inflammation. Which is the relationship among CRP, Troponin T and proteinuria in hemodialysis, if any?. Both CRP and Troponin T have been employed as markers of highly prevalent complications as inflammation and cardiovascular disease in dialysis subjects. CRP has been reported to be elevated in 30 to 60% of dialysis patients, and can be employed as a predictor of cardiovascular mortality in hemodialysis [123]. In addition, it has been established that troponin T levels are increased in subjects with renal failure, even in the absence of myocardial ischemia [124-125]. In fact, approximately 53% of patients with chronic kidney disease present with elevated troponin T without acute myocardial necrosis [126] As troponin T is normally cleared by the kidneys, it could be elevated in chronic kidney disease owing to delayed clearance [127]. However, other reasons could also explain the high troponin T levels, as left ventricular hypertrophy, congestive heart failure, and sepsis [125,126,128]. The combination of increased levels of CRP and troponin T levels are associated with an increased risk of death in chronic kidney disease [129]. Finally, Wong et al state that the positive correlation between Troponin T and CRP could be due to an inflammatory process that could induce a sub-clinical myocardial damage resulting from endothelial injury and atherosclerosis [130]. How does proteinuria fit into this process?: In dialysis, proteinuria could be an important cause of inflammation and of endothelial dysfunction and atherosclerosis and peripheral vascular disease as in previous stages of chronic kidney disease [91, 117, 131], triggering CRP and troponin T elevations. This situation could justify that as proteinuria worsens, the correlation we found between troponin T and CRP rises significantly. It has recently been published that in a murine model of spontaneous albuminuric chronic kidney disease, the systemic endothelial glycocalyx is altered in its glycosylated components due to proteinuria itself. Therefore, it becomes reasonable to speculate that as this meshwork of surface-bound and loosely adherent glycosaminoglycans and proteoglycans modulates vascular function, its loss could contribute to both renal and systemic vascular dysfunction in proteinuric chronic kidney disease, including dialysis patients [132].
Therefore, it ought to be reasonable to focus on proteinuria as a target to treat, as its decrease may portend a better care of residual kidney function and cardiovascular status in stage 5D subjects. However, once patients are started on dialysis, proteinuria generally appears to be ignored and forgotten as a potential factor of morbidity and mortality, as it occurs in predialysis subjects. Proteinuria may contribute to the burden of cardiovascular disease and should be a parameter to pay attention to in dialysis individuals. Finally, despite being on dialysis, proteinuria should be controlled as its persistence may hasten the loss of residual renal function, a relevant item to preserve at any price in this population.
Moreover, proteinuria is not only important as a marker of progression of renal disease, but it is also associated with catabolic processes, protein-energy wasting, hypoalbuminemia, and inflammation. All these processes are prevalent in the dialysis community [11,12,17]. However, the data relating proteinuria and hemodialysis is more than scant. In a work published by Goldwasser et al in 1999, in which they observed a rise in albumin and creatinine in those patients who entered dialysis after six months of treatment, they hypothesized that this phenomenon could be attributed, in part, to a better nutritional status, a gain in muscle mass, and to a decline in residual renal function [121]. This decrease in urinary output could consequently result in lower losses of protein in the urine. Finally, it is well known that as proteinuria progresses, and more importantly without any medical intervention focused specifically on it, parenchymal fibrosis ensues and residual renal function rapidly deteriorates.
One question that needs to be addressed for dialysis patients is the threshold above which proteinuria would be implicated in inflammatory processes and could have any implication or contribution in the development of cardiovascular disease. Should the levels of proteinuria be interpreted in the same way as in pre-dialysis subjects?. Our study suggests that as proteinuria increases, cardiovascular stress and inflammatory processes are more prone to be encountered. No data exists whether proteinuria should be treated in dialysis and, if that were the case, the level to pursue. Our data suggest that proteinuria should be treated, considering its association with inflammation and cardiovascular stress. Although, as mentioned above, angiotensin converting enzyme inhibitors or angiotensin II receptor blockers could have modified the results, these drugs were employed homogeneously in the three groups.
Finally, we have observed (data not published) that at higher degrees of proteinuria, urinary output deteriorates faster. At similar initial urinary output rates, patients with proteinria > 3 g/day performed differently from those < 3 g/day: After three years of follow-up, patients with proteinuria > 3 g/day when entering hemodialysis were anuric and therefore had no residual renal function. Patients with proteinuria < 3 g/day still had residual renal function, and proteinuria did not worsen significantly during the time of follow-up. Whether this was be due to a higher proportion of diabetic patients, to higher degrees of proteinuria, or to other cofactors as previous administration of contrast agents or exposure to nephrotoxic drugs cannot be concluded from our data. Besides, in patients with heavy proteinuria a shorter time on hemodialysis trend was observed. Again, whether this phenomenon should be ascribed to diabetes mellitus itself, or to proteinuria could not be concluded. Interestingly, as mentioned before, in non-dialysis patients proteinuria in diabetics is associated with an increased risk of cardiovascular events and mortality [85-87,95-97]. However, we underscore the critical importance proteinuria may play on hemodialysis as a forgotten, overlooked marker of cardiovascular and inflammation.
Our experience, albeit limited, calls the attention of nephrologists to take proteinuria into account when a hemodialysis patient is assessed. Due to the small number of cases included in our recently published study, conclusions must be drawn cautiously. In this respect, the significant correlation found between CRP and Troponin T may be associated with heavy proteinuria, but other factors not assessed in this study may also be involved. We were unable to measure other inflammatory molecules as interleukin-6 and Tumor Necrosis Factor, or endothelial and procoagulant molecules as Plasminogen Activator Inhibitor-1, which are more sensitive than CRP and would have certainly added more information to the data presented in this study. Finally, no vascular arteriosclerotic parameters as pulse wave velocity were evaluated in our patients, which would have certainly enriched our primary findings. Moreover, as an observational study in a cross-sectional cohort, no follow-up with regard to patient prognosis, to the evolution of proteinuria and its correlation with other biomarkers, and to mortality rates could not be obtained. All these results require validation [120]. However, we believe this work is a call of attention to nephrologists regarding another important aspect of the characteristics of urinary output and residual renal function in dialysis patients.
6. Conclusions
Proteinuria is a strong predictor of chronic kidney disease progression. It is also an important marker of cardiovascular disease, both in patients with or without kidney disease. In hemodialysis individuals, urinary output is associated with morbidity and mortality. At higher levels of diuresis, there is a trend to lesser rates of hospitalization and a higher mortality. Most of renal functions are better preserved if associated with higher volumes of urine. In this regard, proteinuria plays a critical role in renal fibrosis, stimulating sclerosis in the glomerular and in the interstitial compartments. This sclerosis causes in turn local ischaemia and further deterioration of kidney function, which can be clinically assessed with creeping of serum creatinine and a final decline in urinary output. This phenomenon is observed throughout the chronic kidney disease process, even at the dialysis setting. We have found that in chronic hemodialysis patients, at higher degrees of proteinuria, systemic markers of cardiovascular disease and inflammation are elevated. Albeit not proven yet, as proteinuria causes an eventual decline in renal function, and preservation of residual renal function is associated with higher survival rates in dialysis patients, proteinuria may be also associated with a decrease in urinary output and an increase in morbidity events and mortality in chronic hemodialysis.
\n',keywords:null,chapterPDFUrl:"https://cdn.intechopen.com/pdfs/40473.pdf",chapterXML:"https://mts.intechopen.com/source/xml/40473.xml",downloadPdfUrl:"/chapter/pdf-download/40473",previewPdfUrl:"/chapter/pdf-preview/40473",totalDownloads:1872,totalViews:127,totalCrossrefCites:0,totalDimensionsCites:1,totalAltmetricsMentions:0,impactScore:1,impactScorePercentile:68,impactScoreQuartile:3,hasAltmetrics:0,dateSubmitted:"May 1st 2012",dateReviewed:"September 21st 2012",datePrePublished:null,datePublished:"February 27th 2013",dateFinished:"October 24th 2012",readingETA:"0",abstract:null,reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/40473",risUrl:"/chapter/ris/40473",book:{id:"3267",slug:"hemodialysis"},signatures:"Hernán Trimarchi",authors:[{id:"56043",title:"Dr.",name:"Hernan",middleName:null,surname:"Trimarchi",fullName:"Hernan Trimarchi",slug:"hernan-trimarchi",email:"htrimarchi@hotmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Residual renal function in dialysis",level:"1"},{id:"sec_3",title:"3. Proteinuria and chronic kidney disease",level:"1"},{id:"sec_4",title:"4. Residual renal function and proteinuria",level:"1"},{id:"sec_5",title:"5. Hemodialysis: Is there a role of proteinuria as a marker of disease?",level:"1"},{id:"sec_6",title:"6. Conclusions ",level:"1"}],chapterReferences:[{id:"B1",body:'[Culleton BF, Larson MG, Wilson PW, Evans JC, Parfrey PS, Levy D. Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency. Kidney Int 1999; 56: 2214 – 2219.]'},{id:"B2",body:'[Kilickesmez KO, Abaci O, Okcun B, Kocas C, Baskurt M, Arat A, et al. Chronic kidney disease as a predictor of coronary lesion morphology. Angiology 2010; 61: 344 – 349.]'},{id:"B3",body:'[Yagi H, Kawai M, Komukai K, Ogawa T, Minai K, Nagoshi T, et al. 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Proteinuria: An ignored marker of inflammation and cardiovascular disease in chronic hemodialysis International Journal of Nephrology and Renovascular Disease 2012; 5: 1-7.]'},{id:"B121",body:'[Goldwasser P, Kaldas AI, Barth RH. Rise in serum albumin and creatinine in the first half year on hemodialysis. Kidney Int 1999; 56: 2260-2268. ]'},{id:"B122",body:'[Trimarchi H, Muryan A, Martino D, Toscano A, Iriarte R, Campolo-Girard V, Forrester M, Pomeranz V, Fitzsimons C, Lombi F, Young P, Raña M, Alonso M. Creatinine- vs cystatin c-based equations compared with 99mTcDTPA scyntigraphy to assess glomerular filtration rate in chronic kidney disease. Journal of Nephrology 2012; doi: 10.5301/jn.5000083 (Accessed 17 August 2012)]'},{id:"B123",body:'[Yeun JY, Levine RA, Mantadilok V, Kaysen GA. C-reactive protein predicts all-cause and cardiovascular mortality in hemodialysis patients. Am J Kidney Dis 2000; 35: 469-476.]'},{id:"B124",body:'[Li D, Keffer J, Corry K. Nonspecific elevation of troponin T levels in patients with chronic kidney failure. Clin Biochem 1995; 28: 474-477.]'},{id:"B125",body:'[Francis GS, Tang WH. Cardiac troponins in renal insufficiency and other non-ischemic cardiac conditions. Prog Cardiovasc Dis 2004; 47: 196-206.]'},{id:"B126",body:'[Fernandez-Reyes MJ, Mon C, Heras M. Predictive value of troponin T levels for ischemic heart disease and mortality in patients on hemodialysis. J Nephrol 2004; 17: 721-727.]'},{id:"B127",body:'[Kanderian AS, Francis GS. Cardiac troponins and chronic kidney disease. Kidney Int 2006; 69: 1112-1114.]'},{id:"B128",body:'[Mallamaci F, Zoccali C, Parlongo S. Troponin is related to left ventricular mass and predicts all-cause and cardiovascular mortality in hemodialysis patients. Am J Kidney Dis 2002; 40: 68-75. ]'},{id:"B129",body:'[de Filippi C, Wasserman S, Rosanio S. Cardiac troponin T and C-reactive protein for predicting prognosis, coronary atherosclerosis, and cardiomyopathy in patients undergoing long-term hemodialysis. JAMA 2003; 290: 353-359. ]'},{id:"B130",body:'[Wong CK, Szeto CC, Chan MHM, Leung CB, LI PKT, Lam WK. Elevation of Pro-Inflammatory cytokines, C-Reactive Protein and cardiac Troponin T in chronic renal failure patients on dialysis. Immunol Invest 2007; 36: 47-57.]'},{id:"B131",body:'[Kuo HK, Al Snih S, Kuo YF, Raji MA. Cross-sectional associations of albuminuria and C-reactive protein with functional disability in older adults with diabetes. Diabetes Care 2011; 34:710-717.]'},{id:"B132",body:'[Salmon AHJ, Ferguson JK, Burford JL, Gevorgyan H, Nakano D, Harper SJ, Bates DO, Peti-Peterdi J. Loss of the Endothelial Glycocalyx Links Albuminuria and Vascular Dysfunction. J Am Soc Nephrol 2012; 23: 1339-1350.]'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Hernán Trimarchi",address:null,affiliation:'- Chief Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
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Introduction
1.1 Background
There is no health without mental health. Mental health is important at every stage of life, from childhood and adolescence through adulthood to senescence. However, the upsurge of Coronavirus (COVID-19) as a global burden in 2019 in Wuhan, China, its high mortality rate and attendant stressors, such as lock-downs, self-isolation and quarantines, infection fears, inadequate information, job and financial losses, stigma, and discrimination, among others have contributed significantly to the increase of negative psycho-social and mental health disorders globally. Since the WHO’s declaration of the outbreak of coronavirus disease as a Public Health Emergency of International Concern (PHEIC) and a pandemic between 30th January and 11th March 2020, there had held six different International Health Regulations (IHR) Emergency Committee meetings (third to ninth) for COVID-19 in Geneva. The meetings were specifically held on 30 April 2020, 31 July 2020, 29 October 2020, 14 January 2021, 15 April 2021, 14 July 2021, and 22 October 2021. During each of these committee meetings, it was concluded that the pandemic constitutes a major PHEIC.
The physical burden associated with COVID-19 included symptoms such as mild to moderate respiratory illnesses characterized by fever, dry cough, tiredness, difficulty breathing or shortness of breath, and loss of the ability to smell and taste. Between 31st December 2019 and the week 492,021, five out of 316,017 COVID-19-related deaths and 270,327,277 cases have been recorded in line with the applied case definitions and testing strategies of affected countries. The total number of cases recorded in the global community and the EU/EEA are probably an underestimate of the true number of cases and deaths, due to various degrees of under-ascertainment and under-reporting. Between 9th and 16th December 2021, there had been no changes made to the following ECDC variant classification—the variants of concern (VOCs), variants of interest (VOIs), variants under monitoring, and de-escalated variants.
The COVID-19 pandemic has not only disrupted and altered lives in Africa but a surge in depressive cases, public anxieties, worries [1], and increased risk of mental health symptoms and disorders among vulnerable populations, such as unemployed adults, youth, the elderly, and frontline healthcare workers [2]. Its impact in the Democratic Republic of the Congo (DRC) was complicated by the recent Ebola virus disease (EVD) outbreak reported on 8 October 2021, in Butsili Health Area in the Beni Health Zone, North Kivu Province, even though it has been officially declared over on 16 December 2021. In total, eight confirmed and three probable EVD cases, including nine deaths (six among the confirmed cases), were reported since the start of the outbreak (8 October 2021).
Although the WHO and the US CDC have been detecting and characterizing new variants and providing updates to healthcare workers, the public and global partners on the spread and effects of COVID-19 on patients with noncommunicable diseases and co-morbid ailments, Corser [3] posit that the impact of COVID-19 on the mental health of individuals is an unfolding urgent crisis. Additionally, epidemiology and virologic evidence suggest that COVID-19 and its subsequent deadly variants have been associated with mental and neurological manifestations, including delirium or encephalopathy, agitation, acute cerebrovascular disease (including ischaemic and hemorrhagic stroke), meningoencephalitis, impaired sense of smell or taste, anxiety, depression, and sleep problems. WHO [4] found that out of 775 adults, studied in the United States, 55% believed that COVID-19 had dangerous effects on their mental health, while 71% felt agitated about the negative impacts of isolation on their mental health. Pappa, Ntella, Giannakas, Giannakoulis, Papoutsi, and Katsaounou [5] also associated personality changes consistent with depression with COVID-19-induced encephalopathy. Zhang and Ma [6] reported that symptoms of depression, anxiety, fear, stress, and insomnia, increased during the pandemic.
