Summary of ketamine in low-resource countries.
\r\n\tThe development of the interpersonal model and the Kleinian school in the second half of the last century allowed the emergence of an original understanding of the unconscious mind. Within the intersubjective paradigm, the psychoanalytic situation is conceptualized as an interpersonal field to which both the analyst and the patient contribute substantially. We have shown elsewhere how the failure to give a full account of such an intersubjective dimension in both psychoanalytic theory and practice amounts to a core liability in contemporary psychoanalytic discourse.
\r\n\r\n\tThe present book will focus on a few areas where the insufficient development of our discipline is currently apparent: five wounds that mark the body of the psychoanalytic enterprise.
\r\n\r\n\tNew contributions are particularly needed in the following areas: Current conceptualization of the unconscious mind is mechanistic and not suited to incorporate the full network of interpersonal exchanges which unfolds in the analytic room; Furthermore, the development of interpersonal psychoanalysis and the theory of the object relations warrants a greater appreciation of the impact of extratranference relations (e.g., couple, family, peers) on the patient's inner life both within and without the psychoanalytic situation.
\r\n\r\n\tAn integration of theories and models from other psychological paradigms is clearly in order here; the book will also focus on Barangers’ theory of the bi-personal field that makes traditional unipersonal models of the psychoanalytic process untenable. Also, it will help in the understanding of the reciprocal interactions of the two partners in the psychoanalytic dyad in most psychoanalytic institutes the training format relies naively on models from the academic or the professional domains. This fosters rigidity, conformism, and a hierarchical organizational style in the institutional life; e) all over the long span of his creative life Freud showed consistent interest in the application of psychoanalysis to literature, the arts, religion, and politics. Contemporary psychoanalysis is getting more and shyer and is pressed at the margins of social and political debate. The psychoanalytic theory includes unique lore of knowledge about the conscious and unconscious mind. Without it, a comprehensive understanding of human reality will stay out of the reach of contemporary culture.
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This has been described by some clinicians as problems associated with human, technical, investment, and educational resources [1, 2]. Anaesthesia service delivery has also been negatively affected by poor operation theatre infrastructure, unavailability of equipment, lifesaving drugs, and anaesthetic agents, inadequate clean water supply, transportation, electricity, oxygen, and blood banks services [2]. Thus, easy adaptability and proper utilisation of the available resource remains the keyway to delivering safe anaesthesia services in the low-resource countries. The regular use of a cheap, safe, and accessible drug called “ketamine” in clinical practice in the resource-limited countries has become overwhelming, as a result of the unavailability of anaesthesia equipment, oxygen, lifesaving drugs, and anaesthetic agents. A drug that is frequently described as a “unique drug” because it shows hypnotic, analgesic, and anterograde amnesic effects [3].
Ketamine is used in the operating room during induction and maintenance of hypnosis, with its analgesic property being beneficial for intraoperative and early postoperative analgesia. Its place in procedural sedation and total intravenous anaesthesia is insurmountable. Ketamine is used as an adjuvant together with other drugs during peripheral nerve blocks and neuraxial blocks to prolong the duration of analgesia provided by these techniques of anaesthesia [3].
Developing countries and low-income/resource countries are often used interchangeably. A developing country is a nation with a less developed industrial base and a low Human Development Index (HDI) relative to other countries. The term low-income country is often used to refer only to the economy of the country. The World Bank classifies the world’s economies into four groups, based on Gross National Income (GNI) per capita, and these are high, upper-middle, lower-middle, and low-incomes countries. Low-income countries have a GNI per capita of less than 1026 United State dollars [4, 5]. More than 2 billion of the world’s population reside in low- and middle-income countries. In most of these areas, the healthcare systems suffer from issues that involve institutional, human resources, financial, technical, and political developments. The provision of emergency, essential surgical care, and anaesthesia are quite limited. This area of the world has not been able to meet up with the World Health Organization (WHO) 2007 proposed framework of healthcare systems. World Health Organization proposed that, for a country to have an effective healthcare structure, components, such as service delivery, healthcare workforce, healthcare information systems, medicines and technologies, financing, and leadership/governance must be met. Poor governance, funding, and human resource challenges are linked to ineffective integration of services in resource-limited nations [6].
The clinical role of ketamine in providing anaesthesia in low-income countries with inadequate healthcare infrastructure and equipment has been demonstrated. Despite health care being identified as a strategic priority, relatively little information has been established about the capacity of the health system in low-income countries to deliver essential and safe surgical and anaesthesia services. In many rural hospitals in developing countries, patients undergo surgical procedures on room air or rarely with the delivery of oxygen from the oxygen concentrator. The anaesthesia providers keep the patients’ airway open by simply positioning, chin lift, and jaw thrust. The airway is suctioned by the use of mucus extractors, rubber bulb suction devices, and rarely with foot-pedal manually operated suction machines as a result of lack of electricity. An improvised precordial stethoscope becomes vital in monitoring a patient’s breath sounds, heart rate, and volume. Many of these hospitals do not have anaesthesia machines and the ability to provide inhaled anaesthesia, thus, in such situations, ketamine becomes a lifesaver [3, 7, 8].
In the years 2000 and 2007, Hodges and co-workers described the state of anaesthesia delivery in low-resource and Sub-Saharan African countries as inadequate, with emphasis that in the twenty-first century, millions of people in this area of the world may not have access to safe anaesthesia and pain relief during surgery and childbirth, which are considered as a basic human right. This is not different from another report by Adamu and co-workers in 2010, which noted the increasing difficulty with the preparation of patients for emergency surgery and getting them to surgical theatre within an acceptable time in limited-resource countries. The delays were related to the constraints in poor health institutional organisation and the socio-economic status of the patients. Thus, a significant portion of the patients waits too long for emergency surgery at the expense of perioperative morbidity and mortality [1, 9, 10].
An estimation of 234 million surgeries is performed every year to alleviate some disabilities and reduce the risk of death from some common medical conditions, and this is achieved with the help of anaesthesia. However, access to safe surgery has been suggested to be 3.5% in the world third poorest countries. An epidemiological study reported that 30% of the world’s population lack access to safe surgery, as well as safe anaesthesia. In most areas of Sub-Saharan Africa, government hospitals provide few supplies for resuscitation, anaesthesia, and surgery, making patients pay out of their pockets or provide materials for their surgical and anaesthesia care. Sometimes, delays in the procurement of these resources and materials often lead to delayed surgical and anaesthesia intervention, with the poor perioperative outcome. Ketamine has been shown to be safe and effective for a wide range of surgical procedures and its suitable in many clinical situations because of its safety profile [8, 11, 12].
The quality and type of anaesthesia services provided during surgery are highly related to perioperative outcomes. Nevertheless, this can be affected by the level of training of the medical personnel, the availability of surgical theatre infrastructure and resources, anaesthesia drugs, unreliable electricity, unavailability of compressed oxygen and other gases, anaesthesia machines, and modern drugs—a problem common with low-income countries. Thus, physician anaesthetists in this environment have learned to adapt and utilise any available resources to provide safe anaesthetic services and save lives. The use of ketamine as the sole anaesthetic agent has been in clinical use for a long period of time and it has been found to be beneficial and cost-effective. Ketamine has a place in the management of acute pain through intraoperative low-dose infusion, even in opioid-tolerant patients. It has likewise been used in low-resource countries after surgery with minimal psycho-mimetic effects [3, 8].
Ketamine has gained lots of credit in surgical practice in low-resource countries. It has also been demonstrated to be vital in global healthcare practice too. Limited resource countries rely heavily on ketamine as a sole anaesthetic agent in the face of the growing need for surgical services. The global burden of diseases preventable by surgery is on the rise and is expected to surpass those of human immunodeficiency virus, tuberculosis, and malaria by 2026. Ketamine has been shown to be the most widely used and safest anaesthetic drug, as reflected by being ‘always available’ according to 92% of anaesthetists surveyed in Uganda [1, 13].
