Overview of different airway management techniques—advantages and disadvantages in prehospital use.
\\n\\n
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"5948",leadTitle:null,fullTitle:"Vignettes in Patient Safety - Volume 1",title:"Vignettes in Patient Safety",subtitle:"Volume 1",reviewType:"peer-reviewed",abstract:"It is clearly recognized that medical errors represent a significant source of preventable healthcare-related morbidity and mortality. Furthermore, evidence shows that such complications are often the result of a series of smaller errors, missed opportunities, poor communication, breakdowns in established guidelines or protocols, or system-based deficiencies. While such events often start with the misadventures of an individual, it is how such events are managed that can determine outcomes and hopefully prevent future adverse events. The goal of Vignettes in Patient Safety is to illustrate and discuss, in a clinically relevant format, examples in which evidence-based approaches to patient care, using established methodologies to develop highly functional multidisciplinary teams, can help foster an institutional culture of patient safety and high-quality care delivery.",isbn:"978-953-51-3520-3",printIsbn:"978-953-51-3519-7",pdfIsbn:"978-953-51-4653-7",doi:"10.5772/66106",price:119,priceEur:129,priceUsd:155,slug:"vignettes-in-patient-safety-volume-1",numberOfPages:186,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"d9aa14e866ecd2f473e4ff93be2525a2",bookSignature:"Michael S. Firstenberg and Stanislaw P. Stawicki",publishedDate:"September 13th 2017",coverURL:"https://cdn.intechopen.com/books/images_new/5948.jpg",numberOfDownloads:15142,numberOfWosCitations:16,numberOfCrossrefCitations:22,numberOfCrossrefCitationsByBook:2,numberOfDimensionsCitations:25,numberOfDimensionsCitationsByBook:2,hasAltmetrics:1,numberOfTotalCitations:63,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 13th 2016",dateEndSecondStepPublish:"November 15th 2016",dateEndThirdStepPublish:"March 15th 2017",dateEndFourthStepPublish:"May 1st 2017",dateEndFifthStepPublish:"July 1st 2017",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"64343",title:"Dr.",name:"Michael S.",middleName:null,surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/64343/images/system/64343.png",biography:"Dr. Michael S. Firstenberg is a thoracic surgeon at the St. Elizabeth Medical Center (Ascension), Appleton, Wisconsin. He attended Case Western Reserve University Medical School, Cleveland, OH, received his general surgery training at University Hospitals in Cleveland, and completed thoracic surgery fellowships at The Ohio State University and the Cleveland Clinic. He is an active member of the Society of Thoracic Surgeons (STS), American Association of Thoracic Surgeons (AATS), American College of Cardiology (ACC), and American College of Academic International Medicine (ACAIM), for which he served as president in 2021–2022. He has authored more than 250 peer-reviewed manuscripts, abstracts, and book chapters and has edited several textbooks and lectured worldwide on topics ranging from medical leadership, COVID-19, endocarditis, and extra-corporeal membrane oxygenation (ECMO).",institutionString:"St. Elizabeth Medical Center",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"26",totalChapterViews:"0",totalEditedBooks:"13",institution:{name:"The Medical Center of Aurora",institutionURL:null,country:{name:"United States of America"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"181694",title:"Dr.",name:"Stanislaw P.",middleName:null,surname:"Stawicki",slug:"stanislaw-p.-stawicki",fullName:"Stanislaw P. Stawicki",profilePictureURL:"https://mts.intechopen.com/storage/users/181694/images/system/181694.jpeg",biography:"Dr. Stanislaw P. Stawicki is a Professor of Surgery and chair of the Department of Research and Innovation, St. Luke\\'s University Health Network, Bethlehem, Pennsylvania. A specialist in general surgery, surgical critical care, and neurocritical care, he has co-authored more than 650 scholarly works, including more than 20 books. In addition to local, national, and international medical leadership roles, Dr. Stawicki is a member of numerous editorial boards. His areas of expertise are diverse and include health security, medical information security, blockchain technology, patient safety, academic leadership, mentorship and leadership development, traumatology, surgical critical care, and sonography.",institutionString:"St. Luke's University Health Network",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"33",totalChapterViews:"0",totalEditedBooks:"8",institution:{name:"St. Luke's University Health Network",institutionURL:null,country:{name:"United States of America"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1135",title:"Preventive Healthcare",slug:"preventive-healthcare"}],chapters:[{id:"55601",title:"Introductory Chapter: The Decades Long Quest Continues Toward Better, Safer Healthcare Systems",doi:"10.5772/intechopen.69354",slug:"introductory-chapter-the-decades-long-quest-continues-toward-better-safer-healthcare-systems",totalDownloads:1576,totalCrossrefCites:13,totalDimensionsCites:14,hasAltmetrics:0,abstract:null,signatures:"Stanislaw P. Stawicki and Michael S. Firstenberg",downloadPdfUrl:"/chapter/pdf-download/55601",previewPdfUrl:"/chapter/pdf-preview/55601",authors:[{id:"64343",title:"Dr.",name:"Michael S.",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg"},{id:"181694",title:"Dr.",name:"Stanislaw P.",surname:"Stawicki",slug:"stanislaw-p.-stawicki",fullName:"Stanislaw P. Stawicki"}],corrections:null},{id:"56329",title:"Improving Childbirth and Maternal Care - How to Foster the Use of Good Practices for Patient Safety",doi:"10.5772/intechopen.69652",slug:"improving-childbirth-and-maternal-care-how-to-foster-the-use-of-good-practices-for-patient-safety",totalDownloads:1339,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Despite the global effort toward improving childbirth and maternity care, there are still complications (hemorrhage, infections, and high blood pressure) that may arise unexpectedly. To end preventable mortality, every woman needs skilled care at birth. The aim of this chapter is to present some solutions implemented by Frontline professionals and healthcare organizations made available through the Italian Observatory on Good Practices for Patient Safety, a national program to improve patient safety by promoting diffusion and active dissemination of evidence-based practices.",signatures:"Barbara Labella, Roberta De Blasi, Vanda Raho, Giulia De Matteis,\nQuinto Tozzi and Giovanni Caracci",downloadPdfUrl:"/chapter/pdf-download/56329",previewPdfUrl:"/chapter/pdf-preview/56329",authors:[{id:"200247",title:"Ph.D.",name:"Barbara",surname:"Labella",slug:"barbara-labella",fullName:"Barbara Labella"},{id:"201687",title:"MSc.",name:"Giovanni",surname:"Caracci",slug:"giovanni-caracci",fullName:"Giovanni Caracci"},{id:"201693",title:"MSc.",name:"Roberta",surname:"De Blasi",slug:"roberta-de-blasi",fullName:"Roberta De Blasi"},{id:"201694",title:"MSc.",name:"Giulia",surname:"De Matteis",slug:"giulia-de-matteis",fullName:"Giulia De Matteis"},{id:"201695",title:"MSc.",name:"Quinto",surname:"Tozzi",slug:"quinto-tozzi",fullName:"Quinto Tozzi"},{id:"205155",title:"MSc.",name:"Vanda",surname:"Raho",slug:"vanda-raho",fullName:"Vanda Raho"}],corrections:null},{id:"56241",title:"Transitions of Care: Complications and Solutions",doi:"10.5772/intechopen.69381",slug:"transitions-of-care-complications-and-solutions",totalDownloads:1420,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The delivery of medical care relies on effective, succinct, and ongoing communication between healthcare providers, called handoffs. Handoffs involve the transfer of professional responsibility and accountability for aspects of care for patients to another clinician or clinical team on a temporary or permanent basis. Handoffs have the potential for deleterious clinical impact if inadequately done. Only recently has data become available that demonstrate improvements in handoffs reduce the rate of subsequent clinical care error. This clinical vignette and subsequent discussion focuses on physician, particularly the resident physician in training, transfer of care: handoff complications, barriers to effective handoffs, regulatory agencies’ input on handoff improvement, standardization of the handoff process, assessment of the quality of handoff, handoff error avoidance, and improving the quality of handoff.",signatures:"Philip Salen",downloadPdfUrl:"/chapter/pdf-download/56241",previewPdfUrl:"/chapter/pdf-preview/56241",authors:[{id:"198023",title:"M.D.",name:"Philip",surname:"Salen",slug:"philip-salen",fullName:"Philip Salen"}],corrections:null},{id:"55307",title:"Dangers of Polypharmacy",doi:"10.5772/intechopen.69169",slug:"dangers-of-polypharmacy",totalDownloads:1806,totalCrossrefCites:6,totalDimensionsCites:6,hasAltmetrics:1,abstract:"Although the definition of polypharmacy has evolved over time, it has been and remains to be an issue in healthcare. With the prevalence of polypharmacy increasing, those in the health care field must remain vigilant of the adverse effects of medications and work to coordinate care and maintain appropriate prescribing practices. Here we present a clinical vignette that describes an encounter of a patient on multiple medications and the individual, provider, and systems‐level issues that may have contributed to an adverse event resulting in a hospital stay. We will discuss the definition of polypharmacy, review the prevalence and economic implications of drug prescription practices, and examine the consequences and complications of polypharmacy in a number of different patient populations. We will discuss a number of scenarios involving polypharmacy that lead to medication errors, decreased quality of life, and patient harm, and then review evidence‐based methods of interventions aimed at reducing the prevalence of polypharmacy and its associated complications.",signatures:"Pamela L. Valenza, Thomas C. McGinley, James Feldman, Pritiben\nPatel, Kristine Cornejo, Najmus Liang, Roopa Anmolsingh and\nNoble McNaughton",downloadPdfUrl:"/chapter/pdf-download/55307",previewPdfUrl:"/chapter/pdf-preview/55307",authors:[{id:"197829",title:"Dr.",name:"Pamela",surname:"Valenza",slug:"pamela-valenza",fullName:"Pamela Valenza"}],corrections:null},{id:"55550",title:"Wrong Patient, Wrong Drug: An Unfortunate Confluence of Events",doi:"10.5772/intechopen.69168",slug:"wrong-patient-wrong-drug-an-unfortunate-confluence-of-events",totalDownloads:1073,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:1,abstract:"Older adults, aged 65 years or older, represent 14.9% of U.S. population, and are projected to increase to 22% by 2050. It is estimated that almost half of hospitalized patients are older adults and is expected to increase as the population ages. Hospitalized older adults are most vulnerable to adverse events because of aging‐related conditions, physiological changes, and multiple comorbidities as well as fragmented care. The primary goal of health care providers is to improve patient safety and decrease adverse events. This chapter will use a complex clinical scenario with numerous potential overlapping risks to address the many active and latent factors that lead to