1.2 Variants of COVID-19
Toward the end of 2020, the emergence of specific variants of the COVID-19 pandemic that constitute a greater significant risk to global public health led to the listing of specific Variants of Interest (VOIs) and Variants of Concern (VOCs). This classification aided the prioritization of global health monitoring, research, and ongoing response to the pandemic. According to the SIG Variant classification scheme, the following are the four main classes of SARS-CoV-2 variants (see Table 1).
The Variant being monitored (VBM):
SARS-CoV-2 lineage—B.1.1.7: According to the European Centre for Disease Control and Prevention [7], this variant originally detected in the United Kingdom (UK) is defined by multiple spike-protein mutations (deletion 69–70, deletion 144, N501Y, A570D, D614G, P681H, T716I, S982A, D1118H) present as well as mutations in other genomic regions. It is significantly more transmissible than previously circulating variants with an estimated potential to increase the reproductive number (R) by 0.4 or greater with estimated increased transmissibility of up to 70%. This poses a challenge to the monitoring of the spread of the virus at the population level to assess the effectiveness of containment strategies—including vaccination. Vaccine inequity leaves most African countries helpless in the wake of more deadly variants.
The alpha, gamma, and beta variants continue to be monitored but are spreading at much lower levels in the U.S.
The variant of interest (VOI)–Currently, no SARS-CoV-2 variants are designated as VOI
The variant of Concern (VOC): Currently designated variants of concern (VOCs) + are:
Delta (B.1.617.2 and AY lineages): The Delta variant of COVID-19 is highly contagious and still dominant worldwide. It has been labeled a variant of concern by WHO because of its increased transmissibility and increased ability to cause a severe form of the disease. The greatest risk of transmission is among unvaccinated people. People who are fully vaccinated can get vaccine breakthrough infections and spread the virus to others
Omicron (B.1.1.529 and BA lineages): The eCDC classified a SARS-CoV-2 variant belonging to Pango lineage B.1.1.529 as a variant of concern (VOC) on 26 November 2021, due to concerns regarding immune escape and its potentially increased transmissibility. The WHO also classified this variant as a VOC and assigned it the label Omicron. As of 16 December 2021, overall, there were 15,778 confirmed cases of Omicron VOC (an increase of 13,608 cases since the last report on 9 December 2021) reported globally by 85 countries. The number of countries reporting cases with the SARS-CoV-2 Omicron VOC continues to increase globally. Africa has detected 8,982,687 cases; the five countries reporting the most cases are South Africa (3167497), Morocco (951482), Tunisia (719662), Libya (378105), and Ethiopia (373115). Africa has had 224,869 deaths with most deaths occurring in the following five countries—South Africa (90137), Tunisia (25437), Egypt (21060), Morocco (14796), and Ethiopia (6829).
The variant of high consequence (VOHC)n: Currently, no SARS-CoV-2 variants are designated as VOHC
The WHO’s label of COVID-19 Variants | Pango lineage• | GISAID clade | Next strain clade | Additional amino acid changes monitored d° | Earliest documented samples | Date of designation |
---|
Alpha | B.1.1.7 | GRY | 20I (V1) | +S:484 K + S:452R | The United Kingdom, Sep-2020 | 18-Dec-2020 |
Beta | B.1.351 | GH/501Y. V2 | 20H (V2) | +S: L18F | South Africa, May-2020 | 18-Dec-2020 |
Gamma | P.1 | GR/501Y. V3 | 20 J (V3) | +S:681H | Brazil, Nov-2020 | 11-Jan-2021 |
Delta | B.1.617.2 | G/478 K.V1 | 21A, 21I, 21 J + S:417 N | +S:484 K | India, Oct-2020 | VOI: 4-Apr-2021 VOC: 11-May-2021 |
Omicron* | B.1.1.529 | GRA 21 K, 21 L 21 M | +R346K | Multiple countries, Nov-2021 | VUM: 24-Nov-2021 | VOC: 26-Nov-2021 |
All variants of COVID-19 can cause severe disease or death. While data on these complications may be available in the global north and south, there is a paucity of literature in most African States.
1.3 Rationale
The upsurge of Coronavirus as a global pandemic and its attendant gender-related socio-economic problems have sparked up depression, sadism, suicidal ideation, and all manner of psychiatric ailments across the globe. The pandemic that claims millions of lives both recorded and unrecorded deaths created a new wave of mental ill-health and vicarious trauma even for clinicians attending to COVID-19 patients.
The prevalence of these illnesses and traumatic experiences among clinicians and significant persons attending to the sick or those who have lost loved ones to the pandemic is yet to be determined. The policy strategies deployed for containing the spread of the pandemic increased unemployment, financial insecurity, and poverty. It also had grave impacts on mental health by increasing social isolation and loneliness that have been strongly associated with anxiety, depression, self-harm, suicide attempts, and emotional problems across the lifespan. The effect of social (or physical) distancing measures affects mental health within a syndemics approach through interacting socio-demographic forces (eg, aging, rising inequality) and health conditions (eg, chronic diseases and obesity) that yield resultant comorbidities.
More so, the World Health Organization in its new Mental Health Atlas report identified the growing need for mental health support and a worldwide failure to provide people with the mental health services needed during the COVID-19 pandemic. In a policy brief on COVID-19, the United Nations also mandated the need to provide high-quality data on the psychological impacts of the COVID-19 pandemic [8].
1.4 Purpose of study
The purpose of this study is to examine the psychosocial and health implications of COVID-19 Comorbidity-Related Complications among selected vulnerable groups in the African States, identify which sub-groups are most vulnerable to psychological distress, identify the risk and protective factors associated with this population’s mental health, and to highlight recent developments in counseling and therapeutic options.
1.5 Objectives of study
The study contributes to informing where mental health interventions, together with organizational and systemic efforts to support this population’s mental health could be focussed in an effort to support psychological well-being.
1.6 Research questions
What are the COVID-19-related mental health theories?
Are there existing policies or plans for managing mental health issues associated with COVID-19 in Africa?
What is the prevalence of the mental health consequences of COVID-19 containment measures, socio-demographic forces, and other health conditions for vulnerable groups?
How can the mental health consequences of the COVID-19 containment measures, socio-demographic forces, and other health conditions among vulnerable groups be mitigated in Africa?
What are the basic psychosocial counseling principles for COVID-19 positive patients and other significant persons?
2. Methodology
2.1 Research design
To address the stated research questions and objectives, the study adopts a desk review of the literature. The desk review of literature includes scoping existing online records, scientific articles, and reports published in English on the pandemic, related comorbidities, and mental health between 2000 and 2021. All scientific articles were obtained from the online database, while country and continent-specific reports and preprint articles were abstracted using google scholar.
3. Results
Question 1: what are the COVID-19-related mental health theories?
According to WHO [9], mental health is a state of well-being during which the individual realizes his or her own abilities, has the capacity to cope with the normal stresses of life, works productively and fruitfully, and makes meaningful contributions to his or her community. In other words, mental health is not just the absence of mental illness, but the presence of well-being. Cohan and Cole [10] and Ilesanmi and Eboiyehi [11] asserted that disasters have complex, multi-faceted, and long-lasting mental health implications for the people who experience them and vicarious trauma effects on their caregivers. Maths, Nirmala, Moirangthem, and Kumar [12] reported that the prevalence of mental health problems in populations affected by disasters was two to three times higher than that of the general population.
Sturgeon [13] posits that the determinants of mental health and well-being during the pandemic are both psychological and social factors. The psychological factors encompass emotions (e.g., anger, guilt, and grief), thought processes (e.g., hopelessnesses, helplessness associated with the pandemic), beliefs (e.g., about the outbreak, its attribution, and those affected by it), and so on. The social factors entail access to family and community networks during the COVID-19 quarantine, economic factors, stigma and discrimination, cultural practices, and so on. Both psychological and social factors interact with each other to influence the mental health and well-being of individuals during the pandemic.
Consequently, the general theoretical mental health assumption related to COVID-19 and its associated comorbidities as well as the containment measures (quarantine) is that undue distress, a sense of loss, and impairment to social and occupational functioning can stem from losing direct social contacts, loved ones, employment, sources of income, educational opportunities, recreation, freedoms, and social supports. This can be worsened by the gripping fears and anxieties of its morbidity, mortality, and efficacy of high transmission. These anxieties include constant fears of getting infected and passing the infection to friends, families, and coworkers, as well as fear of survival when infected. The development of this mental stress is an emergency needing mental health response. Nearly 20 months into the global health crisis, the pandemic fatigue worsened by the resurgence of more deadly variants is contributing to and creating risks of mental distress of losing jobs, keeping families safe, or the sweeping uncertainty of the future.
Gallagher and Wetherell [14] classified the mental health implications of COVID-19 and its associated comorbidities as peritraumatic stress occurring during or immediately following infection. Biello [15] highlighted the following characteristics of pre-trauma in the current global pandemic scenario as including:
Lack of predictability: This entails the disruption of daily routines as a direct consequence of the pandemic.
Immobilization: This refers to the containment measures, such as physical distancing, limited mobility, and quarantine at home.
Loss of social connection: This refers to the sudden and unnatural interruption in social connectivity and physical engagement, resulting in the sudden disruption of the very nature of human interactions.
Numbing out: Numbing out is a protective reaction that prevents emotional overload. Excessive numbing out can result in the loss of agency and sense of control over individual actions and choices. It entails being aware of oneself, feelings, and emotional discomfort. Non-realization of these feelings and emotional discomforts can result in automatic outbursts of anger, fear, or irritation.
Loss of time perception or dyschronometria: This infers distortion of an individual sense of time perception. It is a condition of cerebellar dysfunction in which an individual cannot accurately estimate the amount of time that has passed as a result of shock from the traumatic situation. It is an overwhelming loss of sense of time, tracks of events, and differences in each and every moment.
Loss of safety: The high rate of COVID-19-related deaths and the associated violence experienced by many during the total lockdown has resulted in the loss of physical sense of safety, social safety, job loss, and loss of social connection.
Loss of meaning for life: The psychotherapists need to assist patients to gain meaning for life out of the current adversity and find their roles and purpose through existential safety and satiation of basic needs such as food, safe shelter, and jobs, as well as on the psychological mind.
Question 2: are there existing policies or plans for managing mental health issues associated with COVID-19 in Africa?
Since Africa recorded its first COVID-19 case in Egypt on 14 February 2020, a significant number of countries have reported cases in capital cities and multiple provinces. As of 2020, out of the WHO’s 194-Member States, only 51% had mental health policies or plans that are in line with international and regional human rights instruments. More so, only 52% met the target relating to mental health promotion and prevention programs, and these are way short of the 80% target. The only 2020 target met was a reduction in the rate of suicide by 10%, but even then, only 35 countries had a stand-alone prevention strategy, policy, or plan.
In compliance with the WHO’s Mental Health Policy Action Plan (2013–2020) that aimed at preventing mental disorders; providing care; enhancing recovery; promoting mental well-being and human rights, as well as reducing the mortality, morbidity, and disability of persons with mental disorders, the following are the existing MHP in African nations:
Kenya:
Mental Health Preparedness and Action Framework (MHPAF): This is the MHP framework in Kenya prior to the pandemic. The MHPAF provided a useful schema for evaluating and guiding the mental health response during the COVID-19 pandemic, its implementation remains a major challenge for the poorly resourced mental health system. Kenya currently has no formal mental health response plan for its COVID-19 response. The nation majorly had an unmet need for psychological first aid.
Mental Health Surveillance System: Kenya also lacked a mental health surveillance system, thereby limiting its ability to design evidence-based interventions [16].
South Africa: South Africa’s mental health laws promote a community-oriented approach
Ghana: The mental health aspect of the pandemic is yet to receive the desired policy attention in Ghana. Although the nation has a Mental Health Act, established Mental Health NGOs, and Increased media attention on mental health care [17], its mental health system has been neglected for far too long while there are doubts about how the system can respond to the mental health aspect of COVID-19 [18]. Like other African nations, the mental health system in Ghana is, generally, a neglected area in the health care system due to years of underinvestment and it still is amidst the COVID-19 pandemic [19]. There is, therefore, an urgent need for mental health policymakers and policies to alleviate the potential threat of the pandemic to the mental health of Ghanaians
Cameroon:
Cameroon Crisis Response Plan 2021–2022: This plan provides tailored lifesaving assistance and protection, complemented by efforts to build community-based approaches for the attainment of durable solutions, seeking to prevent forced displacement and favor reintegration by addressing the drivers of crises, supporting mechanisms of conflict management and reduction, and building resilience in communities
Nigeria:
The Lunacy Act of 1958: The nation’s mental health system is still governed by the Lunacy Act of 1958, which dates back to Nigeria’s colonial era. Although stigmatization and mental health are among the greatest challenges to the national response to COVID-19, Nigeria is yet to prioritize its policy reform for mental health infrastructure.
National Policy on Mental Health Device Delivery 2013: This policy emphasizes the development of community-based services for persons with mental health conditions, but its implementation is very limited across the nation.
The Mental Health and Substance Abuse Bill - 2019: Since the return of democratic governance in Nigeria, no civilian administration has enacted a law focusing on protecting mental health except for the 9th National Assembly that is currently reviewing the Mental Health and Substance Abuse Bill – 2019, which aims at strengthening the capacity and regulatory environment for those who experience mental health distress in the wake of COVID-19.
National Budget: Nigeria has no clearly defined budget allocation for mental health in its national health budget, while there is inequality in the distribution of mental health services and available resources.
Question 3: what are the prevalence of the mental health consequences of COVID-19 containment measures, socio-demographic forces, and other health conditions for vulnerable groups?
The mental health impact of disasters usually outlasts their physical impact, thus indicating that the elevated mental health impacts of COVID-19 will continue well beyond the outbreak of the pandemic. The vicarious trauma of the pandemic on clinicians and other health care providers during outbreaks may last up to three years after an outbreak. According to Carfì, Bernabei, and Landi [20], reports from viral outbreaks in earlier centuries, including the deadly “Spanish Flu” pandemic of 1918–1920, describe an increased incidence of neuropsychiatric symptoms such as insomnia, anxiety, depression, mania, psychosis, and suicidality. They also claimed that the full impact of COVID-19 on mental health may be known for several years, but it is likely to be significant—and potentially chronic in some patients globally.
However, Panchal et al. [21] noted that about four in 10 adults had symptoms of anxiety or depressive disorder prior to the onset of the pandemic between January to June 2019 in the U.S. The Mental Health America (MHA) [22] reported surging rates of depression, anxiety, and other mental health problems because of COVID-19 among the people accessing their online mental health screening services. MHA observed a slight increase in the demand for mental health care between January and April 2020, a sharp spike around May and June of the same year. The MHA report also noted that screenings for anxiety (406%) and depression (457%) in June 2020 were greater than those in January. There was also a spike in the percentage of people diagnosed as “at-risk” for psychosis during the onset of the lockdown and self-isolation in May 2020. This continued to rise in June to more than four times the number in January. A six-fold increase was noted for those considering suicide or self-harm. The MHA [22] observation was confirmed by A KFF Health Tracking Poll in the US around July 2020 to 2021 on the mental health impacts of COVID-19 among adults that showed difficulty sleeping (36%), eating (32%), increases in alcohol consumption or substance use (12%), and worsening chronic conditions (12%), due to worry and stress over the coronavirus.