The clinical administration of ketamine has been shown to be very effective in a wide range of surgical procedures, even amongst all age groups. Ketamine can be administered conveniently through different routes. The intravenous route offers the optimal channel of administration, but sometimes it’s difficult to achieve in emergencies, children, and obese patients. Ketamine can be administered efficiently through the intraosseous and intramuscular routes. The intramuscular administration of ketamine during anaesthesia, is associated with a longer recovery time. The oral administration of ketamine has also been documented, even with its mixture with soda to enhance the oral administration, however, this route has a reduced bioavailability [14, 15, 16].
Ketamine anaesthesia provides analgesia, amnesia, immobility, and loss of consciousness. It has been found to have a wide margin of safety when compared with other general anaesthetic agents. In addition, its sympathomimetic effects provide hemodynamic stability, which is beneficial in critically ill and hemodynamically unstable patients. Furthermore, the use of ketamine in pain medicine (multimodal analgesia, chronic pain, and palliative care), critical care (status epilepticus), emergency medicine, and psychiatry (depression) in developing countries with a shortage of trained personnel could not be overemphasised [3, 7, 8]. Nevertheless, the administration of ketamine is associated with some side effects. It causes dissociative anaesthesia, which alters the sensory perceptions of the patients. It can increase the incidence of postoperative nausea and vomiting, cause transient apnoea especially when administered rapidly, and increases salivary secretions, which may increase the incidence of laryngospasm. The increased salivation can be minimised by co-administration of atropine. Ketamine has been found to provoke imaginative, dissociative states and psychotic symptoms due to its NMDA-antagonistic action, as well as severely impair semantic and episodic memory. It can also cause various emergent phenomena when the patient is awakening from anaesthesia. This has been described as a floating sensation, vivid pleasant dreams, nightmares, hallucinations, and delirium [17, 18].
Most clinicians and nurses involved in anaesthesia service providers understand that they must add benzodiazepines, such as diazepam or midazolam, to combat the hallucinatory effects of ketamine and the emergence phenomenon. Nevertheless, diazepam is readily available and cheap in low-resource countries, thus, ketamine in combination with atropine and diazepam forms a reliable regimen for the conduct of total intravenous general anaesthesia for different modalities of surgery, with room air and minimal equipment [1, 17].
The use of intravenous ketamine at the induction dose of 2 mg/kg in adults or 1 mg/kg in children, followed by an increment of 1–1.5 mg/kg for maintenance of the anaesthesia. While the patients were pre-medicated with intravenous atropine 0.6 mg in adults and 0.3 mg in children plus diazepam 10 mg in adults and 0.45 mg/kg in children was documented in a study conducted in Nigeria, that had the incidence of general anaesthesia with intravenous ketamine of 58.4%. This study involved different varieties of surgeries, such as intra-abdominal operations (herniorrhaphies and herniotomies), perineal, pelvic, and genital surgeries, as well as extremities, chest, head, and neck surgeries. A retrospective study reviewed 295 cases of laparoscopy that were performed over the period of 28 months at a fertility healthcare facility in Nigeria that does not have an anaesthesia machine or trained anaesthesia personnel. They showed that the regimen of atropine-ketamine-diazepam general anaesthesia was safely used for all the patients that had day-case laparoscopy. Elusoji and colleagues also reported the safety of using ketamine anaesthesia in combination with diazepam in 55 patients that had a thyroidectomy in a low-resource country. They reported complications, such as hallucination and postoperative restlessness, which were managed with intravenous diazepam, chlorpromazine, or paraldehyde (Table 1) [19, 20, 21].
Author | Objective | Country | Variables | Discussion | Conclusion |
---|---|---|---|---|---|
Hodges et al. [1] | Assessment of anaesthesia facilities in different units. | Uganda | Availability of ketamine | Ketamine is always available in 92% of the period | Identification of shortages of personnel, drugs, equipment, and anaesthesia training in Uganda |
Vo et al. [13] | Use of ketamine as an anaesthetic compared with basic anaesthetic infrastructure and equipment at facilities in 22 low- and middle-income countries. | Low- and middle-income countries | Ketamine anaesthesia | Current ketamine use exceeds the availability of other anaesthetic options. | Restrictions on ketamine need to consider the larger impact on the global burden of surgical diseases where ketamine is vital in the care of surgical patients. |
Olasinde et al. [19] | To highlight the experience from a specialist hospital in south-western Nigeria | Nigeria (South-West) | Ketamine anaesthesia | 52% ketamine utilisation | Ketamine and local infiltration with lidocaine are commonly used in this environment. |
Ikechebelu et al. [20] | A retrospective review of 295 cases of laparoscopy over 28 months in a fertility unit. | Nigeria (South-East) | Ketamine is used by an untrained healthcare personnel | Ketamine uses for laparoscopic procedures | Ketamine produces a safe, effective and simple general anaesthesia and is recommended for use in day-case laparoscopy |
Elusoji et al. [21] | To evaluate the efficacy and safety of ketamine hydrochloride anaesthesia without endotracheal intubation in thyroidectomy. | Nigeria | Ketamine anaesthesia | Ketamine uses for thyroidectomy | Ketamine anaesthesia is safe and economical for thyroidectomy. |
Lonnée et al. [22] | To assess the type of anaesthesia used for caesarean delivery, the level of training of anaesthesia providers, and to document the availability of essential aesthetic drugs and equipment. | Zimbabwe | Rural setting | 100% ketamine utilisation. Shortage of essential drugs for anaesthesia, inconsistent use of recovery area, and insufficient blood supplies. | Training of medical officers and nurse anaesthetists should be strengthened in leadership, teamwork, and management of complications. |
Nuhu et al. [23] | Evaluation of workforce situation and availability of anaesthetic drugs/equipment in public secondary health facilities. | Nigeria (North-Central) | Ketamine anaesthesia | 100% utilisation | There is a dearth of aesthetic and surgical workforce and basic infrastructure in public hospitals. |
Masaki et al. [24] | To assess the feasibility and safety of ketamine in support of obstetric and gynaecologic surgeries in severely resource-scarce settings when there is no available anaesthetist. | Kenya | Ketamine anaesthesia | Improved provider’s competency due to ketamine raining | Ketamine is safe for use in support of emergency and essential obstetric and gynaecologic surgeries in extremely resource-limited settings when no anaesthetist is available. |
Makin et al. [25] | To gain surgeons’ perceptions on performing operations supported by ketamine and to recommend best practices and techniques. | Low-income countries. | Ketamine is used amongst surgeons | Global standards on ketamine training and use should be established. | Ketamine is safe, can provide increased access to emergency and essential surgery, and requires few operative technical changes. |
Koka et al. [26] | To describe the anaesthesia practice at two tertiary hospitals | Sierra Leone | Ketamine anaesthesia | Utilisation rate of 44.7% | Gaps in the application of internationally recommended anaesthesia practices at both hospitals are caused by a lack of resources. |
Summary of ketamine in low-resource countries.
Anaesthesia is an essential part of healthcare services. In developed countries and some of developing countries, anaesthesia is not merely limited to the operating room, but the services also involve the emergency room, intensive care unit, angiography-catheterisation laboratory, magnetic resonance imaging suite, pain clinics, resuscitative rooms, electroconvulsive therapy room, and other life-saving hospital services. These services require the skill of trained anaesthesia providers, however, in most low-resource countries, there are still no strategic measures for assessing the safe anaesthesia services, particularly in rural areas because of the shortage of anaesthesia personnel. In most of these areas, the health care system is usually overburdened by patients load with limited or no anaesthesia provider.