patient safety‐related adverse events. Factors involved, as well as preventive strategies, will be discussed in detail.",signatures:"Anna Njarlangattil Thomas, Danielle Belser, Stephanie Rabenold,\nOmalara Olabisi Bamgbelu, Amaravani Mandalapu, Michael\nPipestone, Alaa‐Eldin A Mira and Ric Baxter",downloadPdfUrl:"/chapter/pdf-download/55550",previewPdfUrl:"/chapter/pdf-preview/55550",authors:[{id:"188527",title:"Dr.",name:"Ric",surname:"Baxter",slug:"ric-baxter",fullName:"Ric Baxter"},{id:"197822",title:"Dr.",name:"Alaa-Eldin",surname:"Mira",slug:"alaa-eldin-mira",fullName:"Alaa-Eldin Mira"},{id:"202212",title:"Dr.",name:"Anna",surname:"Thomas",slug:"anna-thomas",fullName:"Anna Thomas"},{id:"207003",title:"Dr.",name:"Danielle",surname:"Belser",slug:"danielle-belser",fullName:"Danielle Belser"},{id:"207004",title:"Dr.",name:"Stephanie",surname:"Rabenold",slug:"stephanie-rabenold",fullName:"Stephanie Rabenold"},{id:"207005",title:"Dr.",name:"Omalara",surname:"Bamgbelu",slug:"omalara-bamgbelu",fullName:"Omalara Bamgbelu"},{id:"207006",title:"Dr.",name:"Amaravani",surname:"Mandalapu",slug:"amaravani-mandalapu",fullName:"Amaravani Mandalapu"},{id:"207007",title:"Dr.",name:"Michael",surname:"Pipestone",slug:"michael-pipestone",fullName:"Michael Pipestone"}],corrections:null},{id:"56035",title:"Inadequate Decontamination Procedures: Sepsis Following Uneventful Endoscopy",doi:"10.5772/intechopen.69465",slug:"inadequate-decontamination-procedures-sepsis-following-uneventful-endoscopy",totalDownloads:1281,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Exogenous infection following endoscopy remains rare, however, recent attention in the media and the rise of antibacterial resistant strains of bacteria have emphasized the importance of proper sterilization techniques involved in the reprocessing of endoscopes and accessory devices. This chapter serves as comprehensive review into the epidemiology of exogenous infections as well as basic reprocessing techniques and guidelines for all medical professionals that treat patients that would benefit from endoscopy.",signatures:"Ellyn A. Smith, Kimberly J. Chaput and Berhanu M. Geme",downloadPdfUrl:"/chapter/pdf-download/56035",previewPdfUrl:"/chapter/pdf-preview/56035",authors:[{id:"197821",title:"Dr.",name:"Ellyn",surname:"Smith",slug:"ellyn-smith",fullName:"Ellyn Smith"},{id:"206997",title:"Dr.",name:"Kimberly",surname:"Chaput",slug:"kimberly-chaput",fullName:"Kimberly Chaput"},{id:"206998",title:"Dr.",name:"Berhanu",surname:"Geme",slug:"berhanu-geme",fullName:"Berhanu Geme"}],corrections:null},{id:"55726",title:"Unnecessary Complications: The Forgotten Indwelling Urinary Catheter",doi:"10.5772/intechopen.69467",slug:"unnecessary-complications-the-forgotten-indwelling-urinary-catheter",totalDownloads:1496,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Complications of indwelling urinary catheters (IUCs) are common, with the infectious one accounting for 40% of all reported healthcare-associated infections. Myths and rituals exist among healthcare professionals in the application of the urinary catheter, and the catheter is often forgotten after the placement, resulting in a potentially significant impact on patient outcomes and healthcare cost. The implementation of institutional protocols through a bundled approach can significantly reduce forgotten IUCs and dramatically improve patient safety.",signatures:"Kathleen A. Hromatka and Weidun Alan Guo",downloadPdfUrl:"/chapter/pdf-download/55726",previewPdfUrl:"/chapter/pdf-preview/55726",authors:[{id:"197826",title:"Dr.",name:"Weidun Alan",surname:"Guo",slug:"weidun-alan-guo",fullName:"Weidun Alan Guo"},{id:"207014",title:"Dr.",name:"Kathleen",surname:"Hromatka",slug:"kathleen-hromatka",fullName:"Kathleen Hromatka"}],corrections:null},{id:"56565",title:"Pressure Injury in the ICU: Major Reconstructive Surgery Required",doi:"10.5772/intechopen.69904",slug:"pressure-injury-in-the-icu-major-reconstructive-surgery-required",totalDownloads:1707,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Pressure injury (PI) has replaced the former nomenclature pressure ulcer, a change initiated by the National Pressure Ulcer Advisory Panel (NPUAP) however, substitutes such as pressure ulcers, decubitus ulcers, and bedsores will continue to be used by many. Increased knowledge and awareness of PIs has lead to a decline in their overall prevalence. A review of the most common risk factors, including two risk factor assessment tools, the Braden scale and the Cubbin & Jackson are presented. Diagnosing PIs must be a methodical, meticulous process in order to accurately document and monitor their progression and improvement. In 2016 the NPUAP revised the definitions as well as the stages of PIs incorporating the etiology and anatomical features present or absent in each stage of injury. Treatment strategies such as managing co-morbidities, nutrition optimization, and pain management are important aspects to consider in treating PIs in addition to thorough wound care cleansing and debridement. Highlighted are the various effective debridement options such as surgical sharp, mechanical, autolytic, enzymatic and larval debridement. Wound dressing alternatives, their advantages, disadvantages, indications and contraindications are all are mentioned. Concluding the chapter are pressure injury rates of healing, prognosis and surgical indications.",signatures:"Ashley Jordan",downloadPdfUrl:"/chapter/pdf-download/56565",previewPdfUrl:"/chapter/pdf-preview/56565",authors:[{id:"197827",title:"Dr.",name:"Ashley",surname:"Jordan",slug:"ashley-jordan",fullName:"Ashley Jordan"}],corrections:null},{id:"56101",title:"Wrong Blood Type: Transfusion Reaction",doi:"10.5772/intechopen.69653",slug:"wrong-blood-type-transfusion-reaction",totalDownloads:1437,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Blood products are frequently required in an inpatient setting for a number of serious conditions. It is of the utmost importance that providers are aware of the potential for adverse reactions and human error when ordering or administering these products. Patients who require blood products should have a signed informed consent form and a type and screen performed prior to transfusion. The patient’s identity should be confirmed using two patient identifiers. There are two major categories for blood transfusion reactions, immune-mediated and nonimmune-mediated. Common manifestations of a transfusion reaction are nonspecific and may be attributed to a patient’s other medical problems, so the index of suspicion must be high in order to identify and treat these reactions.",signatures:"Holly Ringhauser and James Cipolla",downloadPdfUrl:"/chapter/pdf-download/56101",previewPdfUrl:"/chapter/pdf-preview/56101",authors:[{id:"187661",title:"Dr.",name:"James",surname:"Cipolla",slug:"james-cipolla",fullName:"James Cipolla"}],corrections:null},{id:"56069",title:"Patient Self-Harm in the Emergency Department: An Evidence- Based Approach",doi:"10.5772/intechopen.69640",slug:"patient-self-harm-in-the-emergency-department-an-evidence-based-approach",totalDownloads:2007,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:1,abstract:"Violence, deliberate self harm, and suicide in emergency departments and hospitals is likely to remain a significant problem for health care systems well into the future. Understanding how to confront, intervene, and manage episodes of patient deliberate self harm is extremely important, and can be life-saving. Here, through a clinical vignette, and a discussion of deliberate self harm we will highlight the importance of the direct observation of such patients, containment procedures (seclusion and physical restraints), and the use of pharmacological adjuncts. We hope that this concise, practically-oriented review will provide our readers with foundational understanding of the topic, including the most important theoretical and clinical considerations.",signatures:"Ronya Silmi, Joshua Luster, Jacqueline Seoane, Stanislaw P.\nStawicki, Thomas J. Papadimos, Farhad Sholevar and Christine\nMarchionni",downloadPdfUrl:"/chapter/pdf-download/56069",previewPdfUrl:"/chapter/pdf-preview/56069",authors:[{id:"181694",title:"Dr.",name:"Stanislaw P.",surname:"Stawicki",slug:"stanislaw-p.-stawicki",fullName:"Stanislaw P. Stawicki"},{id:"202737",title:"Dr.",name:"Ronya",surname:"Silmi",slug:"ronya-silmi",fullName:"Ronya Silmi"},{id:"202738",title:"Dr.",name:"Jacqueline",surname:"Seoane",slug:"jacqueline-seoane",fullName:"Jacqueline Seoane"},{id:"202739",title:"Dr.",name:"Joshua",surname:"Luster",slug:"joshua-luster",fullName:"Joshua Luster"},{id:"202740",title:"Dr.",name:"Christine",surname:"Marchionni",slug:"christine-marchionni",fullName:"Christine Marchionni"},{id:"202741",title:"Dr.",name:"Farhad",surname:"Sholevar",slug:"farhad-sholevar",fullName:"Farhad Sholevar"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"6268",title:"Vignettes in Patient Safety",subtitle:"Volume 2",isOpenForSubmission:!1,hash:"0d2a1e477127a80d432276b11e6806d0",slug:"vignettes-in-patient-safety-volume-2",bookSignature:"Michael S. Firstenberg and Stanislaw P. Stawicki",coverURL:"https://cdn.intechopen.com/books/images_new/6268.jpg",editedByType:"Edited by",editors:[{id:"64343",title:"Dr.",name:"Michael S.",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5202",title:"Extracorporeal Membrane Oxygenation",subtitle:"Advances in Therapy",isOpenForSubmission:!1,hash:"f7c8f9c0cf1cf50455fba7e2607e9268",slug:"extracorporeal-membrane-oxygenation-advances-in-therapy",bookSignature:"Michael S. Firstenberg",coverURL:"https://cdn.intechopen.com/books/images_new/5202.jpg",editedByType:"Edited by",editors:[{id:"64343",title:"Dr.",name:"Michael S.",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. 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Firstenberg",coverURL:"https://cdn.intechopen.com/books/images_new/5351.jpg",editedByType:"Edited by",editors:[{id:"64343",title:"Dr.",name:"Michael S.",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. Firstenberg"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7878",title:"Advances in Extracorporeal Membrane Oxygenation",subtitle:"Volume 3",isOpenForSubmission:!1,hash:"f95bf990273d08098a00f9a1c2403cbe",slug:"advances-in-extracorporeal-membrane-oxygenation-volume-3",bookSignature:"Michael S. Firstenberg",coverURL:"https://cdn.intechopen.com/books/images_new/7878.jpg",editedByType:"Edited by",editors:[{id:"64343",title:"Dr.",name:"Michael S.",surname:"Firstenberg",slug:"michael-s.-firstenberg",fullName:"Michael S. 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\r\n\tOpen seas, enclosed basins as well as coastal areas are of utmost importance for human activities. Hence, since the last world war, scientists and engineers spent much effort in gaining insight on the main (and actually quite fascinating) physical phenomenon that occurs in such a kind of water body: surface waves. Long waves, wind waves, infragravity waves, earthquake-induced tsunamis, landslide-induced impulse waves are only a few examples of the wide range of water oscillations that engineers, with the help of scientists, need to face in order to guide the sustainable use of natural resources represented by water bodies. The new sensibility to climate change and integrated management are only two examples of new challenges to be faced.