These have been worsened by the enforcement of the containment measures, including restriction of movements and self-isolation procedures, which led to increasingly negative and poor mental health outcomes. For many, this has been compounded by job loss and loss of income. In the US, more than half of young adults (ages 18–24) captured by the KFF study reported symptoms of anxiety and/or depressive disorder (56%). While the majority of these had suicidal thoughts (26% vs. 11%) during the pandemic, there were further concerns around poor mental health and well-being for children and their parents, particularly mothers, as many experienced challenges with school closures and lack of childcare. Panchal, Kamal, Orgera, Cox, Garfield, Hamel, and Chidambaram [21] claimed that women with children are more likely to report symptoms of anxiety and/or depressive disorder than men with children (49% vs. 40%).
Panchal et al. [21] further reported that Non-Hispanic Black adults (48%) and Hispanic or Latino adults (46%) are more likely to report symptoms of anxiety and/or depressive disorder than Non-Hispanic White adults (41%) resulting from the pandemic in the US. They also reported that some of the mental health-related challenges experienced by many essential workers include a greater risk of contracting the coronavirus, symptoms of anxiety or depressive disorder (42% vs. 30%), starting or increasing substance use (25% vs. 11%), and suicidal thoughts (22% vs. 8%) than other workers during the pandemic compared to nonessential workers.
MHA [22] posited that the social consequences of the pandemic, rather than the threats of sickness or death, are the major causes of stress among persons using the screening tools. Factors identified as the major cause of depression and anxiety (73%), past trauma (46%), or relationship problems (44%) were loneliness and isolation among girls/women between 11 to 25 years of age.
In the UK, a British Medical Association survey conducted during the pandemic showed that 45% of UK doctors suffered depression, anxiety, stress, burnout, or other mental health conditions relating to, or made worse by, the COVID-19 crisis [23].
In India, the socio-economic and mental health of marginalized communities were disproportionately impacted by the pandemic [24]. Balaji and Patel [25] observed mental health difficulties among women, children, young people, sexual minorities, and people with pre-existing mental health conditions and substance use disorders. In spite of this information, Duggal et al. [26] claimed that there exists a lack of empirical data on the mental health impact of the pandemic on marginalized communities and their needs in India. In a meta-analysis of 31 studies conducted in China, Deng et al. [27] reported that the prevalence of depression among persons diagnosed with COVID-19 was 45%, anxiety was 47%, and sleep disturbances were 34%. Also, the Chinese, Singaporean and Australian governments have identified the psychological side effects of COVID-19 and the long-term impacts of isolation which could cause more harm than the pandemic itself [28, 29, 30].
Zeroing in on the African States, the experience of the disease, breakdown of social support, loss of loved ones, and stigmatization could trigger short-term mental health problems among affected persons and their families, while factors such as economic losses (job and income losses) can potentially trigger long-term mental health problems. Some of the COVID-19-related fears, worries, and anxieties may be borne out of lack of knowledge, rumors, and misinformation, while its associated mental health care has become one of the most neglected areas of health. Frissa and Dessalegn [31] predicted that the impact on mental health will be immense in sub-Saharan Africa due to their weak health care systems. They also hinted that patients with COVID-19 and other illnesses along with significant persons around them consistently experienced post-traumatic stress disorders, anxiety, depression, and insomnia. They further reported that the uptake of mental health care services is generally low in the region while individuals in some communities rely solely on social resources. This was further compounded by poor digital literacy, low smartphone penetration, limited internet connection, and weak expertise in online mental health service delivery even among clinicians and psychotherapists. While the majority of those who need mental health care do not have access to services, receive little or no treatment at all.
The COVID-19-related mental health treatment gap is thus higher in African nations. Consequently, the need to protect individual socio-cultural coping and resilience mechanisms is very critical in the continent, most especially the sub-Saharan African region.
The MTL status of some of the African states shows that:
Cameroon: Cameroonians are vulnerable to mental health problems related to COVID-19 due to the challenges of a weak healthcare system, inadequate mental health workforce, insufficient financing to pay for health care, lack of access to mental health medications, and stigmatization which continues to prevent individuals from seeking mental health care [32].
Ghana: There was an increase in boredom and anxiety symptomatology during the COVID-19 pandemic and a decrease in well-being among Ghanaians [33].
Kenya: the effect of the COVID-19 pandemic in Kenya has been felt by children and young people due to prolonged school closures and loss of learning. There have been more calls for help to deal with psycho-social issues since the pandemic began [34].
Nigeria: Nigeria is ranked 197 out of 201 countries in terms of the quality health system, and is one of the poorest countries among Africans [35]. Prior to 2019, Bloomberg [36] ranked Nigeria as the most stressful country to live in the world, based on multiple factors in the living environment. An estimate from the Federal Ministry of Health reveals that about 20–30% of the population suffers from mental health challenges, such as anxiety, depression, psychosis, substance use disorders, mental disorders in pregnancy and childbirth, childhood psychological/developmental disorders, and suicide among others [37]. Although numerous factors contribute to elevated stress among people, such as heavy workloads, lack of physical or psychological safety, moral conflicts, and workplace-related bullying or lack of social support [2]. These were exacerbated during the pandemic with a wide range of emotions, including uncomfortable feelings such as shame, sadness, anger, frustration, or any other emotional painful feelings. These were worsened during the pandemic (around 2019, 2020, and 2021) and also worsened the existing insecurity, herdsmen attacks, and Boko-Haram violent insurgencies across the nation. High incidence of job loss, domestic violence, rape, battering, sexual assaults, and brutal killings of innocent girls during the lockdown further stressed the mental health stability of individual Nigerians beyond the limit.
Consequently, the pandemic has heightened individual vulnerability to financial insecurity, unemployment, and fear, which have been identified as risk factors for poor mental health among Nigerians [2]. The pandemic amplified existing vulnerabilities, inequalities, societal divides, fragility, instability, and threats to social cohesion and peace processes [38]. Currently, a lot of Nigerians are facing psychological distress that can lead to burnout, depression, anxiety disorders, sleep disorders, and other illnesses due to the absence of protective factors, such as employment, educational engagement, physical exercise, and access to health services during the lockdown [38].
In spite of the fact that mental health challenges are huge across the nation, Nigeria has no clearly defined mental health-related allocated budget. The allocation for health in the entire 2016 National Budget was only 3.65% out of which about 3.3% was barely earmarked for mental health and more than 90% of this amount went to institution-based services provided through eight stand-alone mental hospitals [39].
Another major challenge is the lack of a social welfare package for addressing the mental health needs of the socially marginalized and neglected groups in Nigeria, most especially women, children, the elderly, the homeless, and the very poor. These groups of people are vulnerable to different risk factors associated with mental disorders and also exhibit poor health help-seeking behavior [39]. More than 70% of these categories of patients with mental health problems/disorders in Nigeria seek unorthodox interventions before orthodox care [39].
South Africa: The mental health of South Africans was significantly impacted by the COVID-19 pandemic, especially as a result of a previous history of mental health surges. Mental health issues such as anxiety disorders, post-traumatic stress disorder, loneliness, phobias, mood disorders, and obsessive–compulsive disorders were common issues in the South-African population [40].
Tanzania: In Tanzania, anxiety disorders and fear were rampant among the younger population. The economic issues coupled with the pandemic exacerbated the anxiety states of most people. Among youths, the lack of enrollment in school led to frustration and a feeling of isolation [41]. The uncertainty about the future also affected the mental state of people. Moreover, the diversity of conflicting reports about the pandemic increased fear and anxiety levels [42].
Uganda: In Uganda, like most African countries, mental healthcare was already weak before the epidemic. Which was then worsened by the pandemic [43]. Giebel, Ivan, Burger & Ddumba [44], West, Ddaaki, Nakyanjo, Isabirye, Nakubulwa, Nalugoda & Kennedy [45], and Akena, Kiguba, Muhwezi, Kwesiga, Kigozi, Nakasujja & Lukwata [46] reported increased psychological distress and onset of common mental disorders (CMD), such as major depressive disorders (MDD), generalized anxiety disorders (GAD), post-traumatic stress disorders (PTSD) and substance misuse disorders (SUD), among Ugandaians living with HIV, older adults (aged 60+) and health workers during the COVID-19 pandemics. Lemuel (2021) specifically observed a high incidence of anxiety among respondents with a primary and secondary level of education compared with those with no formal education and a tertiary level of education after the onset of the pandemic.
Question 4: how can the mental health consequences of the COVID-19 containment measures, socio-demographic forces, and other health conditions among vulnerable groups be mitigated in Africa?
Vulnerability to mental health impact of COVID-19:
Vulnerability to the negative psychological impact of the current pandemic varies among different populations across the continent. In post-apartheid South Africa, for instance, even though mental health services have been decentralized and integrated into primary health care, there still remain service gaps within and between provinces, especially in the rural areas [47] According to Jaguga and Kwobah [48], even though preventive and medical actions are critical to the containment of the pandemic, emergency psychological crisis interventions (EPCI) are required for the mitigations of the mental health consequences of the pandemic among affected populations by and other vulnerable groups such as pediatric patients, pregnant women, mothers, older people, PLWDs, other marginalized groups with suspected or confirmed cases and frontline workers. The direct EPCI may be utilized for COVID-19 patients, while the indirect EPCI is employed for their relatives, caregivers, and health care professionals. Forms of Emergency Psychological Crisis Interventions (EPCI) could entail both digital and preventive virtual mental health services aimed at addressing scale and limiting the exposure of patients to COVID-19 at health facilities. Psychological counseling, digital mental health education, and communication materials may be delivered for those in need and shared through Facebook, Twitter, Whatsapp, and other commonly used social media platforms.
There is also the need to proactively identify high-risk groups early on and provide them with targeted interventions. This may be done through research and deployment of artificial intelligence to proactively identify posts on social media from people who are in crisis and likely to commit suicide. Such vulnerable persons may be reached through different types of virtual psychotherapeutic mechanisms, including video-conferencing, the conduct of cognitive-behavioral and mindfulness-based smartphone therapies, and chess-edutainment [49, 50]. Most African nations, especially Nigeria, Ghana, South Africa, and Kenya, already have a telecommunications density exceeding 100%, which serves as a veritable tool for the implementation of mobile psycho-therapeutic care and services. Existing digital psycho-therapeutic clinical care across Africa include Wazi in Kenya, PsyndUp in Nigeria, MindIT in Ghana, and the MEGA project in South Africa and Zambia. There could also be the provision of several mental health hotlines and online therapy services for COVID-19 pandemic emotionally distressed people.
The following vulnerable groups within the larger population in all African nations are particularly needing EPCI and support:
Male and female Persons Living with Disabilities: Psychosocial first aid (PFA) is necessary for people living with disability in periods of crisis, such as the COVID-19 pandemic. This will reduce anxiety levels and feelings of uncertainty [51].
Male and female Survivors of COVID-19: An intervention for adaptation post survival is necessary to prevent segregation and promote social interaction among survivors of the pandemic [6].
Relatives of COVID positive patients: The family members of the COVID positive patients will require an awareness briefing, correct scientific knowledge, and psychosocial first aid in the form of emotional and mental support in a culturally appropriate manner.
Health Care Workers (HCWs), nurses, first responders, and other frontline workers: Both Health and social care workers (HSCWs) have carried a heavy burden during the COVID-19 crisis and, in the challenge to control the virus, have directly faced its consequences. This group may be at risk of experiencing worsening MH during an outbreak, hence supporting their psychological wellbeing should continue to be a priority [52]. The psychological well-being and resilience of Health and social care workers (HSCWs), nurses, first responders, and other frontline workers in close contact with COVID-19 patients need to be enhanced and preserved by ensuring shorter workdays, provision of protective gear, and adequate training in infection control.
Mitigating strategies in Africa—cameroon and Uganda
To mitigate the mental health consequences of COVID-19 in Cameroon among these vulnerable groups, including those living in the hard to reach rural communities, the government (Cameroon’s Ministry of Public Health) in collaboration with WHO and the Red Cross initiated the following strategic actions:
An assessment of the psychological care during the COVID-19 response.
Developed the National Mental Health Strategy: This sets the framework for improvements in psychological care.
Development of other handy and reliable support documents on psychological first aid, confidentiality, and stress management guidelines and procedures for the mental health of children and adolescents, simplified guide on mental health care and mental illness care algorithms, for health workers when deciding on best interventions.
Establishment of a Data Management Tool: This has been continuously used since 2020 to generate data on the psychological impacts of COVID-19 and interventions deployed in the nation.
Establishment of a Psychological Care Team: The National Public Health Emergency Operation Centre established this team and recruited 27 psychologists and 36 nurses across the country. The Centre further conducted the WHO-sponsored training tagged “mental health and psychosocial support during the pandemic” for the newly employed staff, 1500 psychological care specialists, health workers of other specializations, 300 social workers, 120 investigators, and 30 journalists.
Creation of Public Awareness and Enlightenment: The empowered journalists who participated in the WHO’s sponsored training on mental health and psychosocial support during the pandemic created and translated mental health communication into simple and compelling posters, picture boxes, and leaflets for public awareness and enlightenment campaigns on mental health support, including those living in remote areas.
Launch of a toll-free helpline for psychological care: This was an initiative of the Cameroonian government in partnership with WHO and the Red Cross.
Funding support to a local NGO to provide psychosocial support to victims of physical violence perpetrated by armed groups in the southwest part of Cameroon.
Provision of remote medical and psychological support to vulnerable communities, including older people and those with comorbidities: This was provided in partnership with the German Agency for International Cooperation and iDocta Africa
The UN Population Fund and Uni-Psy et Bien-Être have also set up psychological support for pregnant and breastfeeding women including their families, as well as caregivers.
Engagement of key stakeholders in the reduction of the mental health impact of COVID-19 among different populations
The strategies adopted in Uganda include:
Home Visits: Kola, Kohrt, Hanlon, Naslund, Sikander, Balaji and Patel [53] reported that home visits for patients with severe mental illness were ongoing in Uganda amid the pandemic.
Family Group Intervention: This entails the involvement and training of parents to support community health workers in the delivery of “Family Group Intervention” to children with disruptive behaviors during the pandemic. The training intervention strengthens the capacities of family members, caregivers, and children. It also provided opportunities for them to communicate in safe settings with other families who have shared experiences.
Question 5: what are the basic psychosocial counseling principles for COVID-19 positive patients and other significant persons?
The psychosocial counseling principles for understanding and addressing the mental health needs of individuals who are awaiting results of COVID-19 tests confirmed COVID-19 individuals, health care workers working in COVID isolation hospitals and their family members from a nonjudgmental and empathic attitude include:
Psycho-education on Safety, health, and hygiene: This should be objectively and truthfully explained to patients and their caregivers. It should include information about the disease and epidemic situation, time for recovery, quarantine stay facilities, and available treatment process.
Anticipatory Anxieties and Coping skill enhancement: The psychotherapists will need to encourage patients to develop a sense of Calmness by reducing immediate distress and motivating them to rehearse their minds and practice effective coping mechanisms and stress inoculation techniques such as exercising, virtual socializing, performing pleasurable activities, actively seeking emotional support, positive reframing of the situation, using humor and practicing religious prayers.
Stabilization and Hope Building: Stabilization and hope building will help vulnerable populations to overcome an intense fear of dying, feeling of helplessness, anxiety, and fear. It will also improve their health-seeking behavior. Individuals exhibiting such concerns need to consult a psychotherapist who will assist in validating their fear of dying, feeling of helplessness, anxiety, and fear. The therapist will also assist in normalizing their worries, and further assist in developing healthy strategies for addressing the problem and generating a sense of realistic hope.
Addressing Adjustment issues, Self-and collective efficacy: To deal with the emergent psychological problems of people involved in the COVID-19 epidemic, a crisis intervention model that impacts self-efficacy is necessary [54].
Recovery and Connectedness: To reduce the psychological impact of being isolated, the psychotherapists will encourage the patients to strengthen their physical health, create new routines, virtually connect to their loved ones, limit information consumption on COVID-19 online, accept the uncertainty of the situation by focusing on what is within their control and doing as best as they can to handle the situation
Psychotherapeutic approaches that could be deployed for COVID-19 affected persons are approaches in response to disasters, including psychological debriefing, psychological first aid, cognitive-behavioral approaches, crisis intervention, screening and triage models, problem-solving interventions, rumor control, and conflict mitigation [55].