The number of physician anaesthetists in most low-resource countries is below what is needed to provide a safe and quality anaesthesia service. A study conducted by Davies and co-workers recommended a minimum of four physician anaesthetists per 100,000 population for the provision of reasonable, safe, and standard anaesthesia care for surgical interventions. However, this figure is far-fetched in developing countries with steaming and growing populations [27]. World Federation Societies of Anaesthesiologists (WFSA) workforce survey that was based on the 2015 world population estimated that to achieve a minimum density of 1 per 100,000 physician anaesthetists in all countries, over 8000 additional physician anaesthetists would be required. While over 136,000 additional physician anaesthetists would be required worldwide to achieve 5 per 100,000. Nevertheless, the majority of the countries in Sub-Saharan Africa and some in Asia have a physician anaesthetists density of <1 per 100,000 population [28].
Anaesthesia professionals, especially in Sub-Saharan Africa, are often poorly remunerated, supported and undervalued. The recruitment process of healthcare personnel often neglects the anaesthesia providers, thus resulting in shortages of anaesthesia physician and their allied personnel, such as nurse anaesthetist, anaesthesia technicians, and anaesthesia attendants. In some low-resource countries, some of the anaesthesia physician support staff are not included and are sometimes poorly placed in the civil service, making it difficult for them to be remunerated. Ho et al. reported in 2019 that 30.4% of the 344 medical facilities they surveyed had no anaesthesia provider at any level (physicians, nurses, or technicians) accessible for patient care [29]. In most low-income countries, anaesthesia services are often provided by unqualified physician personnel, nurse anaesthetists, or anaesthesia technicians who are trained by physician anaesthetists, to use anaesthesia resources to provide safe anaesthesia services. This day-to-day reality of shortage of physician anaesthetists in the operating room coupled with a lack of resources, persuades the available anaesthesia providers to use simple and effective techniques that are not too expensive and readily available.
The properties of ketamine anaesthesia, such as analgesia, amnesia, immobility, and loss of consciousness make it the technique of choice, alongside local and spinal anaesthesia in low-resource countries. In a study reported in the Democratic Republic of Congo, 771 patients had general anaesthesia with ketamine in an operating room that had no physician or nurse anaesthetist, but untrained personnel. They reported that most of their patients were females (85.86%) and 97.4% of the patients who had surgery were classified as ASA II and the intermediate surgical risk was more represented in 82.9%. The adverse event they noted were arterial hypertension (10.2%), salivation (5.5%), respiratory distress (4.8%), agitation on awakening (30.8%), and hallucinations (22.6%), respectively. They did not record any mortality. Indicating ketamine is safe and effective, even in regions where anaesthesia is conducted by untrained anaesthesia personnel [30].
Anaesthesia in Zambia, a low-resource country, is under-developed and under-resourced. The anaesthesia specialty is focused almost exclusively on intraoperative patient care. In small hospitals and hospitals in rural areas, there is lack adequate staffing. A study conducted in this country showed that 80% of anaesthesia cases were performed by non-physicians with little or no formal training in anaesthesia. The reliance of the anaesthesia providers on ketamine is a result of inadequate training, inexperience with, and access to, more advanced equipment like laryngoscope and materials like endotracheal tubes. A limited number of anaesthetists have almost no involvement in emergency medicine and pain therapy [31].
In most areas of developing countries, a shortage of essential drugs used in anaesthesia practice is a common problem. Thus, the anaesthesia providers engage in the use of simple and effective techniques that are not expensive, but readily available. The properties of ketamine make the drug a product of choice, for simplified general anaesthesia like total intravenous anaesthesia, alongside its use as an additive to prolong the analgesic effect of local and neuraxial anaesthesia. In well-equipped health institutions with trained anaesthesia personnel, inhalation anaesthesia is normally the first choice of maintaining hypnosis during anaesthesia; however, ketamine has proved to be useful in settings without recovery facilities, as well as trained anaesthesia providers and in areas where patients need to wake up in their own beds in the various wards, especially in low-income and middle-income countries, and in emergency situations [1, 32]. Ketamine anaesthesia was found to predominate other techniques or modes of anaesthesia in most hospitals evaluated (72.9%), whereas inhalational anaesthesia was only available in 56.2% of the hospitals. Also, techniques of anaesthesia like regional and spinal anaesthesia, were available in 58.9 and 65.9% of hospitals, respectively studied [28].
A study published in Uganda in 2007 stated that drugs used for the conduct of anaesthesia are usually limited in supply. The availability of narcotics is 45%, nondepolarizing muscle relaxants 15%, inhalational agents 38%, and intravenous induction agents 59% [1]. In another study done by Khan in Pakistan, he reported that there is a non-availability of some essential drugs, such as narcotics, inhalational agents, induction agents, and some vasoactive drugs in Pakistan [33].
There are several factors that contribute to the anaesthesia drug shortages, some of them are common in both high-income and low-income countries. For example, regulatory issues, manufacturing problems, raw material acquisition problems, business decisions based upon the profitability of some drugs, and disturbances or faults in the supply chain. The factors that affect low-income countries alone include issues of licensing by healthcare regulatory authorities, imports from abroad, shortage of ingredients for local manufacture, government policies, and drug smuggling to other countries. The implication of anaesthesia drug shortage is that it can result in the cancellation of surgery which may be psychologically traumatic to both patients and their families. The economic implication for both patients and hospitals are incurred from prolongation of hospital stay and higher risk of exposure to hospital-acquired infections [34, 35].
The anaesthesia gas supply system is designed to provide a safe, cost-effective and convenient system for the delivery of medical gases at the point of use in the hospital. The medical gases used in anaesthesia and intensive care medicine are oxygen, nitrous oxide, medical air, Entonox, carbon dioxide, and heliox. Oxygen is one of the most widely used gases for life-support and respiratory therapy besides anaesthetic procedures. There is a lack of adequate supply of oxygen in most of low-resource countries. In a recent survey of anaesthetic care in 22 low- and middle-income countries, uninterrupted access to oxygen was available in only 46% of the healthcare facilities, while 35% reported no access to oxygen. Ketamine can be administered through various routes and it does not require the availability of oxygen, electricity, anaesthetic equipment, or trained anaesthesia providers, all of which remain scarce in low-resource countries. Hence, ketamine is the most widely used and safest anaesthetic drug in resource-limited environments [13].
Ketamine is an example of how an old drug can still be renowned in the practice of medicine. It has been recognised as the sole anaesthetic/analgesic of choice in areas with low resources. Ketamine administration does not require costly equipment or appropriately trained physician anaesthetists, and it is cheap, readily available, and safe, Ketamine is effective in a wide range of surgical procedures, including short painful, long complex, and day-case procedures. The use of ketamine in low-resource countries has enhanced safe anaesthesia and surgical care, thus reducing perioperative morbidity and mortality, as well as improving surgical outcomes. The regular use of this cheap, safe, and accessible drug called “ketamine” in clinical practice in resource-limited countries has become overwhelming, despite the dwindling number of trained anaesthesia providers.
I want to express my gratitude to God Almighty, for granting me the knowledge and wisdom to contribute a chapter to this book. Also, for helping me to find my ground in human capacity building in Anaesthesia.
The author declares no conflict of interest.
Although pneumothorax has been known in medical history since the times of Hippocrates and Galen, it was the first time that Itard named the term pneumothorax in 1803 [1]. Spontaneous pneumothorax due to bullae rupture was defined for the first time in 1926, and in 1932, Kjaergaard reported that pneumothorax may occur in completely healthy individuals due to isolated lung blebs [2]. In the treatment of pneumothorax, which was tried to be corrected with long bed rest, Noble has used a cannula, plastic drain, and underwater drainage system for the first time in 1873 [3]. The first thoracotomy and bulla resection was performed by Bigger in 1937, pleural abrasion by Churchill in 1941, subtotal parietal pleurectomy by Gaensler in 1956, and the first axillary thoracotomy and bulla excision and apical parietal pleurectomy by Deslauriers in 1980 [3].
Pneumothorax is defined as the free accumulation of air between visceral and parietal pleural space for various reasons. Pneumothorax can be spontaneous, iatrogenic, and traumatic in both neonatal and juvenile patients. Spontaneous pneumothorax is divided into two as primary and secondary. Primary spontaneous pneumothorax occurs secondary to apical blebs or bullae without evidence of other lung pathologies. Secondary spontaneous pneumothorax happens in the context of underlying lung diseases such as cystic fibrosis, asthma, connective tissue disorders, or pneumonia [4, 5].