\r\n\r\n\tMathematical modeling, either analytical or numerical, and experimental investigations are valuable tools that can be used to gain insight about wave generation, propagation, and interaction with the boundaries of water bodies, that are continuously and rapidly improving thanks to the technological advance.
\r\n\t
\r\n\tThis book is intended to provide the reader with a comprehensive overview of the current state-of-the-art about surface water waves, including forecasting and hindcasting of wind waves and storm surge, coastal risk analysis, and wave-structure-soil interaction.
Transition from childhood to adult life is known to be an experience engaging infinite possibilities with unpredictable outcomes. Adolescence or the time period between 10 and 19 years of age represents the nucleus of personal development from the primary inherited self toward building a complex self-identity. The response of individuals exposed to endless possibilities arising from surrounding events and phenomena is what builds up one’s character and nature. Because of the absence of experience along with emotional immaturity—both contributing to a circle of weaknesses—it is considered that teenagers embody a vulnerable population. Therefore, investing in worldwide efforts destined to assure good healthcare for this specific part of the population is well justified.
\nNowadays, the UNICEF states that 16% of the world population (1.2 billion people) is adolescents [1]. The youth’s morbidity emerges from mental health issues, depressive disorders, anxiety, and behavioral problems, which are known to affect adolescent well-being [2]. Social norms have a different impact on young people, especially depending on gender. Specifically, female teenagers have increased mortality and morbidity rates directly related to pregnancy in early stages of transition to adulthood; reports show that approximately 12 million girls aged 15–19 years and at least 777,000 girls under 15 years give birth each year in developing regions, and at the same time, unintended pregnancies affect almost 10 million girls aged 15–19 years old [3]. These concerning statistics and the subsidiary connections between pregnancy body transformation and adolescent psychological immature integrity raised awareness toward this cluster of issues and formed the basis for the sustainable development goal 3 addressed by the United Nations. Preliminary data published in 2019 show that adolescent fertility declined from 56 births per 1000 adolescent women in 2000 to 44 births in 2019; this is promising information regarding the target set to ensure universal access to sexual and reproductive healthcare services until 2030 [4].
\nIt might come as a paradox the fact that in the era of globalization and ultramodern communication devices, teenage access to health guidance and education is still facing serious obstacles [1]. International organizations are starting to use tools as Google Trends in order to identify and respond to the unmet need for proper networking and health services. Moreover, an emerging area of interest called “infodemiology” has been implemented by Eysenbach after epidemiologists came to the conclusion that health-related information seeking affects each individual’s demands for healthcare services and increases healthcare utilization [5, 6]. Assessing data in real time has become crucial under most aspects of our lives, but nevertheless, there are still low- and middle-income countries where information on an inhabitant’s health status is not available. For example, evaluations for mental disorders in people aged 5–17 years are available for only 6–7% of countries reviewed in the Global Burden of Disease project, while suicide remains the second-highest cause of death among people aged 15 to 29 globally [2, 4].
\nOver the last decades, significant attention has been drawn toward adolescent health, especially since severe social and economic consequences are involved in this matter. In several societies depending on cultural values, pregnancy in young women is considered a vector of poverty transmission from one generation to another [7]. Tendency toward school dropout, reduced employment rates, and engagement in noxious behaviors are all social issues related to adolescent pregnancy [7, 8]. Furthermore, the severe impact of all the aforementioned factors on mental health integrity under the shape of stigma or rejection are all leading causes of increased associated morbidity [8]. Articles addressing a global perspective on teenage pregnancy acknowledged the role of the family structure, whether intact or dysfunctional, on young people’s sexual behavior: it has been shown that a close relationship between parents and teenagers based on communication and support has an actual impact on diminishing teenage high-risk behaviors [8].
\nIn the attempt to draw the limits of this international concern, populational studies have estimated that the proportion of adolescent population reached a peak around 1980, from then on being predicted with a decreasing tendency until 2050; at that point, a new prominent increase is foreseen [7]. This demographic representation is, however, subject to change taking into account the alarming fluctuations in traveling populations and pandemics affecting health and life expectancy.
\nHowever, literature proves that adolescents engage in age-related risk behaviors irrespective of cultural and sociopolitical backgrounds: in Latin America and the Caribbean, adolescents play a significant role in the society since they account for almost 30% of the population; this way, it is relevant to mention a 2012 Mexican report that identified that 23% of 12–19-year-old adolescents already initiated their sexual life; however, 14.7% of the boys and 33.4% of the girls did not use contraceptive measures, and this conclusion had determined authorities to apply preventive strategies on this matter [7].
\nWhile most countries around the world struggle with reducing pregnancy and birth rates in adolescent populations, the United States of America managed to achieve a general decline in the rates mentioned above: in 2016 the birth rate of youths aged 15–19 years reached a historic low of 20.3 births per 1000 adolescents [9]; however, there are conflicting results regarding some vulnerable groups, including those teenagers who are homeless or incarcerated and those from rural areas or from small ethnic communities [10]. Here, adapting interventions and precision-focused strategies are still to be developed. In the attempt of breaking this harmful habit cycle, the United States have committed to invest more than 200 million dollars each year in abstinence programs [8]. By using a new perspective on an old problem, multiple interventions developed under legal criteria are destined to empower youths by helping them improve their decision-making abilities as well as preparing them for adulthood [9].
\nThere are studies that describe teenage pregnancy as a positive experience as well [11]; the adolescent perspective on the matter is the main indicator in this theory. Themes from the literature include the search for autonomy, peer recognition, and a place in society. In this research pregnancy is marked as a life project to provide the unfulfilled needs of youngsters. Most of the time, young women who assume motherhood are still operating at different levels—emotional, financial, and cognitive—dependent on other persons; however, there are widespread small communities that are known to recognize early marriage as a tradition, bound by religious and not civil rules.
\nIt is, therefore, a demanding challenge to solve the teenage birth problem using a single solution. Distinctive nations require distinctive measures which fit more or less depending on the surrounding macroenvironment. Taking a step back and learning from the past could help notice that over time the rates in adolescent fertility have remained high in sub-Saharan Africa at around 101 births per 1000 adolescent women [4]. At the opposite side is France with the lowest rates, marking 7 pregnancies per 1000 teenagers aged 15–19 years [11]. The pursuit of the etiology can sometimes reveal a potential connection between geographic area of residence, climate, and health issues. Nevertheless, a closer look on the cultural background of the teenage pregnancy debate is considered more appropriate in this chapter.
\nIn 2013 15.6% of first children in Romania were born to teenage mothers, this being the highest proportion in the European Union according to Eurostat [12]. A social investigation carried in 2017 in this state showed that 6 out of 10 underage mothers never had access to sexual education and reproduction health counseling [13]. The magnitude of teenage pregnancy concern has been more allegiantly expressed by statistics in 2018 when data demonstrated that with respect to women under 19 years old, 12,906 were at their first birth, 3657 at their second, 673 at their third, 63 at their forth, 7 at their fifth, and 1 at her sixth birth [14]. The current situation in this Eastern European country might result from the direct consequences of its political history, i.e., the change from communist ideology into a democracy manifesto has left traces inside the community nucleus. Years before 1989, knowledge on teenage pregnancies was scarce, but the hardship of women with unintended pregnancies who lived under Decree 770, which outlawed abortion for women under 40 with fewer than four children, went beyond imagination. When fertility became an instrument of state control, a woman’s right to decide what is best for her was no longer an option. As well as in other former Soviet countries, statistics in Romania are incomplete, but an increase in adolescent pregnancy has come to be known during the mid-1990s, and since then it reached the limits of a public health issue [1].
\nCambodia, home to the largest adolescent and young adult population in the Southeast Asian region [15], went also through some major political changes during recent decades. The health infrastructure suffered severe damage after the genocide in 1970, and its recovery had been extremely difficult since then. Women in this region confront themselves with limited autonomy, low literacy, and poor wealth status. Consequently, unintended pregnancies mark a universal issue in this country even nowadays as Rizvi et al. concluded in their study following the use of Bronfenbrenner’s social ecological model. This model was the theoretical basis for identifying factors influencing unintended pregnancies. It was in 2008 that Cambodia adopted a formal adolescent reproductive health policy, and later in 2016, the first sexual reproductive health literacy program was launched [15].
\nWhen observing adolescents in their environment, it is important to notice the fact that experiences are what characterize people the most and not their values and beliefs [1]. Beyond religion, faith, and general convictions, personal response to events surrounding oneself is what builds characters and shape personalities [1]. As mentioned above, the sensitive topic of teenage pregnancy in some perceptions has a positive side as well even if there is still an existing global health issue.
\nFactors that were described by Rizvi et al. as predisposing to unintended pregnancies could as well take part in the outbreak of teenage pregnancy, whether they are related to the microenvironment, in the interpersonal, institutional, and community levels, including partners and peers, or to the macroenvironment, in the policy or relevant legislation level [15].
\nA different picture of “young motherhood” is described by Bas et al. in a study performed in Turkey: beside a lower prevalence of adolescent pregnancies compared to World Health Organization global data, 7.9% (3.5–12%) versus 11%, there was a higher likelihood of pregnancies in late adolescent years (18–19 years); plus, the majority of women were married, and pregnancies were desired in the study population. The authors also reported early marriage as a common practice in Turkey. At the same time, the study concluded that there was a specific need for adolescent mothers to prolong hospitalization stays in order to assure proper care and nutrition support for the newborn; 25.3% of the study group subjects were readmitted in the hospital 1 month postpartum due to infant inadequate weight in 34.4% of the cases [16].
\nAn unfavorable fetal outcome following a teenage pregnancy—whether related to preterm delivery with low birth weight or a low Apgar score at 5 minutes or to a possible stillbirth—could provide stressful situations for any woman, especially an adolescent. Literature presents controversial information regarding adverse birth outcomes, and some studies conclude that once results are adjusted for other factors correlated with adverse birth events, early motherhood is not correlated with poorer neonatal status [17].
\nA large cohort study performed between 2009 and 2014 in Canada on 25,263 women concluded that teenage mothers had higher rates of depression during pregnancy (9.8%) compared to mothers aged 20–34 years (5.8%) and ≥ 35 years (6.8%) (p < 0.001) [17]. A possible explanation of these results might reside in the fact that more than 70% of adolescent pregnancies in Canada are unintended. How is it then, possible, that even in high-income countries where access to all kinds of informational materials is freely available that teenagers still engage in disruptive practices? The response to this question seems to be more complex than it looks.
\nOn the matter of teenage mental health, the clash between civilizations is eloquent and understanding of what people grew up to value as their cultural legacy can prove to be an enriching and enlightening experience in the search of socially distinguishable factors involved in human behaviors.
\nThe repercussions of an active reproductive teenage life on the psychological level usually manifests before giving birth, when women experience blame, critics, and social exclusion [7]. After delivery, motherhood responsibilities that sometimes are not shared by male partners can provide feelings of overwhelm, fear, anxiety, guilt, and shame [7]. In time, teenagers get to experiment depressive disorders originating in feelings of failure due to reduced employment opportunities and an inability to reintegrate in the social activities from before or due to denial of current situation [7, 8]. This is consistent with a study performed by Sanchez et al. where 41.7% of pregnant teenagers had emotional alterations due to financial factors, while in 7.8% of the study group, problems related to partners and family support were the main identified stressors [18].