Clinical, counseling, psychotherapeutic and rehabilitation options for special and vulnerable populations, such as pediatric patients, pregnant women, mothers, older people, PLWDs, and other marginalized groups with suspected or confirmed cases, as well as reporting and grief counseling of COVID-19-related death. However, there is also no known coordinated and multidisciplinary continuum of clinical, counseling, and psychotherapy COVID-19 care pathways for symptomatic and asymptomatic patients and their families in the African States. Hence, there was a need for this study that attempts to run a scoping analysis of existing literature on the psychosocial and health implications of COVID-19 Comorbidity-Related Complications for vulnerable persons in developing societies.
4. Conclusion
The short- and long-term mental health implications of the COVID-19 pandemic are far-reaching for clinicians and the significant persons or survivors, especially among those at risk of new or exacerbated psychological illness and those facing barriers to accessing care.
Although the global community is in the vaccination phase against COVID-19, however, many people are refusing to be vaccinated due to fear or uncertainty, and the need for vaccinated people to continue taking existing precautions to mitigate the outbreak. Thereby compounding the psychological and mental health distress of the pandemic. It may also result in an increase in alcohol consumption, drug dependency and abuse, deaths due to suicide, and despair. It is, therefore, important for policymakers to continue to discuss further actions to alleviate the burdens of the COVID-19 pandemic.
5. Recommendations
Globally, the mental health status of vulnerable persons and clinicians has become more acute during the COVID-19 pandemic, while the targets for effective leadership and governance for mental health, provision of mental health services in community-based settings, mental health promotion and prevention, and strengthening of information systems, are far from being attained.
The following are recommendations on organizational measures, policies, and systemic changes needed to address the challenges of prevention, treatment, and education of Africans going forwards on their mental health:
Preventive and treatment interventions for mental health symptoms;
Innovative Intervention for Mental Health: These should be novel and universal interventions that are mechanistically based on experimental and social sciences for issues, such as loneliness;
Arts-based and Life-skills Therapeutic Interventions and Recreational activities, such as outdoor exercises.
Mental Health Bill: This is a policy measure currently needed in Nigeria and other African Nations. The Mental Health Bill will promote and protect the rights of persons with mental health conditions and persons with intellectual, psychosocial, or cognitive disabilities. It will also make provisions for the enhancement and regulation of Mental Health Services.
Need for the prevention of mental disorders and prioritization of mental health as a public health concern;
Need for the attainment of universal access to mental care;
Increase in mental health funding through direct budgetary allocation and integration of mental health into primary care;
There is an increasing need to accelerate the scale-up of investment in mental health and to scale up the quality of mental health services that are aligned with COVID-19 pandemic-related needs.
African nations need a documented mental health policy to tackle the menace in the country noting that the prevalence is one in four individuals. The policy should be formulated to cover a long period of about 5–10 years. It should be an initiative of the government and, the higher the level of government involvement, the higher its chances of success. The policy document will provide a framework and also give priority to the treatment. It will help to develop mental health services in a coordinated and systematic manner. It will help to identify key stakeholders and allow different stakeholders to reach an agreement. People with mental health disorders need equity and should not be discriminated against on the basis of their mental illnesses.
Mental health services should be integrated into other health care services at all levels instead of stand-alone facilities.
There is an urgent need for local governments to invest more in Primary Healthcare Centres (PHCs) as the entry point of other health care systems.
There is also the need to fund young psychiatry practitioners’ interest in research geared toward the development and advancement of mental health delivery in Nigeria.
Acknowledgments
The study acknowledges the contributions of the Centre for Gender, Health, and Social Rehabilitation, Ile-Ife, Nigeria for providing the needed facilities for the conduct of this research within its existing resources. However, the researchers obtained no funding support from any organization or institutions in the implementation of this study.
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International Journal of Environmental Research and Public Health. 2020;17(7):2381. DOI: 10.3390/ijerph17072381]'},{id:"B7",body:'[Threat Assessment Brief: Rapid increase of a SARS-CoV-2 variant with multiple spike protein mutations observed in the United Kingdom. European Centre for Disease Prevention and Control. Solna Municipality, Sweden 2020. Available from: https://www.ecdc.europa.eu/en/publications-data/threat-assessment-brief-rapid-increase-sars-cov-2-variant-united-kingdom. Published December 20, 2020 [Accessed January 13, 2022]]'},{id:"B8",body:'[Policy Brief: COVID-19 and the Need for Action on Mental Health (13 May 2020). New York City: World ReliefWeb; 2020 Accessed January 13, 2022]'},{id:"B9",body:'[Digital health and COVID-19. Bulletin of the World Health Organisation. 2020;98(11):731-732. DOI: 10.2471/blt.20.021120]'},{id:"B10",body:'[Cohan CL, Cole SW. Life course transitions and natural disaster: Marriage, birth, and divorce following hurricane Hugo. 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DOI: 10.1101/2020.08.14.20175190 Accessed January 13, 2022]'},{id:"B19",body:'[Asekere G, Arko AB. The politics of mental health amidst COVID-19 in Ghana. African Journal of Social Sciences Education. 2021;1(1):92-113]'},{id:"B20",body:'[Carfì A, Bernabei R, Landi F. Persistent symptoms in patients after acute COVID-19. Journal of the American Medical Association. 2020;324(6):603. DOI: 10.1001/jama.2020.12603]'},{id:"B21",body:'[Panchal N, Kamal R, Orgera K, et al. The Implications of COVID-19 for Mental Health and Substance Use. San Francisco, California, United States Available from: https://www.rcorp-ta.org/sites/default/files/2020-07/The%20Implications%20of%20COVID-19%20for%20Mental%20Health%20and%20Substance%20Use%20_%20KFF.pdf: KFF; 2020]'},{id:"B22",body:'[AJN. Mental Health Effects of COVID-19. AJN, American Journal of Nursing. 2020;120(11):15. DOI: 10.1097/01.naj.0000721880.79285.04]'},{id:"B23",body:'[National Institute for Health Research. Mental Health and COVID-19. UK: National Institute for Health Research; 2020. DOI: 10.3310/collection_40756 Accessed January 17, 2022]'},{id:"B24",body:'[Rehman U, Shahnawaz MG, Khan NH, et al. Depression, anxiety and stress among Indians in times of Covid-19 lockdown. Community Mental Health Journal. 2020;57(1):42-48. DOI: 10.1007/s10597-020-00664-x]'},{id:"B25",body:'[Patel V, Balaji M. How has COVID-19 Impacted Mental Health in India? India: India Development Review; 2020. Available from: https://idronline.org/mental-health-and-covid-19-in-india/. Published July 29, 2020 Accessed January 17, 2022]'},{id:"B26",body:'[Duggal C, Ray S, Konantambigi R, Kothari A. The nowhere people: Lived experiences of migrant workers during Covid-19 in India. Current Psychology. 2021;1:1-10. DOI: 10.1007/s12144-021-02220-6]'},{id:"B27",body:'[Deng J, Zhou F, Hou W, et al. The prevalence of depression, anxiety, and sleep disturbances in COVID-19 patients: A meta-analysis. 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The Mental Health Impact of the COVID-19 Pandemic: Implications for Sub-Saharan Africa. Charlottesville, Virginia, United States: Center for Open Science; 2020. DOI: 10.31219/osf.io/yq9kn Accessed January 17, 2022]'},{id:"B32",body:'[Kar SK, Yasir Arafat SM, Kabir R, Sharma P, Saxena SK. Coping with mental health challenges during COVID-19. In: Medical Virology: From Pathogenesis to Disease Control. Singapore: Singapore; 2020. pp. 199-213. DOI: 10.1007/978-981-15-4814-7_16 Accessed January 17, 2022]'},{id:"B33",body:'[Boateng GO, Doku DT, Enyan NIE, et al. Prevalence and changes in boredom, anxiety and well-being among Ghanaians during the COVID-19 pandemic: A population-based study. BMC Public Health. 2021;21(1):1-13. DOI: 10.1186/s12889-021-10998-0]'},{id:"B34",body:'[UNICEF. Impact of COVID-19 on Poor Mental Health in Children and Young People ‘Tip of the Iceberg’. New York, New York, United States. Available from: https://www.unicef.org/kenya/press-releases/impact-covid-19-poor-mental-health-children-and-young-people-tip-iceberg-unicef: UNICEF; Accessed January 17, 2022]'},{id:"B35",body:'[Guardian Nigeria. Expert Seeks Policies for Improved Health Care Services. Nigeria Available from: https://guardian.ng/news/expert-seeks-policies-for-improved-health-care-services/. Published October 31, 2021: Guardian Nigeria; Accessed January 17, 2022]'},{id:"B36",body:'[Bloomberg. Are you a Robot? Manhattan, New York. Available from: https://www.bloomberg.com/graphics/best-and-worst/#most-stressed-out-countries: Bloomberg; Accessed January 17, 2022]'},{id:"B37",body:'[Suleiman D. Mental health disorders in Nigeria: A highly neglected disease. Annals of Nigerian Medicine. 2016;10(2):47. DOI: 10.4103/0331-3131.206214]'},{id:"B38",body:'[Vanguard News. COVID-19 Stressing Nigerians’ Mental Health Stability Beyond Limit — Owoeye. Lagos, Nigeria: Vanguard News; 2021. Available from: https://www.vanguardngr.com/2021/11/covid-19-stressing-nigerians-mental-health-stability-beyond-limit. Published November 2, 2021 Accessed January 17, 2022]'},{id:"B39",body:'[Abdulmalik J, Olayiwola S, Docrat S, Lund C, Chisholm D, Gureje O. Sustainable financing mechanisms for strengthening mental health systems in Nigeria. International Journal of Mental Health Systems. 2019;13(1):1-15. DOI: 10.1186/s13033-019-0293-8]'},{id:"B40",body:'[Nguse S, Wassenaar D. Mental health and COVID-19 in South Africa. South Africa Journal of Psychology. 2021;51(2):304-313. DOI: 10.1177/00812463211001543]'},{id:"B41",body:'[University at Buffalo. Issue 16: COVID-19 and Impacts on Mental Health, Violence, and Adolescent Vulnerability in Rural Tanzania. Buffalo, NY: University at Buffalo; 2021. 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DOI: 10.1017/s1041610220004081]'},{id:"B45",body:'[West NS, Ddaalki W, Nakyanjo N, et al. A double stress: The mental health impacts of the COVID-19 pandemic among people living with HIV in Rakai, Uganda. AIDS and Behavior. 2021;26(1):261-265. DOI: 10.1007/s10461-021-03379-6]'},{id:"B46",body:'[Akena D, Kiguba R, Muhwezi WW, et al. The effectiveness of a psycho-education intervention on mental health literacy in communities affected by the COVID-19 pandemic—a cluster randomized trial of 24 villages in central Uganda—a research protocol. Trials. 2021;22(1):1-7. DOI: 10.1186/s13063-021-05391-6]'},{id:"B47",body:'[Petersen I, Lund C, Bhana A, Flisher AJ. A task shifting approach to primary mental health care for adults in South Africa: Human resource requirements and costs for rural settings. Health Policy and Planning. 2011;27(1):42-51. DOI: 10.1093/heapol/czr012]'},{id:"B48",body:'[Jaguga F, Kwobah E. Mental health response to the COVID-19 pandemic in Kenya: A review. International Journal of Mental Health Systems. 2020;14(1):1-6. DOI: 10.1186/s13033-020-00400-8]'},{id:"B49",body:'[Adepoju P. Africa turns to telemedicine to close mental health gap. The Lancet Digital Health. 2020;2(11):e571-e572. DOI: 10.1016/s2589-7500(20)30252-1]'},{id:"B50",body:'[Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). Journal of Telemedicine and Telecare. 2020;26(5):309-313. DOI: 10.1177/1357633x20916567]'},{id:"B51",body:'[Hudcova B. Psychosocial First Aid for People with Disabilities in Crisis Situations – The Role of a Special Education Teacher. In: NORDSCI Conference Proceedings Book 1. Vol. 1. Orpington, Greater London: Saima Consult Ltd; 2018. DOI: 10.32008/nordsci2018/b1/v1/17 Accessed January 17, 2022]'},{id:"B52",body:'[Maunder R, Lancee W, Balderson K, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerging Infectious Diseases. 2006;12(12):1924-1932. DOI: 10.3201/eid1212.060584]'},{id:"B53",body:'[Kola L, Kohrt BA, Hanlon C, et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. The Lancet Psychiatry. 2021;8(6):535-550. DOI: 10.1016/s2215-0366(21)00025-0]'},{id:"B54",body:'[Zhang J, Wu W, Zhao X, Zhang W. Recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in China: A model of West China hospital. Precision Clinical Medicine. 2020;3(1):3-8. DOI: 10.1093/pcmedi/pbaa006]'},{id:"B55",body:'[Halpern J, Vermeulen K. Disaster Mental Health Interventions. New York: Routledge; 2017. DOI: 10.4324/9781315623825 Accessed January 17, 2022]'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Oluwatoyin Olatundun Ilesanmi",address:"toytunduni@gmail.com",affiliation:'- Centre for Gender and Development Studies, Nigeria
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\n\t- UK Research and Innovation (former Research Councils UK (RCUK) - including AHRC, BBSRC, ESRC, EPSRC, MRC, NERC, STFC.) Processing charges for books/book chapters can be covered through RCUK block grants which are allocated to most universities in the UK, which then handle the OA publication funding requests. It is at the discretion of the university whether it will approve the request.)