Apart from these, if we define pneumothorax according to age, we should also mention neonatal and catamenial pneumothorax. Neonatal pneumothorax is the most common pneumothorax in childhood. It is reported that the cause is most likely the high transpulmonary pressure with the onset of breathing [6]. Catamenial pneumothorax is often associated with thoracic endometriosis syndrome.
Pressure in the pleural space is negative throughout the entire respiratory cycle, as the chest wall tends to expand and collapse in the lung. The pressure of −2 to −5 cm H2O in expiration decreases to −25 to −30 cm H2O in inspiration, and this pressure increases approximately 0.25 cm H2O per cm from the lung basal to the apex [7]. Alveolar pressure is always greater than intrapleural pressure. Therefore, due to the high alveolar pressure and tension in the apical region, existing bleps and bullae in the apex may rupture. Thus, it causes air entry from the alveoli to the pleural space. Airflow continues until the pressure in the pleural space is equalized or until air leakage from the alveoli into the pleural space stops. This condition is called pneumothorax. Pneumothorax physiology includes a reduction in vital capacity and a decrease in oxygen partial pressure.
Pneumothoraces can be classified as spontaneous (primary and secondary), iatrogenic, traumatic, neonatal, and catamenial pneumothorax. The types of pneumothoraces are shown in Table 1.
Spontaneous pneumothorax (SP) is a comparatively rare condition in children. The peak age of occurrence in children is either in the neonatal period or in the late adolescent period [8]. Air enters the pleural space without any evident traumatic or iatrogenic mechanism. The incidence of pediatric SP is 4 per 100,000 in males and 1.1 per 100,000 in females with most occurring in patients 16–24 years of age [5, 9, 10]. SP is generally categorized into primary and secondary. In primary spontaneous pneumothorax (PSP), there is no underlying pathology and occurs unknown etiology. PSP refers to a pneumothorax from apical blebs or bullae [10]. However, secondary spontaneous pneumothoraces occur in children with underlying lung problems.
A primary spontaneous pneumothorax (PSP) occurs without a precipitating event and in the absence of clinical lung disease and has an estimated incidence of 3.4 per 100,000 children with 4:1 male predilection [11]. In pediatric studies, the peak age of incidence occurs between 14 and 17 years of age, mainly in late teenagers [8]. The risk factors of PSP include tall and thin stature with low body weight [8]. Smoking is also the primary environmental risk factor for primary spontaneous pneumothorax, especially in teenage patients [12]. Some studies have shown that familial and genetic forms of PSP are related to mutations in the folliculin gene on chromosome 17 in the literatüre [5, 12].
It has been recommended that subpleural blebs and bullae are causally related to the development of primary SP and may be clarified by that these tall and slim children tend to have higher transpulmonary pressure at lung apex, and their rapid growth relative to pulmonary vasculature may result in ischemia and thus blebs evolution at these regions [5, 8].
Most patients are clinically stable on initial evaluation and small cases may present in fulminant distress [1]. Chest pain and shortness of breath are common presenting symptoms of PSP and may be developed at rest or accelerated by any maneuver that increases intrathoracic pressure (Valsalva) [5, 13]. Other clinical findings in patients with pneumothorax include cough, ipsilateral hypoventilation, and nonspecific respiratory distress [4, 5].
Sample chest X-ray and thorax-computed tomography of our patients admitted with primary spontaneous pneumothorax from our archive are shown in Figures 1 and 2.
(a) A 16-year-old male patient presented to the emergency department with a sudden onset of chest pain and was diagnosed with spontaneous pneumothorax on the right side of his chest X-ray (free air in the thorax marked with a red arrow). (b) Film of the same patient after right side chest tube placement (inserted chest tube marked with blue arrow).
A 17-year-old male patient presented to the emergency department with the complaint of sudden onset of chest pain. (a) There was no pneumothorax in the anterior–posterior chest X-ray of the patient. (b) Minimal pneumothorax image on the left side in the thorax-computed tomography of the patient (free air in the thorax marked with red arrows).
Commonly known situations predisposing individuals to a secondary spontaneous pneumothorax (SSP) include primary lung disease as asthma, cystic fibrosis, interstitial emphysema, inflammatory/connective tissue diseases such as Marfan syndrome, Ehlers-Danlos syndrome, juvenile idiopathic arthritis, systemic lupus erythematosus, polymyositis, dermatomyositis, sarcoidosis, Langerhans cell histiocytosis, α1-antitrypsin deficiency, Birt–Hogg–Dube syndrome, infections such as
|
|
|
|
|
|
|
Types of pneumothoraces.
Primary lung disease: asthma, cystic fibrosis, interstitial emphysema | Infection: |
Inflammatory/connective tissue disease: Marfan syndrome, Ehlers-Danlos syndrome, juvenile idiopathic arthritis, systemic lupus erythematosus, polymyositis, dermatomyositis, sarcoidosis, Langerhans cell histiocytosis, α1-antitrypsin deficiency, Birt–Hogg–Dube syndrome | Malignancy—lymphoma, metastases |
Foreign body aspiration | Congenital malformation: congenital cystic adenomatoid malformation, congenital lobar emphysema |
The theorized mechanism is chronic airway inflammation that causes small airway obstructions and creates the pressure needed for air to escape into the pleural space. These conditions can make the lung pleura more susceptible to rupture and subsequent development of pneumothorax [15]. The most important symptom of SSP is dyspnea, tachypnea, and tachycardia.
Cystic fibrosis (CF) is a severe obstructive airways disease and one of the most common causes of secondary spontaneous pneumothorax. Pneumothorax is seen approximately 3.4% of all patients will suffer from CF during their lifetime and mostly occurs in adult patients [16, 17]. Cysts, blebs, and bullae are all commonly found in the lungs of CF patients, and these cause gas to accumulate in the small airways, resulting in a cystic appearance. The typical presentation is acute onset of chest pain and breathlessness, and the treatment decisions include the size of the pneumothorax, severity of disease, stability of the patient, and whether this is the first or a recurrent pneumothorax [16]. Pneumothorax due to cystic fibrosis can also be seen in the childhood age group and invasive surgeries may be required. A spontaneous pneumothorax chest X-ray film of a CF patient from our archive is shown in Figure 3a–f.
A 13-year-old male patient followed up with the diagnosis of cystic fibrosis was admitted to the emergency department with respiratory distress. Upon the presence of pneumothorax in the right upper lobe in the thorax in computed tomography (a, b) and the chest X-ray (c), a pig-tail catheter was placed in the right thorax (d). The child’s clinical condition did not improve and thoracotomy with pleurectomy was performed. The child was followed up with a chest tube after the operation (e), and has been covered and discharged (f).
The most frequent cause of iatrogenic pneumothorax is a transthoracic pulmonary biopsy, but it also may appear as a complication of many other procedures and caused by barotrauma secondary to mechanical ventilation [18, 19]. Iatrogenic pneumothorax is related to underlying lung disease along with high ventilatory settings [19]. The most common cause of iatrogenic pneumothorax is invasive diagnostic and therapeutic procedures, such as central venous access, thoracocentesis, thoracic surgery, or intubation [1]. Iatrogenic pneumothorax may also develop during cardiopulmonary resuscitation and tracheostomy.
Although thoracic injuries occur less frequently in children than adults, thoracic trauma in children carries a 5% mortality [20, 21]. The most causes of trauma in pediatric patients are traffic accidents, followed by falling from heights, and bicycle accidents [22]. The greater flexibility of the thoracic cage in young children permits the anterior ribs to be compressed to meet the posterior ribs [23]. Because of the flexibility, pulmonary contusions are more common than rib fractures in children [23].
The most common injury in children with blunt thoracic trauma is pulmonary contusion and pneumothorax, which is observed as isolated injury in 30% of the cases [22].