\nGiving birth in adolescence implies peculiar events strictly dependable on the ability of the growing body to support the mechanism of labor. While in some states cesarean section is a compulsory medical management of birth in adolescents, studies performed in other countries recorded high rates of cephalopelvic disproportion (18.5%) or prolonged labor (16%) leading to emergency cesarean section delivery [7, 16]. Adding the increasing trend in practicing defensive medicine especially defensive cesarean sections, it comes as no surprise the report coming from a tertiary care unit from Bucharest revealing 71.6% rate of cesarean section in the adolescent study population [19].
\nIn the search of best methods to be used in order to reduce the psychological vulnerabilities of teenagers, screening interventions play a significant role [19]. Nevertheless, therapeutic management is compulsory for every diagnosed patient.
\nAcross the globe, Thailand has the highest rate of adolescent births in Southeast Asia and second-highest in the world [20]. It was the appropriate context to certify the usefulness of a questionnaire-based strategy implemented by a John Hopkins work team in order to assess birth preparedness and complication readiness (BPCR) in young mothers. Results obtained were encouraging, showing that a good BPCR score was present in 78.4% of cases, and further correlated mostly with pregnant women undergoing ≥4 antenatal consultations (odds ratio 3.2, 95% CI 1.13–9.05, p = 0.023) [20]. In other words, it is reassuring to find that with correct prenatal monitoring, not only good perinatal obstetrical and neonatal outcomes can be foreseen but also prevention of psychological disturbances can be achieved as well.
\nOne of the best organized healthcare systems around the world is certainly the one from Sweden [21]. Oddly, this state has the highest abortion rate in Western Europe, while 23% of parous women never used any contraception method [21]. New patient-centered instruments were rapidly assessed in order to be implemented in primary care, and since nowadays 5% of all Internet searches are health-related, researchers considered that a reproductive life planning tool using a website could best benefit patients. Follow-up conclusions showed this strategy to be positively received by midwifes who in this country are licensed to prescribe contraceptives [21] and are in the frontline of promoting medical care. Accepting and exploring online networking as a supportive engine to promote healthy habits and access to medical guidance can actually make a difference. This is important especially in developed countries where education and access to information are no longer restricted areas of lifestyle.
\nResuming the facts on perinatal depression, it is safe to say that patients suffering from this medical condition would best benefit from a multidisciplinary approach at the time of delivery or even earlier [21]. Birth-related psychological changes and further psychiatric ramifications represent a less explored field by obstetrician and midwives; this could explain why in many areas around the globe physicians tend to underestimate or even fail to recognize signs and symptoms leading to proper early diagnosis. Repercussions gravitate not only around the mother but also around the well-being of the fetus and of the entire family. Involvement of mothers of young age transforms this subject into a more confounding one.
\nAlthough information on the subject is still scarce, there are two recent trials presenting relevant and promising insights. The first one [22] was based on the screening for perinatal depression; a number of 8580 adults and 772 adolescents were assessed during pregnancy and 6 months after birth. Results showed that the incidence of depression in the teenage group was almost three times higher than the one in the adult group (17.7 and 6.9%, p < 0.001). Furthermore, despite the fact that there were no observed differences between the severity of depression, examination of patients diagnosed with perinatal depression revealed that adolescents had significantly different attitudes to pregnancy, motherhood, and parenting skills than adults. This trial draws equal conclusions with other similar assessments that support the body of evidence that younger maternal age is a strong predictor of adverse pregnancy outcomes [22]. This fact is also suggested by the outcome following remission of depression symptoms in the study groups: no improvement on parenting skills or motherhood adjustment was noted.
\nThe second trial [23] is an ongoing cluster randomized trial based on a hybrid “effectiveness-implementation” plan specifically destined to assess a particular intervention package designed for teenagers with perinatal depression. The objectives of this study are directed toward improving maternal depression symptoms, and by achieving that, enhancing parental skills at 6 months postpartum assessment is also anticipated. Postnatal follow-up on the subjects is expected to end August 2020, and the results will be of interest given that it is considered to be the first trial to address the particular and unique needs of depressive pregnant adolescents.
\nAdhering to noxious behavior related to smoking, alcohol, and drug consumption, later favoring uncontrolled sexual practices culminating in unintended pregnancies can point out the preamble of depressive or anxiety disorders in adolescents [8]. Further interruption of education with associated guilt, absence of family support, and social rejection all contribute to predispose teenagers to misconduct [7].
\nThere is strong evidence that girls are at a higher risk of developing depressive symptoms than their male counterparts, possible explanations being drawn after investigation of cognitive vulnerability deduced from negative ruminating style and negative cognitions [24]. There are also pregnancy and birth related events like premature delivery or giving birth to a low birth weight baby requiring additional neonatal support, which once added to the moment and mode of delivery itself – vaginal or by cesarean section – provide disturbances that may affect the psychic in a negative manner.
\nFacing unpredictable life situations like maternity sometimes interferes with other preexistent teenager struggles like body image concerns and eating or learning disorders [24].
\nScreening tools for early detection of depression have long been studied and improved, but it is a reality that beside being laborious, most of them can only be applied in practice by properly trained medical personnel—in truth, by psychologists and/or psychiatrists. In spite of efforts made to raise awareness on the subject of perinatal adolescent depression during the last decade, interestingly, only half of depressive adolescents are diagnosed before reaching adulthood [25], and this reality undeniably requires for clinical monitoring on any minor clinical sign of mood change.
\nOn the general topic of child and teenage major depressive condition, numerous studies and interventional trials have been conducted. Comprehensive modern strategies integrate psychoeducation as part of patient understanding of disease. Providing information about the associated risks and the importance of treatment has shown to improve patient adherence to the treatment course [24].
\nPsychotherapy and medication are available options of the therapeutic plan: cognitive behavioral therapy—face to face or using online platforms—and interpersonal therapy for adolescents explore the etiology of the disorder, many studies having already confirmed their effectiveness [24]; their applicability in perinatal depression is timidly starting to be fused in current medical practice.
\nOn the other hand, antidepressant medication is far from reaching conclusive recommendations as many clinicians are still resistant in using it since results are sometimes suspicious with some studies even suggesting a possible association with emergent suicidality [24]. The argument in relation to medication was brought into attention with the sole purpose of underlying therapeutic limitations when facing perinatal teenage depression and further intricacy of the disorder.
\nWith restricted use of therapeutic options, complementary medicine has gained space in medical practice. There are an enormous number of products available on the market which are said to equivalate or even outreach the potential of recognized medical treatments. Only few studies actually compared the efficacy of these natural products, but what’s more, evidence regarding their safety and side effects is scant. Adolescents and their parents who are reluctant to medication use sometimes opt for dietary and herbal supplements which they consider “safer,” but little to no data are available on the actual effects they have on psychiatric adolescent disorders [26, 27].
\nIn many areas around the globe, in particular in low-income countries, tradition and human connection with the environment are bound to influence medicine and the response to illness. People there consider it legitimate to refer to mother nature whenever necessary. Most interestingly, their dietary habits have come to influence clinicians around the world: having the potential to interact with other medication, physicians struggle to identify concomitant use of natural remedies when questioning patients. For instance, some authors managed to identify complementary medicine supplements most commonly used in the treatment of depression, anxiety, and attention deficit/hyperactivity disorder (ADHD). These include omega 3 fatty acids for depression and ADHD, St. John’s wort, and S-adenosyl-L-methionine for depression only, while kava root, valerian root, and passionflower root were identified for generalized anxiety disorder [27, 28]. In the absence of regulatory oversight, there is a risk for all aforementioned supplements to induce serious adverse health effects.
\nTraditionally treated or using up-to-date medical guidelines, teenage perinatal depression is a field still waiting to be explored and conquered. The journey to recovery is usually challenging; therefore assertive parent and peer support have long shown their value in facilitating the process [24].
\nThe importance of health and sexual education in the life of teenagers has already been mentioned above, but what are the available resources we can dispose of? This matter is far more complex than it might seem at first sight. Religion, for example, has long been influencing human perception on sexuality aspects; in Ireland, Catholic “morally appropriate” sexuality education had existed for decades before the official implementation of “relationships and sexuality education” curriculum back in 1994 [29]. As Hakansson observed in his study on social judgments over abortion and contraceptive use, where there is a knowledge gap, people tend to find explanations in common beliefs in the society—these ideas being many times based on religious and cultural values [30]. This explains why current sexual education in Kenya is still focused on abstinence even though it has not been proven to reduce unintended teenage pregnancy rates [30].
\nIn other parts of the world, accurate information on this topic is provided: the Swedish National Agency for Education has introduced biology classes in the school curriculum in which methods for preventing unwanted pregnancy are discussed starting with 7–9 school years; further in upper secondary school, topics about body changes during pregnancy are also approached [31]. With a long history of compulsory sex education starting in 1955, Swedish system has managed to adapt not only its classes to the evolving sociopolitical norms but also its teaching methods: from integration of specific subjects in generally known scientific background to individual lessons [31].
\nSolutions in educational system that work in one country cannot always be applied in other countries as well; differing cultural, political, and historical climates have been cited to influence this process even though scientific fundamentals of human sexual response are universal [29, 32].
\nThere is clear evidence that proper sexuality education has a positive impact in preventing unintended adolescent pregnancies [33]. However, beside fundamental school curriculum, there are other factors to consider: the role of teachers in providing knowledge, support, and counseling as well as the involvement of physicians, parents, and outside facilitators in this process.
\nAlthough Sweden’s sexuality education remains open, with no formal curriculum, teachers struggle to provide conventional information, with no specialized training taking place at the university level [29]. Society’s influence on teachers often determines them to adopt stigmatizing attitudes and feel uncomfortable teaching comprehensive sexual education [30].
\nThe absence of training is notable in medical schools as well; a worldwide survey found that up to 30% of medical schools globally have no sexual health curriculum [32]. Sexuality being a critical topic for physicians who deal with issues pertaining to reproduction and mental health, specialty education on this subject should be mandatory for aspiring clinicians [32]. To support this matter, research shows that 85% of adult patients from a US survey claimed that they would want to talk to their physician if they had a sexual problem, while 71% felt that their doctor would dismiss their concerns [34].
\nIn the light of these disadvantageous aspects, parents are the primary source of sexuality information for their children in the United States; studies showed that transmission of information and values from parent to child can make results be more generalizable to the real world than if knowledge was taught in clinic-based sessions [35]. The Greek society, however, does not share the same beliefs: 80% of parents included in a survey considered that school is not an appropriate setting for sexual education, entrusting this task to psychologists and specialized organizations [36].
\nSupplementing or even replacing school lessons on sexuality, health organizations and groups often manage to implement educational initiatives to support and counsel adolescents [29].
\nHome education is not a tradition in Japan either; with human sexuality education introduced in 1970, school courses focus on pregnancy-related topics starting on the first year of middle school at ages 12–13 and later on the third year of middle school at ages 14–15 [36, 37].