\n\t- The Leverhulme Trust (See also the FAQs)
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Abdel Rahman",coverURL:"https://cdn.intechopen.com/books/images_new/7747.jpg",editedByType:"Edited by",editors:[{id:"92718",title:"Prof.",name:"Abdel Rahman",middleName:null,surname:"Rehab O.",slug:"abdel-rahman-rehab-o.",fullName:"Abdel Rahman Rehab O."}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9247",title:"Mineralogy",subtitle:"Significance and Applications",isOpenForSubmission:!1,hash:"5149699e666cbb61c220646173769f18",slug:"mineralogy-significance-and-applications",bookSignature:"Ali Ismail Al-Juboury",coverURL:"https://cdn.intechopen.com/books/images_new/9247.jpg",editedByType:"Edited by",editors:[{id:"58570",title:"Prof.",name:"Ali",middleName:"Ismail",surname:"Al-Juboury",slug:"ali-al-juboury",fullName:"Ali Al-Juboury"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7677",title:"Forecasting Volcanic Eruptions",subtitle:null,isOpenForSubmission:!1,hash:"5afd431dd1f4f5081355b017fd17f237",slug:"forecasting-volcanic-eruptions",bookSignature:"Angelo Paone and Sung-Hyo Yun",coverURL:"https://cdn.intechopen.com/books/images_new/7677.jpg",editedByType:"Edited by",editors:[{id:"182871",title:"Prof.",name:"Angelo",middleName:null,surname:"Paone",slug:"angelo-paone",fullName:"Angelo Paone"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8223",title:"Processing and Analysis of Hyperspectral Data",subtitle:null,isOpenForSubmission:!1,hash:"02b920d9c266e28152227280ff18ebbe",slug:"processing-and-analysis-of-hyperspectral-data",bookSignature:"Jie Chen, Yingying Song and Hengchao Li",coverURL:"https://cdn.intechopen.com/books/images_new/8223.jpg",editedByType:"Edited by",editors:[{id:"218017",title:"Dr.",name:"Jie",middleName:null,surname:"Chen",slug:"jie-chen",fullName:"Jie Chen"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:69,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"17663",doi:"10.5772/24120",title:"Relationships between Lithospheric Flexure, Thrust Tectonics and Stratigraphic Sequences in Foreland Setting: the Southern Apennines Foreland Basin System, Italy",slug:"relationships-between-lithospheric-flexure-thrust-tectonics-and-stratigraphic-sequences-in-foreland-",totalDownloads:3853,totalCrossrefCites:12,totalDimensionsCites:48,abstract:null,book:{id:"1297",slug:"new-frontiers-in-tectonic-research-at-the-midst-of-plate-convergence",title:"New Frontiers in Tectonic Research",fullTitle:"New Frontiers in Tectonic Research - At the Midst of Plate Convergence"},signatures:"Salvatore Critelli, Francesco Muto,\nVincenzo Tripodi and Francesco Perri",authors:[{id:"55590",title:"Prof.",name:"Salvatore",middleName:null,surname:"Critelli",slug:"salvatore-critelli",fullName:"Salvatore Critelli"},{id:"55592",title:"Prof.",name:"Francesco",middleName:null,surname:"Muto",slug:"francesco-muto",fullName:"Francesco Muto"},{id:"55593",title:"Prof.",name:"Vincenzo",middleName:null,surname:"Tripodi",slug:"vincenzo-tripodi",fullName:"Vincenzo Tripodi"},{id:"85117",title:"Dr.",name:"Francesco",middleName:null,surname:"Perri",slug:"francesco-perri",fullName:"Francesco Perri"}]},{id:"37859",doi:"10.5772/50009",title:"Plate Tectonic Evolution of the Southern Margin of Laurussia in the Paleozoic",slug:"plate-tectonic-evolution-of-the-southern-margin-of-laurussia-in-the-paleozoic",totalDownloads:5295,totalCrossrefCites:15,totalDimensionsCites:45,abstract:null,book:{id:"2227",slug:"tectonics-recent-advances",title:"Tectonics",fullTitle:"Tectonics - Recent Advances"},signatures:"Jan Golonka and Aleksandra Gawęda",authors:[{id:"16567",title:"Dr.",name:"Jan",middleName:null,surname:"Golonka",slug:"jan-golonka",fullName:"Jan Golonka"}]},{id:"57384",doi:"10.5772/intechopen.71049",title:"A Review: Remote Sensing Sensors",slug:"a-review-remote-sensing-sensors",totalDownloads:3674,totalCrossrefCites:24,totalDimensionsCites:42,abstract:"The cost of launching satellites is getting lower and lower due to the reusability of rockets (NASA, 2015) and using single missions to launch multiple satellites (up to 37, Russia, 2014). In addition, low-orbit satellite constellations have been employed in recent years. These trends indicate that satellite remote sensing has a promising future in acquiring high-resolution data with a low cost and in integrating high-resolution satellite imagery with ground-based sensor data for new applications. These facts have motivated us to develop a comprehensive survey of remote sensing sensor development, including the characteristics of sensors with respect to electromagnetic spectrums (EMSs), imaging and non-imaging sensors, potential research areas, current practices, and the future development of remote sensors.",book:{id:"6334",slug:"multi-purposeful-application-of-geospatial-data",title:"Multi-purposeful Application of Geospatial Data",fullTitle:"Multi-purposeful Application of Geospatial Data"},signatures:"Lingli Zhu, Juha Suomalainen, Jingbin Liu, Juha Hyyppä, Harri\nKaartinen and Henrik Haggren",authors:[{id:"213512",title:"Dr.",name:"Lingli",middleName:null,surname:"Zhu",slug:"lingli-zhu",fullName:"Lingli Zhu"},{id:"213522",title:"Dr.",name:"Suomalainen",middleName:null,surname:"Juha",slug:"suomalainen-juha",fullName:"Suomalainen Juha"},{id:"213523",title:"Prof.",name:"Jingbin",middleName:null,surname:"Liu",slug:"jingbin-liu",fullName:"Jingbin Liu"},{id:"220941",title:"Prof.",name:"Juha",middleName:null,surname:"Hyyppä",slug:"juha-hyyppa",fullName:"Juha Hyyppä"},{id:"220942",title:"Prof.",name:"Harri",middleName:null,surname:"Kaartinen",slug:"harri-kaartinen",fullName:"Harri Kaartinen"},{id:"220943",title:"Prof.",name:"Henrik",middleName:null,surname:"Haggren",slug:"henrik-haggren",fullName:"Henrik Haggren"}]},{id:"17670",doi:"10.5772/20299",title:"The Qatar–South Fars Arch Development (Arabian Platform, Persian Gulf): Insights from Seismic Interpretation and Analogue Modelling",slug:"the-qatar-south-fars-arch-development-arabian-platform-persian-gulf-insights-from-seismic-interpreta",totalDownloads:8982,totalCrossrefCites:17,totalDimensionsCites:41,abstract:null,book:{id:"1297",slug:"new-frontiers-in-tectonic-research-at-the-midst-of-plate-convergence",title:"New Frontiers in Tectonic Research",fullTitle:"New Frontiers in Tectonic Research - At the Midst of Plate Convergence"},signatures:"C.R. Perotti, S. Carruba, M. Rinaldi, G. Bertozzi, L. Feltre and M. Rahimi",authors:[{id:"38310",title:"Dr.",name:"Stefano",middleName:null,surname:"Carruba",slug:"stefano-carruba",fullName:"Stefano Carruba"},{id:"42459",title:"Prof.",name:"Cesare",middleName:null,surname:"Perotti",slug:"cesare-perotti",fullName:"Cesare Perotti"},{id:"42460",title:"Dr.",name:"Marco",middleName:null,surname:"Rinaldi",slug:"marco-rinaldi",fullName:"Marco Rinaldi"},{id:"42465",title:"Dr.",name:"Giuseppe",middleName:null,surname:"Bertozzi",slug:"giuseppe-bertozzi",fullName:"Giuseppe Bertozzi"},{id:"42466",title:"Dr.",name:"Luca",middleName:null,surname:"Feltre",slug:"luca-feltre",fullName:"Luca Feltre"},{id:"42467",title:"Dr.",name:"Mashallah",middleName:null,surname:"Rahimi",slug:"mashallah-rahimi",fullName:"Mashallah Rahimi"}]},{id:"9498",doi:"10.5772/8283",title:"Remote Sensing of Forest Health",slug:"remote-sensing-of-forest-health",totalDownloads:5355,totalCrossrefCites:14,totalDimensionsCites:30,abstract:null,book:{id:"3345",slug:"geoscience-and-remote-sensing",title:"Geoscience and Remote Sensing",fullTitle:"Geoscience and Remote Sensing"},signatures:"Jyrki Tuominen, Tarmo Lipping, Viljo Kuosmanen and Reija Haapanen",authors:null}],mostDownloadedChaptersLast30Days:[{id:"71931",title:"Open Pit Mining",slug:"open-pit-mining",totalDownloads:1625,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Open pit mining method is one of the surface mining methods that has a traditional cone-shaped excavation and is usually employed to exploit a near-surface, nonselective and low-grade zones deposits. It often results in high productivity and requires large capital investments, low operating costs, and good safety conditions. The main topics that will be discussed in this chapter will include an introduction into the general features of open pit mining, ore body characteristics and configurations, stripping ratios and stripping overburden methods, mine elements and parameters, open pit operation cycle, pit slope angle, stability of mine slopes, types of highwall failures, mine closure and reclamation, and different variants of surface mining methods including opencast mining, mountainous mining, and artisan mining.",book:{id:"8620",slug:"mining-techniques-past-present-and-future",title:"Mining Techniques",fullTitle:"Mining Techniques - Past, Present and Future"},signatures:"Awwad H. Altiti, Rami O. Alrawashdeh and Hani M. Alnawafleh",authors:[{id:"313182",title:"Prof.",name:"Rami",middleName:null,surname:"Alrawashdeh",slug:"rami-alrawashdeh",fullName:"Rami Alrawashdeh"},{id:"313522",title:"Dr.",name:"Awwad",middleName:null,surname:"Altiti",slug:"awwad-altiti",fullName:"Awwad Altiti"},{id:"313523",title:"Prof.",name:"Hani",middleName:null,surname:"Alnawafleh",slug:"hani-alnawafleh",fullName:"Hani Alnawafleh"}]},{id:"64027",title:"Stages of a Integrated Geothermal Project",slug:"stages-of-a-integrated-geothermal-project",totalDownloads:4341,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"A geothermal project constitutes two big stages: the exploration and the exploitation. Each one has a single task whose results allow defining the feasibility of a geothermal project, until achieving the construction and operation stage of the power generation plant. The first stage contains the area recognition, its limitation to the target, and elimination of external factors until defining a geothermal zone with characteristics to be commercially exploited. The main studies and analysis that can be applied during the exploration stage are listed, and the major indicator to continue with the project or suspend is the prefeasibility report. The major risks in the exploration stage are due to studies that are carried out on the surface; at this stage, the costs can be considered low. The main results of the exploration are the selection of sites to drill three or four initial wells. Each well provides a direct overview of the reservoir: depth, production thicknesses, thermodynamic parameters, and production characteristics. The drilling of three to four exploratory wells is recommended, as far as there is certainty of the feasibility of the project, and the development of the field begins with drilling of sufficient wells to feed the plant. In this stage, the cost increases, but the risks decrease.",book:{id:"7504",slug:"renewable-geothermal-energy-explorations",title:"Renewable Geothermal Energy Explorations",fullTitle:"Renewable Geothermal Energy Explorations"},signatures:"Alfonso Aragón-Aguilar, Georgina Izquierdo-Montalvo,\nDaniel Octavio Aragón-Gaspar and Denise N. Barreto-Rivera",authors:[{id:"258358",title:"Dr.",name:"Alfonso",middleName:null,surname:"Aragón-Aguilar",slug:"alfonso-aragon-aguilar",fullName:"Alfonso Aragón-Aguilar"}]},{id:"63059",title:"Generation, Evolution, and Characterization of Turbulence Coherent Structures",slug:"generation-evolution-and-characterization-of-turbulence-coherent-structures",totalDownloads:3618,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"Turbulence stands as one of the most complicated and attractive physical phenomena. The accumulated knowledge has shown turbulent flow to be composed of islands of vortices and uniform-momentum regions, which are coherent in both time and space. Research has been concentrated on these structures, their generation, evolution, and interaction with the mean flow. Different theories and conceptual models were proposed with the aim of controlling the boundary layer flow and improving numerical simulations. Here, we review the different classes of turbulence coherent structures and the presumable generation mechanisms for each. The conceptual models describing the generation of turbulence coherent structures are generally classified under two categories, namely, the bottom-up mechanisms and the top-down mechanisms. The first assumes turbulence to be generated near the surface by some sort of instabilities, whereas the second assigns an active role to the large outer layer structures, perhaps the turbulent bulges. Both categories of models coexist in the flow with the first dominating turbulence generation at low Reynolds number and the second at high Reynolds number, such as the case in the atmospheric boundary layer.",book:{id:"7214",slug:"turbulence-and-related-phenomena",title:"Turbulence and Related Phenomena",fullTitle:"Turbulence and Related Phenomena"},signatures:"Zambri Harun and Eslam Reda Lotfy",authors:[{id:"243152",title:"Dr.",name:"Zambri",middleName:null,surname:"Harun",slug:"zambri-harun",fullName:"Zambri Harun"},{id:"252195",title:"Dr.",name:"Eslam",middleName:null,surname:"Reda",slug:"eslam-reda",fullName:"Eslam Reda"}]},{id:"64562",title:"Electrical Resistivity Tomography: A Subsurface-Imaging Technique",slug:"electrical-resistivity-tomography-a-subsurface-imaging-technique",totalDownloads:3182,totalCrossrefCites:7,totalDimensionsCites:10,abstract:"Electrical resistivity tomography (ERT) is a popular geophysical subsurface-imaging technique and widely applied to mineral prospecting, hydrological exploration, environmental investigation and civil engineering, as well as archaeological mapping. This chapter offers an overall review of technical aspects of ERT, which includes the fundamental theory of direct-current (DC) resistivity exploration, electrode arrays for data acquisition, numerical modelling methods and tomographic inversion algorithms. The section of fundamental theory shows basic formulae and principle of DC resistivity exploration. The section of electrode arrays summarises the previous study on all traditional-electrode arrays and recommends 4 electrode arrays for data acquisition of surface ERT and 3 electrode arrays for cross-hole ERT. The section of numerical modelling demonstrates an advanced version of finite-element method, called Gaussian quadrature grid approach, which is advantageous to a numerical simulation of ERT for complex geological models. The section of tomographic inversion presents the generalised standard conjugate gradient algorithms for both the l1- and l2-normed inversions. After that, some synthetic and real imaging examples are given to show the near-surface imaging capabilities of ERT.",book:{id:"8361",slug:"applied-geophysics-with-case-studies-on-environmental-exploration-and-engineering-geophysics",title:"Applied Geophysics with Case Studies on Environmental, Exploration and Engineering Geophysics",fullTitle:"Applied Geophysics with Case Studies on Environmental, Exploration and Engineering Geophysics"},signatures:"Bing Zhou",authors:null},{id:"17670",title:"The Qatar–South Fars Arch Development (Arabian Platform, Persian Gulf): Insights from Seismic Interpretation and Analogue Modelling",slug:"the-qatar-south-fars-arch-development-arabian-platform-persian-gulf-insights-from-seismic-interpreta",totalDownloads:8964,totalCrossrefCites:16,totalDimensionsCites:40,abstract:null,book:{id:"1297",slug:"new-frontiers-in-tectonic-research-at-the-midst-of-plate-convergence",title:"New Frontiers in Tectonic Research",fullTitle:"New Frontiers in Tectonic Research - At the Midst of Plate Convergence"},signatures:"C.R. Perotti, S. Carruba, M. Rinaldi, G. Bertozzi, L. Feltre and M. Rahimi",authors:[{id:"38310",title:"Dr.",name:"Stefano",middleName:null,surname:"Carruba",slug:"stefano-carruba",fullName:"Stefano Carruba"},{id:"42459",title:"Prof.",name:"Cesare",middleName:null,surname:"Perotti",slug:"cesare-perotti",fullName:"Cesare Perotti"},{id:"42460",title:"Dr.",name:"Marco",middleName:null,surname:"Rinaldi",slug:"marco-rinaldi",fullName:"Marco Rinaldi"},{id:"42465",title:"Dr.",name:"Giuseppe",middleName:null,surname:"Bertozzi",slug:"giuseppe-bertozzi",fullName:"Giuseppe Bertozzi"},{id:"42466",title:"Dr.",name:"Luca",middleName:null,surname:"Feltre",slug:"luca-feltre",fullName:"Luca Feltre"},{id:"42467",title:"Dr.",name:"Mashallah",middleName:null,surname:"Rahimi",slug:"mashallah-rahimi",fullName:"Mashallah Rahimi"}]}],onlineFirstChaptersFilter:{topicId:"104",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81626",title:"Use of Natural Safiot Clay for the Removal of Chemical Substances from Aqueous Solutions by Adsorption: A Combined Experimental and Theoretical Study",slug:"use-of-natural-safiot-clay-for-the-removal-of-chemical-substances-from-aqueous-solutions-by-adsorpti",totalDownloads:24,totalDimensionsCites:0,doi:"10.5772/intechopen.101605",abstract:"The main objective of this work was to investigate the potential of Natural Safiot Clay (NSC), as an adsorbent for the removal of two cationic dyes such as Basic Blue 9 (BB9) and Basic Yellow 28 (BY28) from single and binary systems in aqueous solutions. For this, the effects of three factors controlling the adsorption process, such as initial dye concentration, adsorbent dose, and initial pH on the adsorption extent, were investigated and examined. The natural safiot clay was characterized using the following technique: energy-dispersive X-ray spectroscopy (EDX), scanning electron microscopy (SEM), DRX, and Fourier transform infrared (FT-IR) and pH of the point of zero charge (pHZPC). Energy-dispersive X-ray spectroscopy results indicate high percentages of Silica and Alumina. FT-IR spectrum identified kaolinite as the major mineral phase in the presence of quartz, calcite, and dolomite. The quantum theoretical study confirms the experimental results, through the study of the global and local reactivity and the electrophilicity power of the dyes. The electrophilicity power of dyes affects the removal efficiency. The theoretical study proves that BB9 (ω = 6.178) is more electrophilic than BY28 (ω = 2.480) and more interactions with surface sites. The results of the molecular dynamics simulation indicate that the dyes are adsorbed parallel to the surface of natural Safi clay (kaolinite), implying the strong interaction with the kaolinite atoms. All the results of quantum chemistry calculations and simulations of molecular dynamics are in perfect agreement with the results of the experimental study.