Traumatic pneumothorax can be classified as small occult, tension, and open (Table 3). A small pneumothorax from blunt torso trauma is often asymptomatic, with more than half identified as being occult (defined as a pneumothorax observed on computed tomography scan of the chest, but not on chest radiograph) [22]. However, a large pneumothorax may cause clinical symptoms that overlap with those produced by lung parenchymal damage—tachypnea, distress, and decreased saturation [22]. A traumatic pneumothorax and contusion chest X-ray film of a patient from our archive is shown in Figure 4.
Open pneumothorax | Related to an open chest wall injury |
Occult pneumothorax | Small pneumothorax without clinical significance, typically seen in trauma |
Tension pneumothorax | Rapid accumulation of air within the thoracic cavity that leads to a reduction in central venous return as well as tamponade effect on cardiac output |
Characteristics of traumatic pneumothorax [14].
An 8-year-old male patient applied to the emergency department due to a traffic accident. (a) Pneumothorax in the right thorax and contusion in the left lung were detected in the chest X-ray (free air in the right thorax marked with red arrows and contusion has shown with yellow arrow). (b) Chest X-ray after tube placement in the patient’s right thorax (inserted chest tube marked with blue arrow).
When the mediastinum is displaced to the contralateral side with impairment of the venous return, the tension pneumothorax occurs and is more common in children [22]. The symptoms of tension pneumothorax are tachycardia, severe respiratory distress, and hypoxemia, with hypotension and tracheal deviation. Heartbeat is heard on the opposite side and the neck veins become dilated and severe cyanosis occurs. No chest X-ray is required to insert a chest tube in children with tension pneumothorax. The child’s symptoms improve dramatically with chest tube insertion.
Open pneumothorax is usually seen after penetrating injuries. This causes a collapse in the lung on the side of the trauma and ventilation failure in the other lung. The patient who develops open pneumothorax is cyanosed and has serious respiratory distress is present. In the treatment, the defect should be closed with a sterile gas.
Neonatal pneumothorax, with an incidence of 1–2% in newborns, is symptomatic in 0.08% of all live births and is reported as 5–7% in those with a birth weight of less than 1500 g, although it can reach 30% in those with an underlying lung problem and those who need mechanical ventilation comes out [10, 11]. The most common cause of this condition is barotrauma [13]. In addition, male gender and cesarean delivery are also considered among risk factors [11].
In order to inflate the lungs of a newborn baby when he is not breathing himself, mechanical ventilation with an average pressure of 50–80 cm H2O is required to overcome the high transpleural pressure. During this resuscitation, the air given into the lungs is distributed with an uneven pressure inside the lungs. As a result, some alveoli are ruptured and air passes from the peribronchial area to the mediastinum and pneumothorax develops [24]. A chest X-ray visualization from a newborn from our archive who needed resuscitation at 41-week postpartum and had pneumothorax on the right in the chest X-ray has been shown in Figure 5.
(a) Film of newborn who needed resuscitation at 41-week postpartum and had pneumothorax on the right in the chest X-ray (free air in the thorax marked with red arrows). (b) Film of the same newborn after right-side chest tube placement (inserted chest tube marked with blue arrow).
It most commonly occurs in the first three days and should be suspected in cases of sudden respiratory distress, decrease in oxygen saturation, inability to listen to breath sounds, or when ventilator parameters have to be increased.
It causes high mortality and morbidity, especially in premature babies and newborns with underlying lung parenchyma disease. Whatever the cause, neonatal pneumothorax needs to be treated very quickly because pneumothorax in neonates will lead to serious complications, including lung perforation, phrenic nerve palsy, chylothorax, and hemopericardium [11].
Catamenial pneumothorax (CP) is a form of thoracic endometriosis syndrome, which also includes catamenial hemothorax, catamenial hemoptysis, catamenial hemopneumothorax, and endometriosis lung nodules, as well as some exceptional presentations [25]. The most common extrapelvic manifestation of endometriosis is thoracic endometriosis and often presents as catamenial pneumothorax [10]. Most commonly occurs in women aged 30–40 years, but has been diagnosed in young girls as early as 10 years of age and postmenopausal women (exclusively in women of menstrual age) most with a history of pelvic endometriosis [25].
CP is a rare and important condition of recurrent pneumothoraces, which occurs within 48–72 h from the onset of menses [11]. The pathophysiology is not completely understood but it is treated with hormonal therapies [11].
The diagnosis of pneumothorax can be made by physical examination or imaging studies including chest X-ray, ultrasonography, and computed tomography (CT) scan [19]. A conventional chest X-ray is a typical imaging examination used to confirm the diagnosis of pneumothorax and a CT scan may be validated to show smaller pneumothoraces. CT scan is commonly accepted as the gold standard in pneumothorax diagnosis [1]. Dotson et al. proposed that detection of blebs/bullae on the CT scan may be predictive of recurrence of PSP, especially bilaterally pneumothoraces [5]. There are multiple methods for calculating pneumothorax sizes like Light, Rhea, and Collins for adults, but these methods are not appropriate for the childhood age group [5, 26, 27].
Dahmarde et al. suggested that ultrasound is accurate and reliable for newborn pneumothoraces [28]. Ultrasound can result in timely diagnoses specifically in neonatal pneumothorax and facilitates the therapy process; lack of ionizing radiation and easy operation are the benefits of this imaging technique.
The treatment options are changing by age, size, and the type of pneumothorax in childhood. There are no standardized guidelines for therapeutic interventions for children with pneumothorax; however, early identification and appropriate management can reduce morbidity and mortality.
While the size of the pneumothorax can be calculated by various methods in adults, there is no method that can be applied to children yet. Although minimal pneumothoraxes that do not cause clinical problems can be followed conservatively, most patients require drainage, and a thorax tube is inserted. Nonoperative treatment methods are monitoring with supplemental oxygen (100% high-flow) or needle aspiration. Surgical treatment methods range from the insertion of a chest tube to more invasive interventions such as video-assisted thoracoscopic surgery (VATS) or thoracotomy, including resections, pleurodesis, or bullectomy [10]. Surgical indications for pneumothorax are resistant and prolonged air leak (>4 days), persistent and recurrent pneumothorax, large pneumothorax, first pneumothorax with a history of pneumothorax in the other lung, and bilateral pneumothorax [10, 11]. Chest tube placement should be the first choice in patients with surgical indication, and then, open or closed surgical techniques should be planned according to the child’s clinic. Although the VATS procedure is easily used in the childhood age group, thoracotomy with resections, pleurodesis, or bullectomy may be preferred or needed in cases with severe air leak and recurrent pneumothorax [29].
Pleural catheters are tools that are placed in the fourth, fifth, or sixth intercostal space in generally anterior or midaxillary line with Seldinger technique and placed to water seal in children. In newborns, the catheters are usually placed from the second or third midclavicular line with again Seldinger technique and placed to water seal. The chest tube sizes are changing from the patient’s size and age. The guide for chest tube selection for pneumothorax for children patients is summarized in Table 4 [4].
Children weight (kg) | Tube size (French) |
---|---|
<3 | 8–10 |
3–8 | 10–12 |
8–15 | 12–16 |
16–40 | 16–20 |
>40 | 20–24 |
Guide for chest tube selection for pneumothorax [4].
The aim of surgical treatment is to resect of blebs and bullae and pleurodesis to prevent recurrences. VATS procedure is performed with good results in children with PSP and as the gold standard for surgical management of PSP by using various surgical instruments from 1 to 3 incisions of approximately 1.5–2 cm, which are opened on the chest with the help of a video [29, 30]. Blebs and bullae due to pneumothorax are removed with VATS with the help of staples. Pleurodesis ensures that the parietal and visceral pleura sheets stick together. Pleurodesis can be performed by using pleurectomy, pleural abrasion, or chemicals [31].