\nAlthough health education is not the same around the world, its vital role in the future of adolescents is not to be doubted. Good understanding of sexual health promotes informed decision-making and might prevent misconceptions, fear, and unsupported cultural beliefs which are mentioned in literature as key contributors to the increase in cesarean section rates [38].
\nIn other words, there are numerous variables which interfere with free access to education, especially health education. Along with school and any other institutions which provide knowledge on this issue, the authors, as clinicians, consider that it is also the responsibility of each physician to advise their teenage patients as well as their parents with respect to sexuality matters.
\nPoor acceptability of perinatal depression as a serious pathology involving life-threatening risks both on the mother and child remains a striking concern even in 2020. With 8–47% self-reported depression in perinatal teenagers [39], raising awareness among healthcare providers is legitimate. Boundaries between specialties should be seen less stringent, and as an obstetrician, monitoring of women during pregnancy and puerperium should aim to objectify both physical and mental well-being of the patient. Reaching a patient in a holistic manner can only improve the road to best medical outcomes.
\nPerinatal depression, although an affliction itself, should be seen as a hallmark of psychologic instability in particular when adolescent women are targeted. Dissolution of heterogeneity on the matter of access to medical care is the most powerful obstacle to overcome by physicians in the fight for health and good quality of life.
\nYoung women having children are twice exposed to unfavorable health outcomes: first by acquiring obstetrical morbidity and mortality risks and second by having a gender-associated higher risk of developing depression during adolescence. Therefore, it is compulsory for teenage pregnant girls to become a priority on the axis of health organizations’ millennial goals.
\nQuestioning what remains to be done in this framework is an exceeding perspective in 2020; identifying and acting on key points like family authority and education environment with great impact on adolescent growth and transformation are reasonable steps to be taken in preventing teenage pregnancies. Investing in adolescents not only under economic aspects but also spiritually by providing time, receptivity, and concomitant understanding to their needs is an action that must be involved in the process.
\nWe live in the time when artificial intelligence marked convincing results in replacing humans in various fields of activities; medicine does not make an exception, and with further comprehension that people worldwide are more connected than ever before, good practice of expert solutions has only one option: to thrive in the battle of matter over mind.
\nThe authors declare no conflict of interest.
Traumatic brain injury (TBI) is frequently associated with depressed level of consciousness, compromised protective airway reflexes or apnea, which can increase the risk of aspiration or result in hypoxemia and worsen the secondary brain damage. Therefore, patients with TBI and Glasgow Coma Scale (GCS) ≤ 8 have been traditionally managed by prehospital or emergency room (ER) intubation. This practice is also reflected by the current guidelines: the American College of Surgeons Committee on Trauma Advanced Trauma Life Support (ATLS) recommends intubation for patients with a GCS of 8 or lower for airway protection [1]. Also, the practice management guidelines of the Eastern Association for the Surgery of Trauma give a level 1 recommendation for endotracheal intubation of patients with severe cognitive impairment (GCS ≤ 8) [2].
However, the potential benefit of an intubation in TBI, is also associated with risks: Difficult or failed endotracheal intubation may cause hypoxemia, aspiration, and hypotension and requires admission to the intensive care unit (ICU). In fact, there is no direct evidence supporting routine intubation of all patients with a GCS ≤ 8. Consequently, recent evidence challenged the practice of a strict GCS threshold for intubation and even suggested that routine endotracheal intubation for GCS ≤ 8 in TBI may be harmful [3].
The primary goal in the prehospital care of the trauma patient is to secure adequate ventilation until transfer to hospital care. To achieve this goal, various techniques for airway establishment and subsequent ventilation can be performed: endotracheal intubation has been considered as the gold standard. However, ventilation may also be achieved by less invasive and time consuming procedures such bag-valve mask (BVM) ventilation with the optional use of oropharyngeal (OPA) or nasopharyngeal (NPA) adjuncts. More advanced techniques include supraglottic airway (SGA) devices. There is a wide range of medications available to facilitate intubation prehospital or in the ER.
To date, there are no evidence-based guidelines for TBI patients regarding standardized airway management in the prehospital setting or in the ER. This explains also why indications and techniques for airway establishment vary in different systems and countries around the world. In the United States of America (USA) prehospital care is usually provided by emergency medical technicians or trained paramedics, whereas prehospital care in most European countries is provided by physicians [4]. Following these differences of American and European Emergency Medical Service (EMS) systems, the US prehospital care strategy follows more “scoop and run approach” with prioritizing rapid patient transport to trauma centers. In Europe the priority lies more on field triage, on scene assessment and initiation of procedures such as intubation “stay and play approach” [5].
This chapter will address the question what airway management strategy best meet the patients need and is associated with most favorable outcomes in TBI. Indications and optimal method of securing the airway prehospital and in the ER will be discussed. In addition, technical aspects including medication for pretreatment, induction, paralysis and sedation for endotracheal Intubation in the presence of TBI will be outlined.
Advanced prehospital care has been practiced for several decades in Western countries. In TBI particularly, prehospital airway management is one of the most critical aspects that determine patient outcomes. The importance of the airway management is reflected by the Advanced Trauma Life Support (ATLS) algorithm [1], in which the airway takes priority over any other therapeutic interventions.
General prehospital TBI guidelines [6] are emphasizing avoidance and treatment of hypoxia, prevention and correction of hyperventilation, and avoidance and treatment of hypotension. The implementation of these prehospital guidelines showed that adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission [7]. These findings support the widespread implementation of the prehospital TBI treatment guidelines. However, specific evidence-based guidelines are needed to establish the optimal airway management in the prehospital setting.
Patients require an advanced airway under two sets of circumstances: failure to maintain a patent airway and the inability to oxygenate and ventilate the patient adequately [8]. While endotracheal intubation in the OR is a very safe and straightforward procedure with very low complication rate, emergency intubation of an unstable patient in the field is linked to a high rate of complication with up to 25% mortality in some studies. Emergency intubation remains a hazardous maneuver even under the best conditions. And no matter how skilled the prehospital team is, best conditions are seldom encountered in the field. This is why endotracheal intubation should ideally performed by skilled providers in patients who are likely to benefit from this technique. In a prehospital setting the indication to establish an airway is not always that obvious and depends on multiple factors (Figure 1
Severity of patients’ condition and the presence of hypoxia: Traumatic brain injury (TBI) is frequently associated with depressed level of consciousness, compromised protective airway reflexes or apnea, which can increase the risk of aspiration or result in hypoxemia and worsen the secondary brain damage. During the past 45 years, the quantitative GCS as a simple and practical numeric method for assessing impairment of the level of conscious has become the universal criterion for mental status assessment [10]. Consequently, the GCS is also a frequently used score to decide whether an intubation should be performed or not. According to the ATLS [1] and the practice management guidelines of the Eastern Association for the Surgery of Trauma [2] intubation is recommended for GCS ≤8. However, there is no scientific evidence supporting this practice. The dogma that patients with a GCS ≤ 8 are at higher risk for aspiration or hypoxic injury has now been challenged. A prospective study from Hong Kong, in 2012, showed that of 33 patients with a GCS ≤ 8 36.4% had intact airway reflexes and potentially capable of maintaining their own airway, whilst many patients with a GCS > 8 have impaired airway reflexes and potentially be at risk for aspiration [11].
The need for immediate establishment of an obstructed or impaired airway or hypoxia is unquestionably associated with better outcomes. However, performing an intubation in a suboptimal environment in the field, especially if performed by paramedics, may be challenging and require multiple attempts and in some cases may result in the loss of airway with catastrophic consequences. A difficult intubation may result in hypoxemia, aspiration, and hypotension, factors that may contribute to worse outcomes. Also, prehospital intubation and hand ventilation is often associated with hyperventilation and hypocapnia, which could worsen brain edema and secondary brain damage. Finally, prolonging the prehospital time and delaying definitive care, may have adverse effects on the patient, especially in the presence imminent herniation due to increased intracranial pressure (ICP) or an ongoing hemorrhage.
In conclusion, it is important to identify those patients who might benefit from prehospital endotracheal intubation and those who can potentially be harmed by the procedure. At this moment there is no class I evidence supporting any specific approach. It might be appropriate to attempt prehospital intubation in a small number of selected patients with imminent airway obstruction or hypoxia not responding to oxygen administration.
Training and skills of the EMS personnel and the available equipment: In the United States of America (USA) prehospital care is usually provided by emergency medical technicians for basic life support (BLS) or trained paramedics for advanced life support (ALS), whereas prehospital care in most European countries is provide by physicians. Basic providers are restricted to splinting, bandaging, alignment of displaced limbs, the administration of oxygen including BVM ventilation, chest compression and the use of an automated external defibrillator (AED) in case of cardiac arrest. However, especially in the USA many of BLS providers have obtained an intermediate level (EMT-I); these individuals can obtain a more definitive airway such as using a SGA device or even perform endotracheal intubation. Paramedics are trained and performed endotracheal intubation. However, very often many paramedics, especially in areas with no large trauma volumes may not use this skill very often and may become less competent with the procedure. On the other hand, especially an experienced physician proficient with endotracheal intubation, is more likely to perform an intubation more liberally, often unnecessarily. In the United States, prehospital care strategy follows the principle of “scoop and run” with prioritizing rapid patient transport to trauma centers and minimal interventions on scene. In Europe there is a strong element on field triage and initiation of more advanced therapeutic interventions, such as intubation. This prehospital strategy is also known as “stay and play”. A matched cohort study compared patients with isolated severe TBI in Switzerland and the United States [12]. In line with the described differences in prehospital strategies, patients in Switzerland had significantly longer scene times (23 vs. 9 minutes, p < 0.001) and prehospital endotracheal intubation was more frequently performed (31% vs. 18.7%, p = 0.034). However, no significant differences in outcomes were observed between the two cohorts. The results what prehospital strategy should be prioritized and if an endotracheal intubation should be performed remain controversial, although there is evidence that a “scoop and run” approach is preferable for penetrating trauma. In these scenarios the number of meaningful interventions that can be made by prehospital providers is limited and rapid transportation to the hospital is the most important aspect, because in-hospital surgery is typically needed for hemorrhage control.
Safety and environment on scene: The safety aspect on scene, as well as the transportation mode and the expected time to reach the next hospital are important for considering airway interventions on scene. Especially for longer transports, the time-saving aspect of the scoop and run approach without airway interventions becomes less important and early establishment of an airway may improve patient outcomes.
Prehospital airway-management. The indication to establish an airway in a prehospital setting depends on: the severity of patients’ condition and the presence of hypoxia; the training and skills of the EMS personnel including the available equipment; and the safety and environment on scene. Figure provided by Clerc EMS Monthey, Switzerland.
Considering all factors above, complexity of the decision to perform a prehospital intubation becomes obvious, and it is not surprising that the literature on this topic remains contradictory. A retrospective multicenter study including 13,625 patients with moderate to severe TBI showed that prehospital intubation was independently associated with a decrease in survival [13]. Several other studies implicated out-of-hospital intubation as a factor associated with negative outcomes [14, 15]. In a recently published study prehospital airway management in severe TBI patients did not have a significant impact on mortality or long-term neurological outcomes [16]. Other investigations have also demonstrated no difference or even improved outcomes with field intubation [17, 18].