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Aziz El Kassimi, Mohammadine El Haddad, Rachid Laamari, Mamoune El Himri, Youness Achour and Hicham Yazid"},{id:"80866",title:"Normative Mineralogy Especially for Shales, Slates, and Phyllites",slug:"normative-mineralogy-especially-for-shales-slates-and-phyllites",totalDownloads:44,totalDimensionsCites:0,doi:"10.5772/intechopen.102346",abstract:"First, an insight into normative mineralogy and the most important methods for calculating the standard or norm minerals, such as the CIPW norm, is given. This is followed by a more detailed explanation of “slatenorm” and “slatecalculation” for low and very low metamorphic rocks, such as phyllites, slates, and shales. They are particularly suitable for fine-grained rocks where the mineral content is difficult to determine. They enable the determination of a virtual mineral inventory from full chemical analysis, including the values of carbon dioxide (CO2), carbon (C), and sulfur (S). The determined norm or standard minerals include the minerals—feldspars, carbonates, micas, hydro-micas, chlorites, ore minerals, and quartz. The advantages of slatenorm and slatecalculation compared to other methods for calculating normal minerals of sedimentary rocks are discussed.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Hans Wolfgang Wagner"},{id:"80770",title:"Mg-Ilmenite from Kimberlites, Its Origin",slug:"mg-ilmenite-from-kimberlites-its-origin",totalDownloads:57,totalDimensionsCites:0,doi:"10.5772/intechopen.102676",abstract:"The main regularities of the saturation of kimberlite rocks with the accessory mineral Mg-ilmenite (Ilm), the peculiarities of the distribution of Ilm compositions in individual pipes, in different clusters of pipes, in diamondiferous kimberlite fields, are considered as the example of studies carried out within the Yakutian kimberlite province (Siberian Craton). Interpretation of different crystallization trends in MgO-Cr2O3 coordinates (conventionally named “Haggerty’s parabola”, “Steplike”, “Hockey stick”, as well as the peculiarities of heterogeneity of individual zonal and polygranular Ilm macrocrysts made it possible to propose a three-stage model of crystallization Ilm: (1) Mg-Cr poor ilmenite crystallizing from a primitive asthenospheric melt; (2) Continuing crystallization in the lithospheric contaminated melt by MgO and Cr2O3; (3) Ilmenite subsequently underwent sub-solidus recrystallization in the presence of an evolved kimberlite melt under increasing oxygen fugacity (ƒO2) conditions.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Sergey I. Kostrovitsky"},{id:"80553",title:"Investigation of Accessory Minerals from the Blatná Granodiorite Suite, Bohemian Massif, Czech Republic",slug:"investigation-of-accessory-minerals-from-the-blatn-granodiorite-suite-bohemian-massif-czech-republic",totalDownloads:48,totalDimensionsCites:0,doi:"10.5772/intechopen.102628",abstract:"The Central Bohemian magmatic complex belongs to the Central European Variscan belt. The granitic rocks of this plutonic complex are formed by several suites of granites, granodiorites, and tonalites, together with small bodies of gabbros, gabbro diorites, and diorites. The granodiorites of the Blatná suite are high-K, calc-alkaline to shoshonitic, and metaluminous to slightly peraluminous granitic rocks. Compared to the common I-type granites, granodiorites of the Blatná suite are enriched in Mg (1.0–3.4 wt.% MgO), Ba (838–2560 ppm), Sr. (257–506 ppm), and Zr (81–236 ppm). For granodiorites of the Blatná suite is assemblage of apatite, zircon, titanite, and allanite significant. Zircon contains low Hf concentrations (1.1–1.7 wt.% HfO2). The composition of titanite ranges from 83 to 92 mol.% titanite end-member. Allanite is relatively Al-poor and displays Feox. ratio 0.2–0.5.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Miloš René"},{id:"80423",title:"Minerals as Prebiotic Catalysts for Chemical Evolution towards the Origin of Life",slug:"minerals-as-prebiotic-catalysts-for-chemical-evolution-towards-the-origin-of-life",totalDownloads:106,totalDimensionsCites:0,doi:"10.5772/intechopen.102389",abstract:"A transition from geochemistry to biochemistry has been considered as a necessary step towards the emergence of primordial life. Nevertheless, how did this transition occur is still elusive. The chemistry underlying this transition is likely not a single event, but involves many levels of creation and reconstruction, finally reaching the molecular, structural, and functional buildup of complexity. Among them, one apparent question is: how the biochemical catalytic system emerged from the mineral-based geochemical system? Inspired by the metal–ligand structures in metalloenzymes, many researchers have proposed that transition metal sulfide minerals could have served as structural analogs of metalloenzymes for catalyzing prebiotic redox conversions. This assumption has been tested and verified to some extent by several studies, which focused on using Earth-abundant transition metal sulfides as catalysts for multi-electron C and N conversions. The progress in this field will be introduced, with a focus on the CO2 fixation and ammonia synthesis from nitrate/nitrite reduction and N2 reduction. Recently developed methods for screening effective mineral catalysts were also reviewed.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Yamei Li"},{id:"80338",title:"Ionic Conductivity of Strontium Fluoroapatites Co-doped with Lanthanides",slug:"ionic-conductivity-of-strontium-fluoroapatites-co-doped-with-lanthanides",totalDownloads:54,totalDimensionsCites:0,doi:"10.5772/intechopen.102410",abstract:"Britholites derivatives of apatite’s that contain lanthanium and neodymium in the serial compounds Sr8La2−xNdx(PO4)4(SiO4)2F2 with 0 ≤ x ≤ 2 were subject of the present investigation. The solid state reaction was the route of preparing these materials. Several techniques were employed for the analysis and characterization of the synthesized powders. The chemical analysis results indicated that molar ratio Sr+La+NdP+Si was of about 1.67 value of a stoichiometric powder. The X-ray diffraction data showed single-phase apatites crystallizing in hexagonal structure with P63/m space group were successively obtained. Moreover, the substitution of lanthanium by neodymium in strontium phosphosilicated fluorapatite was total. This was confirmed by the a and c lattice parameters contraction when (x) varies coherently to the sizes of the two cations. The infrared spectroscopy and the 31P NMR (MAS) exhibited the characteristic bands of phosphosilicated fluorapatite. The pressureless sintering of the material achieved a maximum of 89% relative density. The sintered specimens indicated that the Nd content as well as the heating temperature affected the ionic conduction of the materials and the maximum was 1.73 × 10−6 S cm−1 obtained at 1052 K for x = 2.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Khouloud Kthiri, Mohammed Mehnaoui, Samira Jebahi, Khaled Boughzala and Mustapha Hidouri"}],onlineFirstChaptersTotal:10},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:133,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"7",title:"Biomedical Engineering",doi:"10.5772/intechopen.71985",issn:"2631-5343",scope:"Biomedical Engineering is one of the fastest-growing interdisciplinary branches of science and industry. The combination of electronics and computer science with biology and medicine has improved patient diagnosis, reduced rehabilitation time, and helped to facilitate a better quality of life. Nowadays, all medical imaging devices, medical instruments, or new laboratory techniques result from the cooperation of specialists in various fields. The series of Biomedical Engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine, and biology. 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Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:3,paginationItems:[{id:"7",title:"Bioinformatics and Medical Informatics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",isOpenForSubmission:!0,editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",slug:"slawomir-wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",biography:"Professor Sławomir Wilczyński, Head of the Chair of Department of Basic Biomedical Sciences, Faculty of Pharmaceutical Sciences, Medical University of Silesia in Katowice, Poland. His research interests are focused on modern imaging methods used in medicine and pharmacy, including in particular hyperspectral imaging, dynamic thermovision analysis, high-resolution ultrasound, as well as other techniques such as EPR, NMR and hemispheric directional reflectance. Author of over 100 scientific works, patents and industrial designs. Expert of the Polish National Center for Research and Development, Member of the Investment Committee in the Bridge Alfa NCBiR program, expert of the Polish Ministry of Funds and Regional Policy, Polish Medical Research Agency. Editor-in-chief of the journal in the field of aesthetic medicine and dermatology - Aesthetica.",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},{id:"8",title:"Bioinspired Technology and Biomechanics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",isOpenForSubmission:!0,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. His research interests include Biomedical Signal Processing and Modelling, Assistive Technology, Rehabilitation Engineering, Neuroengineering and Parkinson's Disease.",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",isOpenForSubmission:!0,editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",slug:"luis-villarreal-gomez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",biography:"Dr. Luis Villarreal is a research professor from the Facultad de Ciencias de la Ingeniería y Tecnología, Universidad Autónoma de Baja California, Tijuana, Baja California, México. Dr. Villarreal is the editor in chief and founder of the Revista de Ciencias Tecnológicas (RECIT) (https://recit.uabc.mx/) and is a member of several editorial and reviewer boards for numerous international journals. He has published more than thirty international papers and reviewed more than ninety-two manuscripts. 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Banigo, Chigozie A. Nnadiekwe and Emmanuel M. 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For 20 years, he has studied the analysis and processing of biomedical images, emphasizing the full automation of measurement for a large inter-individual variability of patients. Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}}]},{type:"book",id:"7218",title:"OCT",subtitle:"Applications in Ophthalmology",coverURL:"https://cdn.intechopen.com/books/images_new/7218.jpg",slug:"oct-applications-in-ophthalmology",publishedDate:"September 19th 2018",editedByType:"Edited by",bookSignature:"Michele Lanza",hash:"e3a3430cdfd6999caccac933e4613885",volumeInSeries:2,fullTitle:"OCT - Applications in Ophthalmology",editors:[{id:"240088",title:"Prof.",name:"Michele",middleName:null,surname:"Lanza",slug:"michele-lanza",fullName:"Michele Lanza",profilePictureURL:"https://mts.intechopen.com/storage/users/240088/images/system/240088.png",biography:"Michele Lanza is Associate Professor of Ophthalmology at Università della Campania, Luigi Vanvitelli, Napoli, Italy. His fields of interest are anterior segment disease, keratoconus, glaucoma, corneal dystrophies, and cataracts. His research topics include\nintraocular lens power calculation, eye modification induced by refractive surgery, glaucoma progression, and validation of new diagnostic devices in ophthalmology. \nHe has published more than 100 papers in international and Italian scientific journals, more than 60 in journals with impact factors, and chapters in international and Italian books. He has also edited two international books and authored more than 150 communications or posters for the most important international and Italian ophthalmology conferences.",institutionString:'University of Campania "Luigi Vanvitelli"',institution:{name:'University of Campania "Luigi Vanvitelli"',institutionURL:null,country:{name:"Italy"}}}]},{type:"book",id:"7560",title:"Non-Invasive Diagnostic Methods",subtitle:"Image Processing",coverURL:"https://cdn.intechopen.com/books/images_new/7560.jpg",slug:"non-invasive-diagnostic-methods-image-processing",publishedDate:"December 19th 2018",editedByType:"Edited by",bookSignature:"Mariusz Marzec and Robert Koprowski",hash:"d92fd8cf5a90a47f2b8a310837a5600e",volumeInSeries:3,fullTitle:"Non-Invasive Diagnostic Methods - Image Processing",editors:[{id:"253468",title:"Dr.",name:"Mariusz",middleName:null,surname:"Marzec",slug:"mariusz-marzec",fullName:"Mariusz Marzec",profilePictureURL:"https://mts.intechopen.com/storage/users/253468/images/system/253468.png",biography:"An assistant professor at Department of Biomedical Computer Systems, at Institute of Computer Science, Silesian University in Katowice. Scientific interests: computer analysis and processing of images, biomedical images, databases and programming languages. 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Prof. Sarfraz is also an editor-in-chief and editor of various international journals.",institutionString:"Kuwait University",institution:{name:"Kuwait University",country:{name:"Kuwait"}}},{id:"32650",title:"Prof.",name:"Lukas",middleName:"Willem",surname:"Snyman",slug:"lukas-snyman",fullName:"Lukas Snyman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/32650/images/4136_n.jpg",biography:"Lukas Willem Snyman received his basic education at primary and high schools in South Africa, Eastern Cape. He enrolled at today's Nelson Metropolitan University and graduated from this university with a BSc in Physics and Mathematics, B.Sc Honors in Physics, MSc in Semiconductor Physics, and a Ph.D. in Semiconductor Physics in 1987. After his studies, he chose an academic career and devoted his energy to the teaching of physics to first, second, and third-year students. After positions as a lecturer at the University of Port Elizabeth, he accepted a position as Associate Professor at the University of Pretoria, South Africa.\r\n\r\nIn 1992, he motivates the concept of 'television and computer-based education” as means to reach large student numbers with only the best of teaching expertise and publishes an article on the concept in the SA Journal of Higher Education of 1993 (and later in 2003). The University of Pretoria subsequently approved a series of test projects on the concept with outreach to Mamelodi and Eerste Rust in 1993. In 1994, the University established a 'Unit for Telematic Education ' as a support section for multiple faculties at the University of Pretoria. In subsequent years, the concept of 'telematic education” subsequently becomes well established in academic circles in South Africa, grew in popularity, and is adopted by many universities and colleges throughout South Africa as a medium of enhancing education and training, as a method to reaching out to far out communities, and as a means to enhance study from the home environment.\r\n\r\nProfessor Snyman in subsequent years pursued research in semiconductor physics, semiconductor devices, microelectronics, and optoelectronics.