Lewit et al. suggested that nonoperative methods are not suitable for the treatment of pneumothorax and mentioned a decreased recurrence rate in those undergoing surgical treatment at initial presentation in the childhood age group [32]. Also, Lopez et al. have observed decreased median total length of stay and decreased recurrence rate in the surgical group compared with the initial non-VATS group in children [11].
On the other hand, Brown et al. discussed whether conservative management is an acceptable alternative to nonconservative procedures and found that conservative management of primary spontaneous pneumothorax was similar to interventional management, with a lower risk of significant adverse events [33].
The general approach is chest X-ray negative and CT scan positive pneumothoraces do not require invasive methods and they can be followed conservatively [23]. However, since childhood is a wide range, a pneumothorax that looks small may even be mortal for a newborn premature baby. Although thoracic tube insertion is a minor surgical procedure, every procedure has surgical stress, especially for neonatal intensive care patients. Therefore, every child with pneumothorax for whom a follow-up decision is made requires very special close follow-up. Likewise, close follow-up of a child patient with a chest tube placed should be very important in terms of possible complications.
The most common complications of pneumothorax seen in childhood are air leak, tension pneumothorax, pneumomediastinum, subcutaneous emphysema, hemothorax, and very rarely Horner’s syndrome. If the air leak is continued within 48 hours of pneumothorax treatment, it may become resistant. Therefore, a second chest tube or even VATS or thoracotomy may be required for persistent air leakage, depending on the age of the child or the etiology of the pneumothorax [3].
In conclusion, the etiology and management vary according to age and type of pneumothorax in the childhood age group, and this is a life-threatening special condition that requires urgent intervention and special follow-up.
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On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. 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Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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Liposuction is a procedure to improve the body contour and not a surgery to reduce weight, although recently people who have failed in their plans to lose weight look at liposuction as a means to contour their body figure. Tumescent liposuction of large volumes requires a meticulous selection of each patient; their preoperative evaluation and perioperative management are essential to obtain the expected results. The various techniques of general anesthesia are the most recommended and should be monitored in the usual way, as well as monitoring the total doses of infiltrated local anesthetics to avoid systemic toxicity. The management of intravenous fluids is controversial, but the current trend is the restricted use of hydrosaline solutions. The most feared complications are deep vein thrombosis, pulmonary thromboembolism, fat embolism, lung edema, hypothermia, infections and even death. The adherence to the management guidelines and prophylaxis of venous thrombosis/thromboembolism is mandatory.",book:{id:"6221",slug:"anesthesia-topics-for-plastic-and-reconstructive-surgery",title:"Anesthesia Topics for Plastic and Reconstructive Surgery",fullTitle:"Anesthesia Topics for Plastic and Reconstructive Surgery"},signatures:"Sergio Granados-Tinajero, Carlos Buenrostro-Vásquez, Cecilia\nCárdenas-Maytorena and Marcela Contreras-López",authors:[{id:"273532",title:"Dr.",name:"Sergio Octavio",middleName:null,surname:"Granados Tinajero",slug:"sergio-octavio-granados-tinajero",fullName:"Sergio Octavio Granados Tinajero"}]},{id:"30178",title:"Chest Mobilization Techniques for Improving Ventilation and Gas Exchange in Chronic Lung Disease",slug:"chest-mobilization-techniques-for-improving-ventilation-and-gas-exchange-in-chronic-lung-disease",totalDownloads:31227,totalCrossrefCites:0,totalDimensionsCites:5,abstract:null,book:{id:"648",slug:"chronic-obstructive-pulmonary-disease-current-concepts-and-practice",title:"Chronic Obstructive Pulmonary Disease",fullTitle:"Chronic Obstructive Pulmonary Disease - Current Concepts and Practice"},signatures:"Donrawee Leelarungrayub",authors:[{id:"73709",title:"Associate Prof.",name:"Jirakrit",middleName:null,surname:"Leelarungrayub",slug:"jirakrit-leelarungrayub",fullName:"Jirakrit Leelarungrayub"}]},{id:"46082",title:"Fecal Incontinence",slug:"fecal-incontinence",totalDownloads:3866,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"3835",slug:"fecal-incontinence-causes-management-and-outcome",title:"Fecal Incontinence",fullTitle:"Fecal Incontinence - Causes, Management and Outcome"},signatures:"Arzu Ilce",authors:[{id:"30672",title:"Dr.",name:"Arzu",middleName:null,surname:"Ilce",slug:"arzu-ilce",fullName:"Arzu Ilce"}]}],onlineFirstChaptersFilter:{topicId:"16",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"83087",title:"Role of Cellular Responses in Periodontal Tissue Destruction",slug:"role-of-cellular-responses-in-periodontal-tissue-destruction",totalDownloads:1,totalDimensionsCites:null,doi:"10.5772/intechopen.106645",abstract:"Periodontal tissue destruction is the deterioration of tooth-supporting components, particularly the periodontal ligament (PDL) and alveolar bone, resulting in gingival recession, root exposure, tooth mobility and drifting, and, finally, tooth loss. The breakdown of the epithelial barriers by infection or mechanical damage allows bacteria and their toxins to enter and stimulates the immune response. The bacteria cause periodontal damage via the cascade of the host reaction which is crucial in the destruction of the connective tissue around the tooth. The OPG/RANKL/RANK system is the key player in bone regulation of periodontal tissue and was controlled by both immune and non-immune cells. This knowledge has predicated the successfulness of implant and orthodontics treatments with the predictable healing and regeneration of the bone and supporting tissues surrounding the teeth.",book:{id:"11566",title:"Periodontology - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11566.jpg"},signatures:"Nam Cong-Nhat Huynh"},{id:"83086",title:"Therapeutic Options in Graves’ Hyperthyroidism",slug:"therapeutic-options-in-graves-hyperthyroidism",totalDownloads:1,totalDimensionsCites:null,doi:"10.5772/intechopen.106562",abstract:"The classical approach to treating Graves’ hyperthyroidism involves rapid control of the symptoms, generally with a beta adrenergic blocker, and reduction of thyroid hormone secretion by antithyroid drugs (ATDs) and/or using one of the several modalities available, including radioactive iodine therapy (RAI), and surgery; the selection of the treatment modalities often varies according to different guidelines, patient preferences and local traditions. Thionamides are invariably used as first-line medication to control hyperthyroidism and induce remission of the disease, thereby relieving the symptoms. In case of failure of the medical therapy, which is not uncommon, definitive treatment with surgery or RAI is the standard modality of management after due consideration and discussion with the patients. However, the therapeutic options available for patients with Graves’ hyperthyroidism have remained largely unchanged for the past several decades despite the current treatments having either limited efficacy or significant adverse effects. The clinical demand for new therapeutic regimens of Graves’ disease has led to the emergence of several new therapeutic ideas/options like biologic, peptide immunomodulation and small molecules, currently under investigations which may lead to the restoration of a euthyroid state without the requirement for ongoing therapy, but the potential risk of immunocompromise and cost implications needs careful consideration.",book:{id:"11712",title:"Hyperthyroidism - Recent Updates",coverURL:"https://cdn.intechopen.com/books/images_new/11712.jpg"},signatures:"Javaid Ahmad Bhat, Shoiab Mohd Patto, Pooran Sharma, Mohammad Hayat Bhat and Shahnaz Ahmad Mir"},{id:"83085",title:"Research Progress on the Health Benefits of Scented Tea",slug:"research-progress-on-the-health-benefits-of-scented-tea",totalDownloads:0,totalDimensionsCites:null,doi:"10.5772/intechopen.106605",abstract:"Scented tea, also known as fragrant tea, mainly comprises green tea as the tea base and the dried and processed flowers of various plants. It is a unique reprocessed tea in China. There are many types of scented tea, including jasmine, lily, osmanthus, rose and honeysuckle. The scenting process greatly influences the quality of the scented tea. Humidifying continuous scenting processes, frying flower processes and innovative drying methods have been developed to resolve the issues of cumbersome, time-consuming and low utilisation rates of flowers in the process of making scented tea. The main chemical components of scented tea are polyphenols