Besides intubation, different other options for airway management are available in a prehospital setting. The simplest approaches such as the jaw thrust or chin lift maneuver are included in the first aid. Oropharyngeal (OPA) or nasopharyngeal (NPA) adjuncts may be inserted orally or nasally to secure an open airway. More advanced airway techniques include the establishment of an airway using an SGA device and finally the performance of endotracheal intubation. In particular cases, a surgical airway must also be considered. A major challenge in prehospital airway management is to determine the appropriate approach for the individual patient in the present environment and setting. Table 1 shows various airway management techniques and summarizes advantages and disadvantages in prehospital use.
Airway management techniques | Skills | Training needed | Time needed | Possible complications | Level of sedation/unconsciousness needed | Equipment needed | Protection against aspiration and airway shutdown | Ventilation possible without face mask |
---|---|---|---|---|---|---|---|---|
Trauma jaw thrust, trauma chin lift | ||||||||
Oropharyngeal airway, Nasopharyngeal airway | ||||||||
Laryngeal mask, laryngeal tube | ||||||||
Endotracheal intubation, surgical airway |
Overview of different airway management techniques—advantages and disadvantages in prehospital use.
A recently published systematic review [19] was assessing comparative benefits and harms across three different airway management approaches (BVM, SGA, and endotracheal intubation) for patients with trauma, cardiac arrest, or medical emergencies requiring prehospital ventilatory support or airway protection. Overall, 99 studies involving 630,397 patients from 1990 to September 2020 were considered for analysis. The evaluated outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Different meta-analyses were stratified first by study design (RCTs or observational studies), and then by emergency type (cardiac arrest, trauma, medical) and population age (adult, pediatric, mixed-age). All meta-analyses outcomes were reported as favoring one of the two compared approaches, or no difference. Sufficient evidence was not available to address all outcomes and all patient characteristics, provider characteristics, and variations in techniques that were specified a priori. For adult trauma patients 1-month post incidence survival was not different when BVM was compared to endotracheal intubation. Other comparisons for adult trauma patients did not show sufficient evidence to favor an airway management strategy over another. Potential harms of airway management for the entire study population were also compared. When comparing BVM vs. SGA and BVM vs. endotracheal intubation, no difference was found. When comparing SGA to endotracheal intubation, SGA was superior in terms of multiple insertion attempts; endotracheal intubation was superior in terms of inadequate ventilation. No difference was recorded for aspiration, oral/airway trauma and regurgitation. The authors concluded that the currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. However, most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.
Similar to the prehospital setting the standard indications for an advanced airway establishment in the ER, include low GCS, failure to maintain a patent airway and the inability to oxygenate and ventilate the patient adequately. In the presence of a TBI a diminished level of consciousness with the concern for the loss of airway control is very common and likely the most frequent indication for ER intubation. Therefore, the GCS is most commonly used to decide whether an intubation should be performed or not.
Patients with TBI and a GCS ≤ 8 have been traditionally managed by ER endotracheal intubation. However, this practice is based mainly on expert opinion and long-standing dogma. There is very little evidence to support this policy! Recent work has challenged this practice! A recently published study including patients with isolated severe head injuries suggested that routine endotracheal intubation in the ER for GCS of 7 and 8 may be even harmful [3]. In this study 2727 patients with GCS 7/8 and isolated blunt head trauma were included. Overall, 1866 (68.4%) patients were intubated within 1 hour of admission (immediate intubation), 223 (8.2%) had an intubation >1 hour of admission (delayed intubation), and 638 (23.4%) patients were not intubated at all. After correcting for age, gender, overall comorbidities, tachycardia, GCS, alcohol, illegal drug use, and head injury severity, immediate intubation was independently associated with higher mortality (OR 1.79, CI 95% 1.31–2.44, p < 0.001) and more overall complications (OR 2.46, CI 95% 1.62–3.73, p < 0.001).
A study [20] evaluating a general trauma population with GCS of 6–8 came to a similar conclusion. An intubation within 1 hour of arrival was associated with an increase in mortality and longer ICU and overall length of stay compared to patients without an intubation. The authors also performed a subgroup analysis of patients with head injury and found similar results to that of the overall trauma population.
These two studies showing worse outcomes associated with immediate intubation and suggest that the existing GCS threshold to mandate intubation in patients with isolated head injuries should be revisited.
Beside the GCS, additional clinical criteria may help to guide the decision to intubate TBI patients in the future. A recently published study showed that head abbreviated injury scale (AIS), tachycardia and younger age were independent clinical factors associated with intubation [3]. These factors could potentially be taken into account to formulate a more selective approach to immediate intubation. In the mentioned study a policy of intubating all isolated blunt head injury patients ≤45 years with head AIS 5 and GCS 7 would have improved intubation management, with 7 immediate instead of delayed intubations and only three potentially unnecessary intubations. If these defined criteria are met (high specificity), an early intubation should be strongly considered. On the other hand, the defined criteria are not suitable to identify patients who definitely do not require an intubation (low sensitivity). Future research should focus on defining more adequate clinical parameters to identify patients requiring immediate intubation and should avoid fixed GCS threshold.
Muakkassa et al. [21] compared trauma patients who were intubated because of combativeness, and not because of medical necessity. In line with the findings above intubating for combativeness was associated with longer hospital LOS, increased rates of pneumonia, and worse discharge status when compared with matched non-intubated patients. It appears that the risks and adverse events of intubation may outweigh the potential benefits of intubation in specific trauma populations.
Therefore, the following potential risks associated with intubation in TBI patients need to be considered by every health care provider. Laryngoscopy and the endotracheal tube can cause a sympathetic or parasympathetic stimulation. Sympathetic stimulation may increase heart rate, blood pressure [22] and ICP [23], whereas parasympathetic stimulation can trigger bronchospasm or hypotension. Especially the increase in ICP from the sympathetic surge can cause an increase in cerebral blood volume, cerebral edema, and development of worsening hemorrhage or hematoma. Finally, both, sympathetic and parasympathetic stimulations may increase mortality and brain injury.
Ventilation after intubation need to be monitored closely, because both hyper- and hypoventilation can contribute to worse outcomes. Severe hyperventilation (arterial pCO2 below 25 mm Hg) should be avoided due to the risk of vasoconstriction and cerebral ischemia. In general, a normo-ventilation with an arterial pCO2 within 35–45 mm Hg should be targeted. However, mild hyperventilation (arterial pCO2 within 30–34 mm Hg) is commonly used to address high intracranial pressure and may potentially be beneficial [24]. More important to address the elevated ICP in TBI patients is the initiation of hyperosmolar therapy with mannitol or hypertonic saline when additional bleeding is suspected [25].
Technical aspects and medications for endotracheal intubation carries also risks for TBI patients. The following section gives an overview including recommendations for pretreatment, induction, paralysis, and sedation of patients with TBI to prevent secondary brain damage.
Endotracheal intubation remains the gold standard for airway management in trauma patients and should be performed via the oral route and a manual in-line stabilization maneuver [26]. Rapid sequence induction (RSI) is widely used for emergency intubation and often considered as the gold standard for trauma patients. This technique uses a fast acting anesthetic in combination with a fast acting relaxant to achieve rapid intubation. Only a few people are aware that this technique was formally described by P. Safar back in 1970 [27]. The primary goal of this technique was to prevent regurgitation during induction of anesthesia in patients with bowel obstruction. Hypoxemia and hypotension were hardly considered at that time, when advanced monitoring and pulse oximetry were still tools of the future. From today’s point of view, this technique is not ideally suited to prevent hypoxemia and hypotension. While in standard OR practice, such short events will hardly result in more than a check on the Q/A sheet, they may have devastating consequences on outcomes in patients with TBI.
In addition, complication rate increases significantly with the number of intubation attempts, with a sharp increase if more than 2 attempts are needed [28]. This suggests that first pass success should be the gold standard in emergency intubation, and return to basic maneuvers or surgical airway should be considered if 2 attempts have failed.
Another important aspect is efficient airway clearance before intubation, which has been shown to significantly increase first pass success [29]. That is why suction of the airway, while having little relevance in the OR can be a game changer in emergency intubation.
Good oxygenation throughout the procedure is paramount in brain injured patients, so meticulous attention should be paid to optimizing precondition. A recent study [30] has shown that when intubation is attempted in a patient with a SpO2 < 93%, there is almost 100% incidence of severe hypoxemia while incidence goes down to 17% if SpO2 is 95% or more. While optimizing oxygenation status may take some time, it certainly pays off in terms of patient outcome.
Last but not least a close monitoring during intubation is mandatory. Studies have shown that episodes of hypoxemia during intubation attempts often go unrecognized, both in the field and in the ER. Furthermore, after intubation attention should be taken to avoid hyperventilation as it can cause hypocapnia and thus cerebral vasoconstriction; it also can impair venous return leading to hypotension. As trivial as it might seem, having a team member watching the vital signs is an important factor in the intubation process.
In the following section medication for pretreatment, induction, paralysis and sedation for endotracheal intubation in the presence of TBI are discussed.
There is currently no evidence to support the use of intravenous lidocaine as an intubation pretreatment for RSI in patients with TBI [23]. High-dose fentanyl (at 2–3 mcg/kg) can help to blunt the sympathetic stimulation of intubation and is currently recommended for neuroprotection in patients with increased ICP.
In TBI the induction with etomidate is popular all over the world because of its mild hemodynamic profile. Particularly, in TBI a drop in mean arterial pressure (MAP) and the subsequent decrease in cerebral perfusion pressure (CPP) may have devasting consequences. It’s important to be aware that etomidate has no analgesic properties, and neuroexcitation may need to be addressed separately.
Ketamine for induction is a good option, with the additional benefit of analgesic properties. The concern of sympathetic stimulation, leading to an increase in ICP is no longer valid. On the contrary, ketamine may, in fact, be neuroprotective due to an increase in MAP and CPP [31], without an increase in cerebral oxygen consumption or reducing regional glucose metabolism [32]. Ketamine may best be used for induction in the presence of hypotension because of for the described effect of increasing MAP and CPP [33].
For paralysis succinylcholine or rocuronium can be utilized [34]. Succinylcholine, as a depolarizing neuromuscular blocking agent has the advantage of rapid onset and offset properties, which is beneficial in TBI patients regarding early neurological examinations. Rocuronium on the other hand can lead to delays in proper neurological examinations due to prolonged paralysis. A retrospective study of 2016 compared 233 TBI patients requiring intubation in the ER. RSI was either performed with succinylcholine or rocuronium. Overall mortality rate was similar between the two groups. However, for patients with a high head AIS score (4–6), succinylcholine was associated with increased mortality compared with rocuronium (44% vs. 23%, odds ratio (OR) 4.10, 95% confidence interval (CI) 1.18–14.12; p = 0.026). Prospective studies are need to clarify these findings.