\r\n\r\nIn 2000 he joined the TUT as a full professor. Here served for a period as head of the Department of Electronic Engineering. Here he makes contributions to solar energy development, microwave and optoelectronic device development, silicon photonics, as well as contributions to new mobile telecommunication systems and network planning in SA.\r\n\r\nCurrently, he teaches electronics and telecommunications at the TUT to audiences ranging from first-year students to Ph.D. level.\r\n\r\nFor his research in the field of 'Silicon Photonics” since 1990, he has published (as author and co-author) about thirty internationally reviewed articles in scientific journals, contributed to more than forty international conferences, about 25 South African provisional patents (as inventor and co-inventor), 8 PCT international patent applications until now. Of these, two USA patents applications, two European Patents, two Korean patents, and ten SA patents have been granted. A further 4 USA patents, 5 European patents, 3 Korean patents, 3 Chinese patents, and 3 Japanese patents are currently under consideration.\r\n\r\nRecently he has also published an extensive scholarly chapter in an internet open access book on 'Integrating Microphotonic Systems and MOEMS into standard Silicon CMOS Integrated circuitry”.\r\n\r\nFurthermore, Professor Snyman recently steered a new initiative at the TUT by introducing a 'Laboratory for Innovative Electronic Systems ' at the Department of Electrical Engineering. The model of this laboratory or center is to primarily combine outputs as achieved by high-level research with lower-level system development and entrepreneurship in a technical university environment. Students are allocated to projects at different levels with PhDs and Master students allocated to the generation of new knowledge and new technologies, while students at the diploma and Baccalaureus level are allocated to electronic systems development with a direct and a near application for application in industry or the commercial and public sectors in South Africa.\r\n\r\nProfessor Snyman received the WIRSAM Award of 1983 and the WIRSAM Award in 1985 in South Africa for best research papers by a young scientist at two international conferences on electron microscopy in South Africa. He subsequently received the SA Microelectronics Award for the best dissertation emanating from studies executed at a South African university in the field of Physics and Microelectronics in South Africa in 1987. In October of 2011, Professor Snyman received the prestigious Institutional Award for 'Innovator of the Year” for 2010 at the Tshwane University of Technology, South Africa. This award was based on the number of patents recognized and granted by local and international institutions as well as for his contributions concerning innovation at the TUT.",institutionString:null,institution:{name:"University of South Africa",country:{name:"South Africa"}}},{id:"317279",title:"Mr.",name:"Ali",middleName:"Usama",surname:"Syed",slug:"ali-syed",fullName:"Ali Syed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/317279/images/16024_n.png",biography:"A creative, talented, and innovative young professional who is dedicated, well organized, and capable research fellow with two years of experience in graduate-level research, published in engineering journals and book, with related expertise in Bio-robotics, equally passionate about the aesthetics of the mechanical and electronic system, obtained expertise in the use of MS Office, MATLAB, SolidWorks, LabVIEW, Proteus, Fusion 360, having a grasp on python, C++ and assembly language, possess proven ability in acquiring research grants, previous appointments with social and educational societies with experience in administration, current affiliations with IEEE and Web of Science, a confident presenter at conferences and teacher in classrooms, able to explain complex information to audiences of all levels.",institutionString:null,institution:{name:"Air University",country:{name:"Pakistan"}}},{id:"75526",title:"Ph.D.",name:"Zihni Onur",middleName:null,surname:"Uygun",slug:"zihni-onur-uygun",fullName:"Zihni Onur Uygun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/75526/images/12_n.jpg",biography:"My undergraduate education and my Master of Science educations at Ege University and at Çanakkale Onsekiz Mart University have given me a firm foundation in Biochemistry, Analytical Chemistry, Biosensors, Bioelectronics, Physical Chemistry and Medicine. After obtaining my degree as a MSc in analytical chemistry, I started working as a research assistant in Ege University Medical Faculty in 2014. In parallel, I enrolled to the MSc program at the Department of Medical Biochemistry at Ege University to gain deeper knowledge on medical and biochemical sciences as well as clinical chemistry in 2014. In my PhD I deeply researched on biosensors and bioelectronics and finished in 2020. Now I have eleven SCI-Expanded Index published papers, 6 international book chapters, referee assignments for different SCIE journals, one international patent pending, several international awards, projects and bursaries. In parallel to my research assistant position at Ege University Medical Faculty, Department of Medical Biochemistry, in April 2016, I also founded a Start-Up Company (Denosens Biotechnology LTD) by the support of The Scientific and Technological Research Council of Turkey. Currently, I am also working as a CEO in Denosens Biotechnology. The main purposes of the company, which carries out R&D as a research center, are to develop new generation biosensors and sensors for both point-of-care diagnostics; such as glucose, lactate, cholesterol and cancer biomarker detections. My specific experimental and instrumental skills are Biochemistry, Biosensor, Analytical Chemistry, Electrochemistry, Mobile phone based point-of-care diagnostic device, POCTs and Patient interface designs, HPLC, Tandem Mass Spectrometry, Spectrophotometry, ELISA.",institutionString:null,institution:{name:"Ege University",country:{name:"Turkey"}}},{id:"267434",title:"Dr.",name:"Rohit",middleName:null,surname:"Raja",slug:"rohit-raja",fullName:"Rohit Raja",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/267434/images/system/267434.jpg",biography:"Dr. Rohit Raja received Ph.D. in Computer Science and Engineering from Dr. CVRAMAN University in 2016. His main research interest includes Face recognition and Identification, Digital Image Processing, Signal Processing, and Networking. Presently he is working as Associate Professor in IT Department, Guru Ghasidas Vishwavidyalaya (A Central University), Bilaspur (CG), India. He has authored several Journal and Conference Papers. He has good Academics & Research experience in various areas of CSE and IT. He has filed and successfully published 27 Patents. He has received many time invitations to be a Guest at IEEE Conferences. He has published 100 research papers in various International/National Journals (including IEEE, Springer, etc.) and Proceedings of the reputed International/ National Conferences (including Springer and IEEE). He has been nominated to the board of editors/reviewers of many peer-reviewed and refereed Journals (including IEEE, Springer).",institutionString:"Guru Ghasidas Vishwavidyalaya",institution:{name:"Guru Ghasidas Vishwavidyalaya",country:{name:"India"}}},{id:"246502",title:"Dr.",name:"Jaya T.",middleName:"T",surname:"Varkey",slug:"jaya-t.-varkey",fullName:"Jaya T. Varkey",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/246502/images/11160_n.jpg",biography:"Jaya T. Varkey, PhD, graduated with a degree in Chemistry from Cochin University of Science and Technology, Kerala, India. She obtained a PhD in Chemistry from the School of Chemical Sciences, Mahatma Gandhi University, Kerala, India, and completed a post-doctoral fellowship at the University of Minnesota, USA. She is a research guide at Mahatma Gandhi University and Associate Professor in Chemistry, St. Teresa’s College, Kochi, Kerala, India.\nDr. Varkey received a National Young Scientist award from the Indian Science Congress (1995), a UGC Research award (2016–2018), an Indian National Science Academy (INSA) Visiting Scientist award (2018–2019), and a Best Innovative Faculty award from the All India Association for Christian Higher Education (AIACHE) (2019). She Hashas received the Sr. Mary Cecil prize for best research paper three times. She was also awarded a start-up to develop a tea bag water filter. \nDr. Varkey has published two international books and twenty-seven international journal publications. She is an editorial board member for five international journals.",institutionString:"St. Teresa’s College",institution:null},{id:"250668",title:"Dr.",name:"Ali",middleName:null,surname:"Nabipour Chakoli",slug:"ali-nabipour-chakoli",fullName:"Ali Nabipour Chakoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/250668/images/system/250668.jpg",biography:"Academic Qualification:\r\n•\tPhD in Materials Physics and Chemistry, From: Sep. 2006, to: Sep. 2010, School of Materials Science and Engineering, Harbin Institute of Technology, Thesis: Structure and Shape Memory Effect of Functionalized MWCNTs/poly (L-lactide-co-ε-caprolactone) Nanocomposites. Supervisor: Prof. Wei Cai,\r\n•\tM.Sc in Applied Physics, From: 1996, to: 1998, Faculty of Physics & Nuclear Science, Amirkabir Uni. of Technology, Tehran, Iran, Thesis: Determination of Boron in Micro alloy Steels with solid state nuclear track detectors by neutron induced auto radiography, Supervisors: Dr. M. Hosseini Ashrafi and Dr. A. Hosseini.\r\n•\tB.Sc. in Applied Physics, From: 1991, to: 1996, Faculty of Physics & Nuclear Science, Amirkabir Uni. of Technology, Tehran, Iran, Thesis: Design of shielding for Am-Be neutron sources for In Vivo neutron activation analysis, Supervisor: Dr. M. Hosseini Ashrafi.\r\n\r\nResearch Experiences:\r\n1.\tNanomaterials, Carbon Nanotubes, Graphene: Synthesis, Functionalization and Characterization,\r\n2.\tMWCNTs/Polymer Composites: Fabrication and Characterization, \r\n3.\tShape Memory Polymers, Biodegradable Polymers, ORC, Collagen,\r\n4.\tMaterials Analysis and Characterizations: TEM, SEM, XPS, FT-IR, Raman, DSC, DMA, TGA, XRD, GPC, Fluoroscopy, \r\n5.\tInteraction of Radiation with Mater, Nuclear Safety and Security, NDT(RT),\r\n6.\tRadiation Detectors, Calibration (SSDL),\r\n7.\tCompleted IAEA e-learning Courses:\r\nNuclear Security (15 Modules),\r\nNuclear Safety:\r\nTSA 2: Regulatory Protection in Occupational Exposure,\r\nTips & Tricks: Radiation Protection in Radiography,\r\nSafety and Quality in Radiotherapy,\r\nCourse on Sealed Radioactive Sources,\r\nCourse on Fundamentals of Environmental Remediation,\r\nCourse on Planning for Environmental Remediation,\r\nKnowledge Management Orientation Course,\r\nFood Irradiation - Technology, Applications and Good Practices,\r\nEmployment:\r\nFrom 2010 to now: Academic staff, Nuclear Science and Technology Research Institute, Kargar Shomali, Tehran, Iran, P.O. Box: 14395-836.\r\nFrom 1997 to 2006: Expert of Materials Analysis and Characterization. Research Center of Agriculture and Medicine. Rajaeeshahr, Karaj, Iran, P. O. Box: 31585-498.",institutionString:"Atomic Energy Organization of Iran",institution:{name:"Atomic Energy Organization of Iran",country:{name:"Iran"}}},{id:"248279",title:"Dr.",name:"Monika",middleName:"Elzbieta",surname:"Machoy",slug:"monika-machoy",fullName:"Monika Machoy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/248279/images/system/248279.jpeg",biography:"Monika Elżbieta Machoy, MD, graduated with distinction from the Faculty of Medicine and Dentistry at the Pomeranian Medical University in 2009, defended her PhD thesis with summa cum laude in 2016 and is currently employed as a researcher at the Department of Orthodontics of the Pomeranian Medical University. She expanded her professional knowledge during a one-year scholarship program at the Ernst Moritz Arndt University in Greifswald, Germany and during a three-year internship at the Technical University in Dresden, Germany. She has been a speaker at numerous orthodontic conferences, among others, American Association of Orthodontics, European Orthodontic Symposium and numerous conferences of the Polish Orthodontic Society. She conducts research focusing on the effect of orthodontic treatment on dental and periodontal tissues and the causes of pain in orthodontic patients.",institutionString:"Pomeranian Medical University",institution:{name:"Pomeranian Medical University",country:{name:"Poland"}}},{id:"252743",title:"Prof.",name:"Aswini",middleName:"Kumar",surname:"Kar",slug:"aswini-kar",fullName:"Aswini Kar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252743/images/10381_n.jpg",biography:"uploaded in cv",institutionString:null,institution:{name:"KIIT University",country:{name:"India"}}},{id:"204256",title:"Dr.",name:"Anil",middleName:"Kumar",surname:"Kumar Sahu",slug:"anil-kumar-sahu",fullName:"Anil Kumar Sahu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204256/images/14201_n.jpg",biography:"I have nearly 11 years of research and teaching experience. I have done my master degree from University Institute of Pharmacy, Pt. Ravi Shankar Shukla University, Raipur, Chhattisgarh India. I have published 16 review and research articles in international and national journals and published 4 chapters in IntechOpen, the world’s leading publisher of Open access books. I have presented many papers at national and international conferences. I have received research award from Indian Drug Manufacturers Association in year 2015. My research interest extends from novel lymphatic drug delivery systems, oral delivery system for herbal bioactive to formulation optimization.",institutionString:null,institution:{name:"Chhattisgarh Swami Vivekanand Technical University",country:{name:"India"}}},{id:"253468",title:"Dr.",name:"Mariusz",middleName:null,surname:"Marzec",slug:"mariusz-marzec",fullName:"Mariusz Marzec",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/253468/images/system/253468.png",biography:"An assistant professor at Department of Biomedical Computer Systems, at Institute of Computer Science, Silesian University in Katowice. Scientific interests: computer analysis and processing of images, biomedical images, databases and programming languages. He is an author and co-author of scientific publications covering analysis and processing of biomedical images and development of database systems.",institutionString:"University of Silesia",institution:null},{id:"212432",title:"Prof.",name:"Hadi",middleName:null,surname:"Mohammadi",slug:"hadi-mohammadi",fullName:"Hadi Mohammadi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/212432/images/system/212432.jpeg",biography:"Dr. Hadi Mohammadi is a biomedical engineer with hands-on experience in the design and development of many engineering structures and medical devices through various projects that he has been involved in over the past twenty years. Dr. Mohammadi received his BSc. and MSc. degrees in Mechanical Engineering from Sharif University of Technology, Tehran, Iran, and his PhD. degree in Biomedical Engineering (biomaterials) from the University of Western Ontario. He was a postdoctoral trainee for almost four years at University of Calgary and Harvard Medical School. He is an industry innovator having created the technology to produce lifelike synthetic platforms that can be used for the simulation of almost all cardiovascular reconstructive surgeries. He’s been heavily involved in the design and development of cardiovascular devices and technology for the past 10 years. He is currently an Assistant Professor with the University of British Colombia, Canada.",institutionString:"University of British Columbia",institution:{name:"University of British Columbia",country:{name:"Canada"}}},{id:"254463",title:"Prof.",name:"Haisheng",middleName:null,surname:"Yang",slug:"haisheng-yang",fullName:"Haisheng Yang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/254463/images/system/254463.jpeg",biography:"Haisheng Yang, Ph.D., Professor and Director of the Department of Biomedical Engineering, College of Life Science and Bioengineering, Beijing University of Technology. He received his Ph.D. degree in Mechanics/Biomechanics from Harbin Institute of Technology (jointly with University of California, Berkeley). Afterwards, he worked as a Postdoctoral Research Associate in the Purdue Musculoskeletal Biology and Mechanics Lab at the Department of Basic Medical Sciences, Purdue University, USA. He also conducted research in the Research Centre of Shriners Hospitals for Children-Canada at McGill University, Canada. Dr. Yang has over 10 years research experience in orthopaedic biomechanics and mechanobiology of bone adaptation and regeneration. He earned an award from Beijing Overseas Talents Aggregation program in 2017 and serves as Beijing Distinguished Professor.",institutionString:null,institution:{name:"Beijing University of Technology",country:{name:"China"}}},{id:"89721",title:"Dr.",name:"Mehmet",middleName:"Cuneyt",surname:"Ozmen",slug:"mehmet-ozmen",fullName:"Mehmet Ozmen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/89721/images/7289_n.jpg",biography:null,institutionString:null,institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"242893",title:"Ph.D. Student",name:"Joaquim",middleName:null,surname:"De Moura",slug:"joaquim-de-moura",fullName:"Joaquim De Moura",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/242893/images/7133_n.jpg",biography:"Joaquim de Moura received his degree in Computer Engineering in 2014 from the University of A Coruña (Spain). In 2016, he received his M.Sc degree in Computer Engineering from the same university. He is currently pursuing his Ph.D degree in Computer Science in a collaborative project between ophthalmology centers in Galicia and the University of A Coruña. His research interests include computer vision, machine learning algorithms and analysis and medical imaging processing of various kinds.",institutionString:null,institution:{name:"University of A Coruña",country:{name:"Spain"}}},{id:"294334",title:"B.Sc.",name:"Marc",middleName:null,surname:"Bruggeman",slug:"marc-bruggeman",fullName:"Marc Bruggeman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/294334/images/8242_n.jpg",biography:"Chemical engineer graduate, with a passion for material science and specific interest in polymers - their near infinite applications intrigue me. \n\nI plan to continue my scientific career in the field of polymeric biomaterials as I am fascinated by intelligent, bioactive and biomimetic materials for use in both consumer and medical applications.",institutionString:null,institution:null},{id:"255757",title:"Dr.",name:"Igor",middleName:"Victorovich",surname:"Lakhno",slug:"igor-lakhno",fullName:"Igor Lakhno",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255757/images/system/255757.jpg",biography:"Igor Victorovich Lakhno was born in 1971 in Kharkiv (Ukraine). \nMD – 1994, Kharkiv National Medical Univesity.