as well as exogenous plant glycosides, flavonoids, lactones, coumarins, quercetin, steroids, terpenoids and other compounds. Scented tea plays an active role in the prevention and treatment of various diseases and has as anti-oxidant, anti-cancer, hypoglycaemic, hypolipidemic, immunomodulatory and neuromodulatory effects. This chapter mainly reviews and summarises the types of scented teas and their related health functions.",book:{id:"11821",title:"Health Benefits of Tea - Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/11821.jpg"},signatures:"Bowen Liu, Jun Zhang, Xiaojian Zhou, Shuduan Deng and Guanben Du"},{id:"83084",title:"Association of Fatness and Leg Power with Blood Pressure in Adolescents",slug:"association-of-fatness-and-leg-power-with-blood-pressure-in-adolescents",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.106279",abstract:"This cross-sectional study examined the independent and joint association of fatness and leg power (LP) with resting blood pressure (BP) in adolescents (12 to 15 years) in Benue state of Nigeria. The present study comprised 2047 adolescents, including 1087 girls. Participants were assessed for body mass index (BMI), LP, and resting BP. Multivariate regression models assessing the associations of the independent variables with BP were conducted. Fatness and LP were independent predictors of resting BP among participants and the relationship of LP with BP was more robust in girls than boys. Combined fatness and LP in predicting BP was modest (R2 = 10.4–14.3%) after controlling for maturity status. Low LP was associated with systolic blood pressure (SBP) in both girls (R2 = 9.0%, β = 0.260, p = 0.001) and boys (R2 = 11.0%, β = 0.226, p = 0.001). In the model for diastolic blood pressure (DBP), only fatness was associated with BP in girls (p = 0.001). The odd of hypertension (HTN) risk among overweight girls was 2.6 times that compared to their healthy-weight peers. Girls with low LP were 0.40 times more likely to develop HTN risk compared to their counterparts with high LP. This study has demonstrated that lower body muscle power is more important than fatness in predicting HTN in adolescent boys and girls.",book:{id:"11022",title:"Weight Management - Challenges and Opportunities",coverURL:"https://cdn.intechopen.com/books/images_new/11022.jpg"},signatures:"Danladi Musa, Daniel Iornyor and Andrew Tyoakaa"},{id:"82915",title:"Imaging Ankylosing Spondylitis",slug:"imaging-ankylosing-spondylitis",totalDownloads:1,totalDimensionsCites:0,doi:"10.5772/intechopen.106345",abstract:"Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the spine and the sacroiliac joints. AS occurs with the inflammation of the entheses and formation of syndesmophytes and finally sacral and spinal ankylosis. Imaging demonstrates both inflammatory and chronic lesions. Sacroiliitis is the hallmark of the disease. Spinal changes usually take place in advanced stages of the disease. 1984 The Modified New York criteria evaluated for the diagnosis of AS with definite radiological sacroiliitis (bilaterally grade 2 or unilateral grade 3/4 sacroiliitis) on imaging. The Modified New York criteria are well performed in diagnosing the established disease but its sensitivity is too low in early disease identification and leads to a diagnostic delay. So, in 2009 The Assessment in Spondyloarthritis International Society (ASAS) recommended classification criteria for axial spondyloarthritis (axSpA). Patients have sacroiliitis on imaging and ≥1 SpA features (imaging arm) or positive HLA B27 and ≥2 SpA features (clinical arm) are classified as axial SpA. On the imaging arm, either radiographic sacroiliitis according to Modified New York criteria or active inflammation on MRI is required. Imaging is also used for determining extent of disease, monitoring activity and progression of the disease, assessment of the treatment effect, and prognosis in AS patients.",book:{id:"11273",title:"Ankylosing Spondylitis",coverURL:"https://cdn.intechopen.com/books/images_new/11273.jpg"},signatures:"Esra Dilsat Bayrak"},{id:"83074",title:"Targeted Regulation and Cellular Imaging of Tumor-Associated Macrophages in Triple-Negative Breast Cancer: From New Mechanistic Insights to Candidate Translational Applications",slug:"targeted-regulation-and-cellular-imaging-of-tumor-associated-macrophages-in-triple-negative-breast-c",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.105654",abstract:"The complex interplay between immune cells and tumor cells within the tumor microenvironment (TME) can lead to disease progression. Specifically, signals generated in the TME can cause immunosuppression, promoting angiogenesis and immune evasion, which leads to tumor development. The interplay of M1 and M2 macrophage populations that coincide with these tumor markers is particularly important in the TME. Triple-negative breast cancer (TNBC) often presents as advanced disease, and these tumors are also often bereft of recognized molecular targets that can be found in other subtypes, limiting their therapeutic options. However, tumor-associated macrophages (TAMs) infiltration in TNBC is frequently observed. Moreover, a high density of TAMs, particularly M2 macrophages, is associated with poorer outcomes in various cancers, including TNBC. This provides a strong basis for exploiting TAMs as potential therapeutic targets. Specifically, efforts to increase M2 to M1 repolarization are promising therapeutic approaches in TNBC, and four recent studies wherein divergent approaches to target the M2-rich macrophage population and reverse immune subversion are described. These and similar efforts may yield promising diagnostic or therapeutic options for TNBC, a great clinical need.",book:{id:"11277",title:"Macrophages -140 Years of Their Discovery",coverURL:"https://cdn.intechopen.com/books/images_new/11277.jpg"},signatures:"Anupama Hooda-Nehra, Tracey L. Smith, Alejandra I. Ferrer, Fernanda I. 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The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"7",title:"Biomedical Engineering",doi:"10.5772/intechopen.71985",issn:"2631-5343",scope:"Biomedical Engineering is one of the fastest-growing interdisciplinary branches of science and industry. The combination of electronics and computer science with biology and medicine has improved patient diagnosis, reduced rehabilitation time, and helped to facilitate a better quality of life. Nowadays, all medical imaging devices, medical instruments, or new laboratory techniques result from the cooperation of specialists in various fields. The series of Biomedical Engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine, and biology. This series is intended for doctors, engineers, and scientists involved in biomedical engineering or those wanting to start working in this field.",coverUrl:"https://cdn.intechopen.com/series/covers/7.jpg",latestPublicationDate:"August 14th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:12,editor:{id:"50150",title:"Prof.",name:"Robert",middleName:null,surname:"Koprowski",slug:"robert-koprowski",fullName:"Robert Koprowski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTYNQA4/Profile_Picture_1630478535317",biography:"Robert Koprowski, MD (1997), PhD (2003), Habilitation (2015), is an employee of the University of Silesia, Poland, Institute of Computer Science, Department of Biomedical Computer Systems. For 20 years, he has studied the analysis and processing of biomedical images, emphasizing the full automation of measurement for a large inter-individual variability of patients. Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:3,paginationItems:[{id:"7",title:"Bioinformatics and Medical Informatics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",isOpenForSubmission:!0,editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",slug:"slawomir-wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",biography:"Professor Sławomir Wilczyński, Head of the Chair of Department of Basic Biomedical Sciences, Faculty of Pharmaceutical Sciences, Medical University of Silesia in Katowice, Poland. His research interests are focused on modern imaging methods used in medicine and pharmacy, including in particular hyperspectral imaging, dynamic thermovision analysis, high-resolution ultrasound, as well as other techniques such as EPR, NMR and hemispheric directional reflectance. Author of over 100 scientific works, patents and industrial designs. Expert of the Polish National Center for Research and Development, Member of the Investment Committee in the Bridge Alfa NCBiR program, expert of the Polish Ministry of Funds and Regional Policy, Polish Medical Research Agency. Editor-in-chief of the journal in the field of aesthetic medicine and dermatology - Aesthetica.",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},{id:"8",title:"Bioinspired Technology and Biomechanics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",isOpenForSubmission:!0,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. His research interests include Biomedical Signal Processing and Modelling, Assistive Technology, Rehabilitation Engineering, Neuroengineering