Propofol in TBI patients for post-intubation sedation is widely used and has the advantage of rapid onset of action and short duration of action. However, since it has no analgesic effect, it needs to be combined with medication for pain control. Furthermore, care should be taken in hypotensive patients because it may lower the MAP and subsequently the CPP. For post-intubation continuous sedation, a combination of propofol and fentanyl in the normotensive or hypertensive patient is therefore recommended. Fentanyl is a potent analgesia without appropriate sedation properties. While the hemodynamic properties of fentanyl are relatively stable, a decrease in MAP and HR frequently occur due to the cessation of the sympathetic stimulus triggered by pain. In addition, an increase in ICP has been described in several studies. A minimal appropriate dose for TBI patients is therefore recommended.
In hypotensive patients a combination of midazolam and fentanyl or ketamine alone is a good option. Midazolam as a sedative has the additional benefit of anxiolytic and anticonvulsant properties. Compared to propofol the effect on ICP and CPP are comparable. However, it’s important to have in mind that the onset and offset action of midazolam is initially relatively fast but tissue accumulation over time may be associated with delayed awakening. This is particularly disadvantageous in patients with TBI, as rapid clinical assessment after cessation of the drug is wanted.
A relatively new approach for emergency intubation is the delayed sequence induction (DSI) technique described by Weingart and colleagues [35]. In contrast to RSI, the technique of delayed sequence intubation temporally separates administration of the induction agent from the administration of the muscle relaxant to allow adequate pre-intubation preparation. This technique uses ketamine sedation to optimize preoxygenation with CPAP or assisted ventilation before muscle relaxant is given and intubation performed. Recent studies have shown an improved safety profile in emergency intubation using this technique. A ketamine-only breathing intubation, in which ketamine is used without a paralytic is another promising alternative. In this case the patient continues to breathe spontaneously, while ketamine provide hemodynamic benefits compared to standard RSI and is also a valuable agent for post-intubation analgesia and sedation. When RSI is not an optimal airway management strategy, ketamine’s unique pharmacology can be harnessed to facilitate alternative approaches that may increase patient safety [36].
Airway control is particularly important for patients with TBI because hypoxemia and hypercarbia may cause secondary brain damage.
In a prehospital setting the indication to establish an airway depends on multiple factors such as (a) severity of patients’ condition including the presence of hypoxia, (b) the training and skills of the EMS personnel including the available equipment, (c) the safety and environment on scene.
In the presence of a TBI a diminished level of consciousness with the concern for the loss of airway control is very common and likely the most frequent indication for intubation. Traditionally patients with TBI and Glasgow Coma Scale (GCS) ≤ 8 have been managed by prehospital or ER endotracheal intubation. However, recent evidence challenged this practice and even suggested that routine intubation may be harmful. There is evidence that intubation according to a strict GCS threshold is associated with risks and adverse events that may outweigh the potential benefits of intubation in TBI patients. Future research should focus on defining more adequate clinical parameters to identify patients requiring immediate intubation and should avoid fixed GCS threshold. Furthermore, less invasive airway management strategies such as BVM ventilation or the use of SGA devices may be equally effective and potentially associated with less complications. The cornerstone of prehospital airway management should focus on aggressive prevention and treatment of hypoxemia, hypotension, and, if the patient receiving positive pressure ventilation, prevention of hyperventilation. If an intubation is performed in a TBI patient induction with etomidate or ketamine in the presence of hypotension is recommended. For paralysis succinylcholine or rocuronium can be used. Recommendations for post-intubation continuous sedation medications include a combination of propofol and fentanyl in the normotensive or hypertensive patient. A combination of midazolam and fentanyl or ketamine alone should be considered in the hypotensive patient. Delayed sequence induction (DSI) or a ketamine-only intubation, in which ketamine is used without a paralytic are very promising options for emergency intubation and may become the standard of care in the future. The benefit of these strategies compared to RSI need to be confirmed in large randomized clinical trials.
We thank Clerc EMS Monthey, Switzerland for providing Figure 1.
The authors declare no conflict of interest.
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Then take a masters degree in science in Germany (Animal breeding). Take a doctorate in animal science at the UANL.",institutionString:null,institution:{name:"Universidad Autónoma de Nuevo León",country:{name:"Mexico"}}},{id:"309250",title:"Dr.",name:"Miguel",middleName:null,surname:"Quaresma",slug:"miguel-quaresma",fullName:"Miguel Quaresma",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/309250/images/9059_n.jpg",biography:"Miguel Nuno Pinheiro Quaresma was born on May 26, 1974 in Dili, Timor Island. He is married with two children: a boy and a girl, and he is a resident in Vila Real, Portugal. He graduated in Veterinary Medicine in August 1998 and obtained his Ph.D. degree in Veterinary Sciences -Clinical Area in February 2015, both from the University of Trás-os-Montes e Alto Douro. He is currently enrolled in the Alternative Residency of the European College of Animal Reproduction. 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(2002), and Ph.D. (2008) degrees in Veterinary Medicine, Animal Pathology and Veterinary Microbiology from College of Veterinary Medicine, Addis Ababa University, Ethiopia; College of Veterinary Medicine, Utrecht University, the Netherlands and Western College of Veterinary Medicine, University of Saskatchewan, Canada respectively. He did his Postdoctoral training in microbial pathogenesis (2009 - 2015) in the Department of Animal Science, the University of Tennessee, Institute of Agriculture, Knoxville, Tennessee. Dr. Kerro Dego’s research focuses on the prevention and control of infectious diseases of farm animals, particularly mastitis, improving dairy food safety, and mitigation of antimicrobial resistance. Dr. Kerro Dego has extensive experience in studying the pathogenesis of bacterial infections, identification of virulence factors, and vaccine development and efficacy testing against major bacterial mastitis pathogens. Dr. Kerro Dego conducted numerous controlled experimental and field vaccine efficacy studies, vaccination, and evaluation of immunological responses in several species of animals, including rodents (mice) and large animals (bovine and ovine).",institutionString:"University of Tennessee at Knoxville",institution:{name:"University of Tennessee at Knoxville",country:{name:"United States of America"}}},{id:"251314",title:"Dr.",name:"Juan Carlos",middleName:null,surname:"Gardón Poggi",slug:"juan-carlos-gardon-poggi",fullName:"Juan Carlos Gardón Poggi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/251314/images/system/251314.jpeg",biography:"Juan Carlos Gardón Poggi received University degree from the Faculty of Agrarian Science in Argentina, in 1983. Also he received Masters Degree and PhD from Córdoba University, Spain. He is currently a Professor at the Catholic University of Valencia San Vicente Mártir, at the Department of Medicine and Animal Surgery. He teaches diverse courses in the field of Animal Reproduction and he is the Director of the Veterinary Farm. He also participates in academic postgraduate activities at the Veterinary Faculty of Murcia University, Spain. His research areas include animal physiology, physiology and biotechnology of reproduction either in males or females, the study of gametes under in vitro conditions and the use of ultrasound as a complement to physiological studies and development of applied biotechnologies. Routinely, he supervises students preparing their doctoral, master thesis or final degree projects.",institutionString:null,institution:{name:"Valencia Catholic University Saint Vincent Martyr",country:{name:"Spain"}}},{id:"309529",title:"Dr.",name:"Albert",middleName:null,surname:"Rizvanov",slug:"albert-rizvanov",fullName:"Albert Rizvanov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/309529/images/9189_n.jpg",biography:'Albert A. Rizvanov is a Professor and Director of the Center for Precision and Regenerative Medicine at the Institute of Fundamental Medicine and Biology, Kazan Federal University (KFU), Russia. He is the Head of the Center of Excellence “Regenerative Medicine” and Vice-Director of Strategic Academic Unit \\"Translational 7P Medicine\\". Albert completed his Ph.D. at the University of Nevada, Reno, USA and Dr.Sci. at KFU. He is a corresponding member of the Tatarstan Academy of Sciences, Russian Federation. Albert is an author of more than 300 peer-reviewed journal articles and 22 patents. He has supervised 11 Ph.D. and 2 Dr.Sci. dissertations. Albert is the Head of the Dissertation Committee on Biochemistry, Microbiology, and Genetics at KFU.\nORCID https://orcid.org/0000-0002-9427-5739\nWebsite https://kpfu.ru/Albert.Rizvanov?p_lang=2',institutionString:"Kazan Federal University",institution:{name:"Kazan Federal University",country:{name:"Russia"}}},{id:"210551",title:"Dr.",name:"Arbab",middleName:null,surname:"Sikandar",slug:"arbab-sikandar",fullName:"Arbab Sikandar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210551/images/system/210551.jpg",biography:"Dr. Arbab Sikandar, PhD, M. Phil, DVM was born on April 05, 1981. He is currently working at the College of Veterinary & Animal Sciences as an Assistant Professor. He previously worked as a lecturer at the same University. \nHe is a Member/Secretory of Ethics committee (No. CVAS-9377 dated 18-04-18), Member of the QEC committee CVAS, Jhang (Regr/Gen/69/873, dated 26-10-2017), Member, Board of studies of Department of Basic Sciences (No. CVAS. 2851 Dated. 12-04-13, and No. CVAS, 9024 dated 20/11/17), Member of Academic Committee, CVAS, Jhang (No. CVAS/2004, Dated, 25-08-12), Member of the technical committee (No. CVAS/ 4085, dated 20,03, 2010 till 2016).