\nOb&Gyn; – 1997, master courses in Kharkiv Medical Academy of Postgraduate Education.\nPh.D. – 1999, Kharkiv National Medical Univesity.\nDSC – 2019, PL Shupik National Academy of Postgraduate Education \nProfessor – 2021, Department of Obstetrics and Gynecology of VN Karazin Kharkiv National University\nHead of Department – 2021, Department of Perinatology, Obstetrics and gynecology of Kharkiv Medical Academy of Postgraduate Education\nIgor Lakhno has been graduated from international training courses on reproductive medicine and family planning held at Debrecen University (Hungary) in 1997. Since 1998 Lakhno Igor has worked as an associate professor in the department of obstetrics and gynecology of VN Karazin National University and an associate professor of the perinatology, obstetrics, and gynecology department of Kharkiv Medical Academy of Postgraduate Education. Since June 2019 he’s been a professor in the department of obstetrics and gynecology of VN Karazin National University and a professor of the perinatology, obstetrics, and gynecology department. He’s affiliated with Kharkiv Medical Academy of Postgraduate Education as a Head of Department from November 2021. Igor Lakhno has participated in several international projects on fetal non-invasive electrocardiography (with Dr. J. A. Behar (Technion), Prof. D. Hoyer (Jena University), and José Alejandro Díaz Méndez (National Institute of Astrophysics, Optics, and Electronics, Mexico). He’s an author of about 200 printed works and there are 31 of them in Scopus or Web of Science databases. Igor Lakhno is a member of the Editorial Board of Reproductive Health of Woman, Emergency Medicine, and Technology Transfer Innovative Solutions in Medicine (Estonia). He is a medical Editor of “Z turbotoyu pro zhinku”. Igor Lakhno is a reviewer of the Journal of Obstetrics and Gynaecology (Taylor and Francis), British Journal of Obstetrics and Gynecology (Wiley), Informatics in Medicine Unlocked (Elsevier), The Journal of Obstetrics and Gynecology Research (Wiley), Endocrine, Metabolic & Immune Disorders-Drug Targets (Bentham Open), The Open Biomedical Engineering Journal (Bentham Open), etc. He’s defended a dissertation for a DSc degree “Pre-eclampsia: prediction, prevention, and treatment”. Three years ago Igor Lakhno has participated in a training course on innovative technologies in medical education at Lublin Medical University (Poland). Lakhno Igor has participated as a speaker in several international conferences and congresses (International Conference on Biological Oscillations April 10th-14th 2016, Lancaster, UK, The 9th conference of the European Study Group on Cardiovascular Oscillations). His main scientific interests: are obstetrics, women’s health, fetal medicine, and cardiovascular medicine. \nIgor Lakhno is a consultant at Kharkiv municipal perinatal center. He’s graduated from training courses on endoscopy in gynecology. He has 28 years of practical experience in the field.",institutionString:null,institution:null},{id:"244950",title:"Dr.",name:"Salvatore",middleName:null,surname:"Di Lauro",slug:"salvatore-di-lauro",fullName:"Salvatore Di Lauro",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0030O00002bSF1HQAW/ProfilePicture%202021-12-20%2014%3A54%3A14.482",biography:"Name:\n\tSALVATORE DI LAURO\nAddress:\n\tHospital Clínico Universitario Valladolid\nAvda Ramón y Cajal 3\n47005, Valladolid\nSpain\nPhone number: \nFax\nE-mail:\n\t+34 983420000 ext 292\n+34 983420084\nsadilauro@live.it\nDate and place of Birth:\nID Number\nMedical Licence \nLanguages\t09-05-1985. Villaricca (Italy)\n\nY1281863H\n474707061\nItalian (native language)\nSpanish (read, written, spoken)\nEnglish (read, written, spoken)\nPortuguese (read, spoken)\nFrench (read)\n\t\t\nCurrent position (title and company)\tDate (Year)\nVitreo-Retinal consultant in ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl. National Health System.\nVitreo-Retinal consultant in ophthalmology. Instituto Oftalmologico Recoletas. Red Hospitalaria Recoletas. Private practise.\t2017-today\n\n2019-today\n\t\n\t\nEducation (High school, university and postgraduate training > 3 months)\tDate (Year)\nDegree in Medicine and Surgery. University of Neaples 'Federico II”\nResident in Opthalmology. Hospital Clinico Universitario Valladolid\nMaster in Vitreo-Retina. IOBA. University of Valladolid\nFellow of the European Board of Ophthalmology. Paris\nMaster in Research in Ophthalmology. University of Valladolid\t2003-2009\n2012-2016\n2016-2017\n2016\n2012-2013\n\t\nEmployments (company and positions)\tDate (Year)\nResident in Ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl.\nFellow in Vitreo-Retina. IOBA. University of Valladolid\nVitreo-Retinal consultant in ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl. National Health System.\nVitreo-Retinal consultant in ophthalmology. Instituto Oftalmologico Recoletas. Red Hospitalaria Recoletas. \n\t2012-2016\n2016-2017\n2017-today\n\n2019-Today\n\n\n\t\nClinical Research Experience (tasks and role)\tDate (Year)\nAssociated investigator\n\n' FIS PI20/00740: DESARROLLO DE UNA CALCULADORA DE RIESGO DE\nAPARICION DE RETINOPATIA DIABETICA BASADA EN TECNICAS DE IMAGEN MULTIMODAL EN PACIENTES DIABETICOS TIPO 1. Grant by: Ministerio de Ciencia e Innovacion \n\n' (BIO/VA23/14) Estudio clínico multicéntrico y prospectivo para validar dos\nbiomarcadores ubicados en los genes p53 y MDM2 en la predicción de los resultados funcionales de la cirugía del desprendimiento de retina regmatógeno. Grant by: Gerencia Regional de Salud de la Junta de Castilla y León.\n' Estudio multicéntrico, aleatorizado, con enmascaramiento doble, en 2 grupos\nparalelos y de 52 semanas de duración para comparar la eficacia, seguridad e inmunogenicidad de SOK583A1 respecto a Eylea® en pacientes con degeneración macular neovascular asociada a la edad' (CSOK583A12301; N.EUDRA: 2019-004838-41; FASE III). Grant by Hexal AG\n\n' Estudio de fase III, aleatorizado, doble ciego, con grupos paralelos, multicéntrico para comparar la eficacia y la seguridad de QL1205 frente a Lucentis® en pacientes con degeneración macular neovascular asociada a la edad. (EUDRACT: 2018-004486-13). Grant by Qilu Pharmaceutical Co\n\n' Estudio NEUTON: Ensayo clinico en fase IV para evaluar la eficacia de aflibercept en pacientes Naive con Edema MacUlar secundario a Oclusion de Vena CenTral de la Retina (OVCR) en regimen de tratamientO iNdividualizado Treat and Extend (TAE)”, (2014-000975-21). Grant by Fundacion Retinaplus\n\n' Evaluación de la seguridad y bioactividad de anillos de tensión capsular en conejo. Proyecto Procusens. Grant by AJL, S.A.\n\n'Estudio epidemiológico, prospectivo, multicéntrico y abierto\\npara valorar la frecuencia de la conjuntivitis adenovírica diagnosticada mediante el test AdenoPlus®\\nTest en pacientes enfermos de conjuntivitis aguda”\\n. National, multicenter study. Grant by: NICOX.\n\nEuropean multicentric trial: 'Evaluation of clinical outcomes following the use of Systane Hydration in patients with dry eye”. Study Phase 4. Grant by: Alcon Labs'\n\nVLPs Injection and Activation in a Rabbit Model of Uveal Melanoma. Grant by Aura Bioscience\n\nUpdating and characterization of a rabbit model of uveal melanoma. Grant by Aura Bioscience\n\nEnsayo clínico en fase IV para evaluar las variantes genéticas de la vía del VEGF como biomarcadores de eficacia del tratamiento con aflibercept en pacientes con degeneración macular asociada a la edad (DMAE) neovascular. Estudio BIOIMAGE. IMO-AFLI-2013-01\n\nEstudio In-Eye:Ensayo clínico en fase IV, abierto, aleatorizado, de 2 brazos,\nmulticçentrico y de 12 meses de duración, para evaluar la eficacia y seguridad de un régimen de PRN flexible individualizado de 'esperar y extender' versus un régimen PRN según criterios de estabilización mediante evaluaciones mensuales de inyecciones intravítreas de ranibizumab 0,5 mg en pacientes naive con neovascularización coriodea secunaria a la degeneración macular relacionada con la edad. CP: CRFB002AES03T\n\nTREND: Estudio Fase IIIb multicéntrico, randomizado, de 12 meses de\nseguimiento con evaluador de la agudeza visual enmascarado, para evaluar la eficacia y la seguridad de ranibizumab 0.5mg en un régimen de tratar y extender comparado con un régimen mensual, en pacientes con degeneración macular neovascular asociada a la edad. CP: CRFB002A2411 Código Eudra CT:\n2013-002626-23\n\n\n\nPublications\t\n\n2021\n\n\n\n\n2015\n\n\n\n\n2021\n\n\n\n\n\n2021\n\n\n\n\n2015\n\n\n\n\n2015\n\n\n2014\n\n\n\n\n2015-16\n\n\n\n2015\n\n\n2014\n\n\n2014\n\n\n\n\n2014\n\n\n\n\n\n\n\n2014\n\nJose Carlos Pastor; Jimena Rojas; Salvador Pastor-Idoate; Salvatore Di Lauro; Lucia Gonzalez-Buendia; Santiago Delgado-Tirado. Proliferative vitreoretinopathy: A new concept of disease pathogenesis and practical\nconsequences. Progress in Retinal and Eye Research. 51, pp. 125 - 155. 03/2016. DOI: 10.1016/j.preteyeres.2015.07.005\n\n\nLabrador-Velandia S; Alonso-Alonso ML; Di Lauro S; García-Gutierrez MT; Srivastava GK; Pastor JC; Fernandez-Bueno I. Mesenchymal stem cells provide paracrine neuroprotective resources that delay degeneration of co-cultured organotypic neuroretinal cultures.Experimental Eye Research. 185, 17/05/2019. DOI: 10.1016/j.exer.2019.05.011\n\nSalvatore Di Lauro; Maria Teresa Garcia Gutierrez; Ivan Fernandez Bueno. Quantification of pigment epithelium-derived factor (PEDF) in an ex vivo coculture of retinal pigment epithelium cells and neuroretina.\nJournal of Allbiosolution. 2019. ISSN 2605-3535\n\nSonia Labrador Velandia; Salvatore Di Lauro; Alonso-Alonso ML; Tabera Bartolomé S; Srivastava GK; Pastor JC; Fernandez-Bueno I. Biocompatibility of intravitreal injection of human mesenchymal stem cells in immunocompetent rabbits. Graefe's archive for clinical and experimental ophthalmology. 256 - 1, pp. 125 - 134. 01/2018. DOI: 10.1007/s00417-017-3842-3\n\n\nSalvatore Di Lauro, David Rodriguez-Crespo, Manuel J Gayoso, Maria T Garcia-Gutierrez, J Carlos Pastor, Girish K Srivastava, Ivan Fernandez-Bueno. A novel coculture model of porcine central neuroretina explants and retinal pigment epithelium cells. Molecular Vision. 2016 - 22, pp. 243 - 253. 01/2016.\n\nSalvatore Di Lauro. Classifications for Proliferative Vitreoretinopathy ({PVR}): An Analysis of Their Use in Publications over the Last 15 Years. Journal of Ophthalmology. 2016, pp. 1 - 6. 01/2016. DOI: 10.1155/2016/7807596\n\nSalvatore Di Lauro; Rosa Maria Coco; Rosa Maria Sanabria; Enrique Rodriguez de la Rua; Jose Carlos Pastor. Loss of Visual Acuity after Successful Surgery for Macula-On Rhegmatogenous Retinal Detachment in a Prospective Multicentre Study. Journal of Ophthalmology. 2015:821864, 2015. DOI: 10.1155/2015/821864\n\nIvan Fernandez-Bueno; Salvatore Di Lauro; Ivan Alvarez; Jose Carlos Lopez; Maria Teresa Garcia-Gutierrez; Itziar Fernandez; Eva Larra; Jose Carlos Pastor. Safety and Biocompatibility of a New High-Density Polyethylene-Based\nSpherical Integrated Porous Orbital Implant: An Experimental Study in Rabbits. Journal of Ophthalmology. 2015:904096, 2015. DOI: 10.1155/2015/904096\n\nPastor JC; Pastor-Idoate S; Rodríguez-Hernandez I; Rojas J; Fernandez I; Gonzalez-Buendia L; Di Lauro S; Gonzalez-Sarmiento R. Genetics of PVR and RD. Ophthalmologica. 232 - Suppl 1, pp. 28 - 29. 2014\n\nRodriguez-Crespo D; Di Lauro S; Singh AK; Garcia-Gutierrez MT; Garrosa M; Pastor JC; Fernandez-Bueno I; Srivastava GK. Triple-layered mixed co-culture model of RPE cells with neuroretina for evaluating the neuroprotective effects of adipose-MSCs. Cell Tissue Res. 358 - 3, pp. 705 - 716. 2014.\nDOI: 10.1007/s00441-014-1987-5\n\nCarlo De Werra; Salvatore Condurro; Salvatore Tramontano; Mario Perone; Ivana Donzelli; Salvatore Di Lauro; Massimo Di Giuseppe; Rosa Di Micco; Annalisa Pascariello; Antonio Pastore; Giorgio Diamantis; Giuseppe Galloro. Hydatid disease of the liver: thirty years of surgical experience.Chirurgia italiana. 59 - 5, pp. 611 - 636.\n(Italia): 2007. ISSN 0009-4773\n\nChapters in books\n\t\n' Salvador Pastor Idoate; Salvatore Di Lauro; Jose Carlos Pastor Jimeno. PVR: Pathogenesis, Histopathology and Classification. Proliferative Vitreoretinopathy with Small Gauge Vitrectomy. Springer, 2018. ISBN 978-3-319-78445-8\nDOI: 10.1007/978-3-319-78446-5_2. \n\n' Salvatore Di Lauro; Maria Isabel Lopez Galvez. Quistes vítreos en una mujer joven. Problemas diagnósticos en patología retinocoroidea. Sociedad Española de Retina-Vitreo. 2018.\n\n' Salvatore Di Lauro; Salvador Pastor Idoate; Jose Carlos Pastor Jimeno. iOCT in PVR management. OCT Applications in Opthalmology. pp. 1 - 8. INTECH, 2018. DOI: 10.5772/intechopen.78774.\n\n' Rosa Coco Martin; Salvatore Di Lauro; Salvador Pastor Idoate; Jose Carlos Pastor. amponadores, manipuladores y tinciones en la cirugía del traumatismo ocular.Trauma Ocular. Ponencia de la SEO 2018..\n\n' LOPEZ GALVEZ; DI LAURO; CRESPO. OCT angiografia y complicaciones retinianas de la diabetes. PONENCIA SEO 2021, CAPITULO 20. (España): 2021.\n\n' Múltiples desprendimientos neurosensoriales bilaterales en paciente joven. Enfermedades Degenerativas De Retina Y Coroides. SERV 04/2016. \n' González-Buendía L; Di Lauro S; Pastor-Idoate S; Pastor Jimeno JC. Vitreorretinopatía proliferante (VRP) e inflamación: LA INFLAMACIÓN in «INMUNOMODULADORES Y ANTIINFLAMATORIOS: MÁS ALLÁ DE LOS CORTICOIDES. RELACION DE PONENCIAS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGIA. 10/2014.",institutionString:null,institution:null},{id:"265335",title:"Mr.",name:"Stefan",middleName:"Radnev",surname:"Stefanov",slug:"stefan-stefanov",fullName:"Stefan Stefanov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/265335/images/7562_n.jpg",biography:null,institutionString:null,institution:null},{id:"243698",title:"Dr.",name:"Xiaogang",middleName:null,surname:"Wang",slug:"xiaogang-wang",fullName:"Xiaogang Wang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243698/images/system/243698.png",biography:"Dr. Xiaogang Wang, a faculty member of Shanxi Eye Hospital specializing in the treatment of cataract and retinal disease and a tutor for postgraduate students of Shanxi Medical University, worked in the COOL Lab as an international visiting scholar under the supervision of Dr. David Huang and Yali Jia from October 2012 through November 2013. 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Aside from the criteria used to describe the hard tissue response at the implant level, the success criteria in implant dentistry include three additional aspects: peri-implant soft tissue, prosthesis, and patient’s satisfaction.
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