and Parkinson's Disease.",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",isOpenForSubmission:!0,editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",slug:"luis-villarreal-gomez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",biography:"Dr. Luis Villarreal is a research professor from the Facultad de Ciencias de la Ingeniería y Tecnología, Universidad Autónoma de Baja California, Tijuana, Baja California, México. Dr. Villarreal is the editor in chief and founder of the Revista de Ciencias Tecnológicas (RECIT) (https://recit.uabc.mx/) and is a member of several editorial and reviewer boards for numerous international journals. He has published more than thirty international papers and reviewed more than ninety-two manuscripts. His research interests include biomaterials, nanomaterials, bioengineering, biosensors, drug delivery systems, and tissue engineering.",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:27,paginationItems:[{id:"83092",title:"Novel Composites for Bone Tissue Engineering",doi:"10.5772/intechopen.106255",signatures:"Pugalanthipandian Sankaralingam, Poornimadevi Sakthivel and Vijayakumar Chinnaswamy Thangavel",slug:"novel-composites-for-bone-tissue-engineering",totalDownloads:0,totalCrossrefCites:null,totalDimensionsCites:0,authors:null,book:{title:"Biomimetics - Bridging the Gap",coverURL:"https://cdn.intechopen.com/books/images_new/11453.jpg",subseries:{id:"8",title:"Bioinspired Technology and Biomechanics"}}},{id:"82800",title:"Repurposing Drugs as Potential Therapeutics for the SARS-Cov-2 Viral Infection: Automatizing a Blind Molecular Docking High-throughput Pipeline",doi:"10.5772/intechopen.105792",signatures:"Aldo Herrera-Rodulfo, Mariana Andrade-Medina and Mauricio Carrillo-Tripp",slug:"repurposing-drugs-as-potential-therapeutics-for-the-sars-cov-2-viral-infection-automatizing-a-blind-",totalDownloads:7,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Molecular Docking - Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/11451.jpg",subseries:{id:"7",title:"Bioinformatics and Medical Informatics"}}},{id:"82582",title:"Protecting Bioelectric Signals from Electromagnetic Interference in a Wireless World",doi:"10.5772/intechopen.105951",signatures:"David Marcarian",slug:"protecting-bioelectric-signals-from-electromagnetic-interference-in-a-wireless-world",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Biosignal Processing",coverURL:"https://cdn.intechopen.com/books/images_new/11153.jpg",subseries:{id:"7",title:"Bioinformatics and Medical Informatics"}}},{id:"82586",title:"Fundamentals of Molecular Docking and Comparative Analysis of Protein–Small-Molecule Docking Approaches",doi:"10.5772/intechopen.105815",signatures:"Maden Sefika Feyza, Sezer Selin and Acuner Saliha Ece",slug:"fundamentals-of-molecular-docking-and-comparative-analysis-of-protein-small-molecule-docking-approac",totalDownloads:27,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Molecular Docking - Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/11451.jpg",subseries:{id:"7",title:"Bioinformatics and Medical Informatics"}}}]},overviewPagePublishedBooks:{paginationCount:12,paginationItems:[{type:"book",id:"6692",title:"Medical and Biological Image Analysis",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6692.jpg",slug:"medical-and-biological-image-analysis",publishedDate:"July 4th 2018",editedByType:"Edited by",bookSignature:"Robert Koprowski",hash:"e75f234a0fc1988d9816a94e4c724deb",volumeInSeries:1,fullTitle:"Medical and Biological Image Analysis",editors:[{id:"50150",title:"Prof.",name:"Robert",middleName:null,surname:"Koprowski",slug:"robert-koprowski",fullName:"Robert Koprowski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTYNQA4/Profile_Picture_1630478535317",biography:"Robert Koprowski, MD (1997), PhD (2003), Habilitation (2015), is an employee of the University of Silesia, Poland, Institute of Computer Science, Department of Biomedical Computer Systems. For 20 years, he has studied the analysis and processing of biomedical images, emphasizing the full automation of measurement for a large inter-individual variability of patients. Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. 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He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:{name:"Association for Computing Machinery",country:{name:"United States of America"}}},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:"Manufacturing and Technology Integrated Campus – SENAI CIMATEC",institution:null},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:'"Politechnica" University Timişoara',institution:null},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"426586",title:"Dr.",name:"Oladunni A.",middleName:null,surname:"Daramola",slug:"oladunni-a.-daramola",fullName:"Oladunni A. Daramola",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Federal University of Technology",country:{name:"Nigeria"}}},{id:"357014",title:"Prof.",name:"Leon",middleName:null,surname:"Bobrowski",slug:"leon-bobrowski",fullName:"Leon Bobrowski",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Bialystok University of Technology",country:{name:"Poland"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"354126",title:"Dr.",name:"Setiawan",middleName:null,surname:"Hadi",slug:"setiawan-hadi",fullName:"Setiawan Hadi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Padjadjaran University",country:{name:"Indonesia"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"332603",title:"Prof.",name:"Kumar S.",middleName:null,surname:"Ray",slug:"kumar-s.-ray",fullName:"Kumar S. Ray",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Statistical Institute",country:{name:"India"}}},{id:"415409",title:"Prof.",name:"Maghsoud",middleName:null,surname:"Amiri",slug:"maghsoud-amiri",fullName:"Maghsoud Amiri",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Allameh Tabataba'i University",country:{name:"Iran"}}},{id:"357085",title:"Mr.",name:"P. Mohan",middleName:null,surname:"Anand",slug:"p.-mohan-anand",fullName:"P. Mohan Anand",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356696",title:"Ph.D. Student",name:"P.V.",middleName:null,surname:"Sai Charan",slug:"p.v.-sai-charan",fullName:"P.V. Sai Charan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"357086",title:"Prof.",name:"Sandeep K.",middleName:null,surname:"Shukla",slug:"sandeep-k.-shukla",fullName:"Sandeep K. Shukla",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}}]}},subseries:{item:{id:"87",type:"subseries",title:"Economics",keywords:"Globalization, Economic Integration, Growth and Development, International Trade, Environmental Development, Developed Countries, Developing Countries, Technical Innovation, Knowledge Management, Political Economy Analysis, Banking and Financial Markets",scope:"
\r\n\tThe topic on Economics is designed to disseminate knowledge around broad global economic issues. Original submissions will be accepted in English for applied and theoretical articles, case studies and reviews about the specific challenges and opportunities faced by the economies and markets around the world. The authors are encouraged to apply rigorous economic analysis with significant policy implications for developed and developing countries. Examples of subjects of interest will include, but are not limited to globalization, economic integration, growth and development, international trade, environmental development, country specific comparative analysis, technical innovation and knowledge management, political economy analysis, and banking and financial markets.
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Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',annualVolume:11404,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"49517",title:"Prof.",name:"Hitoshi",middleName:null,surname:"Tsunashima",fullName:"Hitoshi Tsunashima",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTP4QAO/Profile_Picture_1625819726528",institutionString:null,institution:{name:"Nihon University",institutionURL:null,country:{name:"Japan"}}},{id:"425354",title:"Dr.",name:"Marcus",middleName:"Fraga",surname:"Vieira",fullName:"Marcus Vieira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003BJSgIQAX/Profile_Picture_1627904687309",institutionString:null,institution:{name:"Universidade Federal de Goiás",institutionURL:null,country:{name:"Brazil"}}},{id:"196746",title:"Dr.",name:"Ramana",middleName:null,surname:"Vinjamuri",fullName:"Ramana Vinjamuri",profilePictureURL:"https://mts.intechopen.com/storage/users/196746/images/system/196746.jpeg",institutionString:"University of Maryland, Baltimore County",institution:{name:"University of Maryland, Baltimore County",institutionURL:null,country:{name:"United States of America"}}}]},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering",scope:"The Biotechnology - Biosensors, Biomaterials and Tissue Engineering topic within the Biomedical Engineering Series aims to rapidly publish contributions on all aspects of biotechnology, biosensors, biomaterial and tissue engineering. We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. 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