\n\nDr. Arbab Sikandar contributed in five days hands-on-training on Histopathology at the Department of Pathology, UVAS from 12-16 June 2017. He received a Certificate of appreciation for contributions for Popularization of Science and Technology in the Society on 17-11-15. He was the resource person in the lecture series- ‘scientific writing’ at the Department of Anatomy and Histology, UVAS, Lahore on 29th October 2015. He won a full fellowship as a principal candidate for the year 2015 in the field of Agriculture, EICA, Egypt with ref. to the Notification No. 12(11) ACS/Egypt/2014 from 10 July 2015 to 25th September 2015.; he received a grant of Rs. 55000/- as research incentives from Director, Advanced Studies and Research, UVAS, Lahore upon publications of research papers in IF Journals (DR/215, dated 19-5-2014.. He obtained his PhD by winning a HEC Pakistan indigenous Scholarship, ‘Ph.D. fellowship for 5000 scholars – Phase II’ (2av1-147), 17-6/HEC/HRD/IS-II/12, November 15, 2012. \n\nDr. Sikandar is a member of numerous societies: Registered Veterinary Medical Practitioner (life member) and Registered Veterinary Medical Faculty of Pakistan Veterinary Medical Council. The Registration code of PVMC is RVMP/4298 and RVMF/ 0102.; Life member of the University of Veterinary and Animal Sciences, Lahore, Alumni Association with S# 664, dated: 6-4-12. ; Member 'Vets Care Organization Pakistan” with Reference No. VCO-605-149, dated 05-04-06. :Member 'Vet Crescent” (Society of Animal Health and Production), UVAS, Lahore.",institutionString:"University of Veterinary & Animal Science",institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}},{id:"311663",title:"Dr.",name:"Prasanna",middleName:null,surname:"Pal",slug:"prasanna-pal",fullName:"Prasanna Pal",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311663/images/13261_n.jpg",biography:null,institutionString:null,institution:{name:"National Dairy Research Institute",country:{name:"India"}}},{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. Dr. Rutland has also written popular science books for the public. https://orcid.org/0000-0002-2009-4898. www.nottingham.ac.uk/vet/people/catrin.rutland",institutionString:null,institution:{name:"University of Nottingham",country:{name:"United Kingdom"}}},{id:"283315",title:"Prof.",name:"Samir",middleName:null,surname:"El-Gendy",slug:"samir-el-gendy",fullName:"Samir El-Gendy",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRduYQAS/Profile_Picture_1606215849748",biography:"Samir El-Gendy is a Professor of anatomy and embryology at the faculty of veterinary medicine, Alexandria University, Egypt. Samir obtained his PhD in veterinary science in 2007 from the faculty of veterinary medicine, Alexandria University and has been a professor since 2017. Samir is an author on 24 articles at Scopus and 12 articles within local journals and 2 books/book chapters. His research focuses on applied anatomy, imaging techniques and computed tomography. Samir worked as a member of different local projects on E-learning and he is a board member of the African Association of Veterinary Anatomists and of anatomy societies and as an associated author at local and international journals. Orcid: https://orcid.org/0000-0002-6180-389X",institutionString:null,institution:{name:"Alexandria University",country:{name:"Egypt"}}},{id:"246149",title:"Dr.",name:"Valentina",middleName:null,surname:"Kubale",slug:"valentina-kubale",fullName:"Valentina Kubale",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/246149/images/system/246149.jpg",biography:"Valentina Kubale is Associate Professor of Veterinary Medicine at the Veterinary Faculty, University of Ljubljana, Slovenia. Since graduating from the Veterinary faculty she obtained her PhD in 2007, performed collaboration with the Department of Pharmacology, University of Copenhagen, Denmark. She continued as a post-doctoral fellow at the University of Copenhagen with a Lundbeck foundation fellowship. She is the editor of three books and author/coauthor of 23 articles in peer-reviewed scientific journals, 16 book chapters, and 68 communications at scientific congresses. Since 2008 she has been the Editor Assistant for the Slovenian Veterinary Research journal. She is a member of Slovenian Biochemical Society, The Endocrine Society, European Association of Veterinary Anatomists and Society for Laboratory Animals, where she is board member.",institutionString:"University of Ljubljana",institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"258334",title:"Dr.",name:"Carlos Eduardo",middleName:null,surname:"Fonseca-Alves",slug:"carlos-eduardo-fonseca-alves",fullName:"Carlos Eduardo Fonseca-Alves",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/258334/images/system/258334.jpg",biography:"Dr. Fonseca-Alves earned his DVM from Federal University of Goias – UFG in 2008. He completed an internship in small animal internal medicine at UPIS university in 2011, earned his MSc in 2013 and PhD in 2015 both in Veterinary Medicine at Sao Paulo State University – UNESP. Dr. Fonseca-Alves currently serves as an Assistant Professor at Paulista University – UNIP teaching small animal internal medicine.",institutionString:null,institution:{name:"Universidade Paulista",country:{name:"Brazil"}}},{id:"245306",title:"Dr.",name:"María Luz",middleName:null,surname:"Garcia Pardo",slug:"maria-luz-garcia-pardo",fullName:"María Luz Garcia Pardo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/245306/images/system/245306.png",biography:"María de la Luz García Pardo is an agricultural engineer from Universitat Politècnica de València, Spain. She has a Ph.D. in Animal Genetics. Currently, she is a lecturer at the Agrofood Technology Department of Miguel Hernández University, Spain. Her research is focused on genetics and reproduction in rabbits. The major goal of her research is the genetics of litter size through novel methods such as selection by the environmental sensibility of litter size, with forays into the field of animal welfare by analysing the impact on the susceptibility to diseases and stress of the does. Details of her publications can be found at https://orcid.org/0000-0001-9504-8290.",institutionString:null,institution:{name:"Miguel Hernandez University",country:{name:"Spain"}}},{id:"350704",title:"M.Sc.",name:"Camila",middleName:"Silva Costa",surname:"Ferreira",slug:"camila-ferreira",fullName:"Camila Ferreira",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/350704/images/17280_n.jpg",biography:"Graduated in Veterinary Medicine at the Fluminense Federal University, specialist in Equine Reproduction at the Brazilian Veterinary Institute (IBVET) and Master in Clinical Veterinary Medicine and Animal Reproduction at the Fluminense Federal University. She has experience in analyzing zootechnical indices in dairy cattle and organizing events related to Veterinary Medicine through extension grants. I have experience in the field of diagnostic imaging and animal reproduction in veterinary medicine through monitoring and scientific initiation scholarships. I worked at the Equus Central Reproduction Equine located in Santo Antônio de Jesus – BA in the 2016/2017 breeding season. I am currently a doctoral student with a scholarship from CAPES of the Postgraduate Program in Veterinary Medicine (Pathology and Clinical Sciences) at the Federal Rural University of Rio de Janeiro (UFRRJ) with a research project with an emphasis on equine endometritis.",institutionString:null,institution:null},{id:"41319",title:"Prof.",name:"Lung-Kwang",middleName:null,surname:"Pan",slug:"lung-kwang-pan",fullName:"Lung-Kwang Pan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41319/images/84_n.jpg",biography:null,institutionString:null,institution:null},{id:"125292",title:"Dr.",name:"Katy",middleName:null,surname:"Satué Ambrojo",slug:"katy-satue-ambrojo",fullName:"Katy Satué Ambrojo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/125292/images/system/125292.jpeg",biography:"Katy Satué Ambrojo received her Veterinary Medicine degree, Master degree in Equine Technology and doctorate in Veterinary Medicine from the Faculty of Veterinary, CEU-Cardenal Herrera University in Valencia, Spain.Dr. Satué is accredited as a Private University Doctor Professor, Doctor Assistant, and Contracted Doctor by AVAP (Agència Valenciana d'Avaluació i Prospectiva) and currently, as a full professor by ANECA (since January 2022). To date, Katy has taught 22 years in the Department of Animal Medicine and Surgery at the CEU-Cardenal Herrera University in undergraduate courses in Veterinary Medicine (General Pathology, integrated into the Applied Basis of Veterinary Medicine module of the 2nd year, Clinical Equine I of 3rd year, and Equine Clinic II of 4th year). Dr. Satué research activity is in the field of Endocrinology, Hematology, Biochemistry, and Immunology in the Spanish Purebred mare. She has directed 5 Doctoral Theses and 5 Diplomas of Advanced Studies, and participated in 11 research projects as a collaborating researcher. She has written 2 books and 14 book chapters in international publishers related to the area, and 68 scientific publications in international journals. Dr. Satué has attended 63 congresses, participating with 132 communications in international congresses and 19 in national congresses related to the area. Dr. Satué is a scientific reviewer for various prestigious international journals such as Animals, American Journal of Obstetrics and Gynecology, Veterinary Clinical Pathology, Journal of Equine Veterinary Science, Reproduction in Domestic Animals, Research Veterinary Science, Brazilian Journal of Medical and Biological Research, Livestock Production Science and Theriogenology, among others. Since 2014 she has been responsible for the Clinical Analysis Laboratory of the CEU-Cardenal Herrera University Veterinary Clinical Hospital.",institutionString:null,institution:null},{id:"201721",title:"Dr.",name:"Beatrice",middleName:null,surname:"Funiciello",slug:"beatrice-funiciello",fullName:"Beatrice Funiciello",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/201721/images/11089_n.jpg",biography:"Graduated from the University of Milan in 2011, my post-graduate education included CertAVP modules mainly on equines (dermatology and internal medicine) and a few on small animal (dermatology and anaesthesia) at the University of Liverpool. After a general CertAVP (2015) I gained the designated Certificate in Veterinary Dermatology (2017) after taking the synoptic examination and then applied for the RCVS ADvanced Practitioner status. After that, I completed the Postgraduate Diploma in Veterinary Professional Studies at the University of Liverpool (2018). My main area of work is cross-species veterinary dermatology.",institutionString:null,institution:null},{id:"291226",title:"Dr.",name:"Monica",middleName:null,surname:"Cassel",slug:"monica-cassel",fullName:"Monica Cassel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/291226/images/8232_n.jpg",biography:'Degree in Biological Sciences at the Federal University of Mato Grosso with scholarship for Scientific Initiation by FAPEMAT (2008/1) and CNPq (2008/2-2009/2): Project \\"Histological evidence of reproductive activity in lizards of the Manso region, Chapada dos Guimarães, Mato Grosso, Brazil\\". Master\\\'s degree in Ecology and Biodiversity Conservation at Federal University of Mato Grosso with a scholarship by CAPES/REUNI program: Project \\"Reproductive biology of Melanorivulus punctatus\\". PhD\\\'s degree in Science (Cell and Tissue Biology Area) \n at University of Sao Paulo with scholarship granted by FAPESP; Project \\"Development of morphofunctional changes in ovary of Astyanax altiparanae Garutti & Britski, 2000 (Teleostei, Characidae)\\". She has experience in Reproduction of vertebrates and Morphology, with emphasis in Cellular Biology and Histology. She is currently a teacher in the medium / technical level courses at IFMT-Alta Floresta, as well as in the Bachelor\\\'s degree in Animal Science and in the Bachelor\\\'s degree in Business.',institutionString:null,institution:null},{id:"442807",title:"Dr.",name:"Busani",middleName:null,surname:"Moyo",slug:"busani-moyo",fullName:"Busani Moyo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Gwanda State University",country:{name:"Zimbabwe"}}},{id:"439435",title:"Dr.",name:"Feda S.",middleName:null,surname:"Aljaser",slug:"feda-s.-aljaser",fullName:"Feda S. Aljaser",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"423023",title:"Dr.",name:"Yosra",middleName:null,surname:"Soltan",slug:"yosra-soltan",fullName:"Yosra Soltan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Alexandria University",country:{name:"Egypt"}}},{id:"349788",title:"Dr.",name:"Florencia Nery",middleName:null,surname:"Sompie",slug:"florencia-nery-sompie",fullName:"Florencia Nery Sompie",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sam Ratulangi University",country:{name:"Indonesia"}}},{id:"428600",title:"MSc.",name:"Adriana",middleName:null,surname:"García-Alarcón",slug:"adriana-garcia-alarcon",fullName:"Adriana García-Alarcón",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}},{id:"428599",title:"MSc.",name:"Gabino",middleName:null,surname:"De La Rosa-Cruz",slug:"gabino-de-la-rosa-cruz",fullName:"Gabino De La Rosa-Cruz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}},{id:"428601",title:"MSc.",name:"Juan Carlos",middleName:null,surname:"Campuzano-Caballero",slug:"juan-carlos-campuzano-caballero",fullName:"Juan Carlos Campuzano-Caballero",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}}]}},subseries:{item:{id:"95",type:"subseries",title:"Urban Planning and Environmental Management",keywords:"Circular Economy, Contingency Planning and Response to Disasters, Ecosystem Services, Integrated Urban Water Management, Nature-based Solutions, Sustainable Urban Development, Urban Green Spaces",scope:"