Passive hemostats.
\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
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Global warming and climate change refer to an increase in average global temperatures. Natural events and human activities are believed to be main contributors to such increases in average global temperatures. The climate change, caused by rising emissions of carbon dioxide from vehicles, factories and power stations, will not only effects the atmosphere and the sea but also will alter the geology of the Earth. Emissions of carbon dioxide due to our use of fossil energy will change the climate and the temperature is estimated to increase by 2 to 6o Celsius within year 2100, which is a tremendous increase from our current average temperature of 1.7o Celsius as predicted by IPCC. This may cause huge changes to our civilization, both positive and negative, but the total impact on our society is currently very uncertain. Forecasts indicate that major storms could devastate New York City in next decade whereas Gulf countries will get affected badly well before.
Global warming primarily caused by increases in “greenhouse” gases such as Carbon Dioxide (CO2), Nitrous oxide (NOX), Sulphur dioxide (SO2), Hydrogen etc.,. A warming planet thus leads to climate changes which can adversely affect weather in different ways. Some of the prominent indicators for a global warming are detailed below:
Temperature over land
Snow cover on Hills
Glaciers on Hills
Ocean Heat content
Sea Ice
Sea level
Sea surface temperature
Temperature Over Ocean
Humidity
Tropospheric Temperature
Past decade, according to Scientists in 48 Countries, it was recorded warmest time phase during meeting of
Global warming in today’s scenario is threat to the survival of mankind. In 1956, an US based Chief consultant and oil geologist Marion King Hubert, (1956) predicted that if oil is consumed with high rate, US oil production may peak in 1970 and thereafter it will decline. He also described that other countries may attain peak oil day within 20-30 years and many more may suffer with oil crises within 40 years, when oil wells are going to dry. He illustrated the projection with a bell shaped
Crude oil, coal and gas are the main resources for world energy supply. The size of fossil fuel reserves and the dilemma that when non-renewable energy will be diminished, is a fundamental and doubtful question that needs to be answered. A new formula for calculating, when fossil fuel reserves are likely to be depleted, is presented along with an econometrics model to demonstrate the relationship between fossil fuel reserves and some main variables (Shahriar Shafiee et.al. 2009). The new formula is modified from the Klass model and thus assumes a continuous compound rate and computes fossil fuel reserve depletion times for oil, coal and gas of approximately 35, 107 and 37 years, respectively. This means that coal reserves are available up to 2112, and will be the only fossil fuel remaining after 2042.
In India, vehicular pollution is estimated to have increased eight times over the last two decades. This source alone is estimated to contribute about 70 per cent to the total air pollution. With 243.3 million tons of carbon released from the consumption and combustion of fossil fuels in 1999, India is ranked fifth in the world behind the U.S., China, Russia and Japan. India\'s contribution to world carbon emissions is expected to increase in the coming years due to the rapid pace of urbanization, shift from non-commercial to commercial fuels, increased vehicular usage and continued use of older and more inefficient coal-fired and fuel power-plants (Singh, BR, et al., 2010).
Thus, peak oil year may be the turning point for mankind which may lead to the end of 100 year of easy growth, if self-sufficiently and sustainability of energy is not maintained on priority. This chapter describes the efforts being made to explore non-conventional energy resources such as: solar energy, wind energy, bio-mass and bio-gas, hydrogen, bio-diesel which may help for the sustainable fossil fuel reserves and reduce the tail pipe emission and other pollutants like: CO2, NOX etc.. The special emphasis is also given for the storage of energy such as compressed air stored from solar, wind and or other resources like: climatic energy to maintain energy sustainability of 21st century. This may also leads to environmentally and ecologically better future.
In September 1816, Lord Byron set off from Geneva with his friend Hob house, and kept a journal for his half-sister Augusta. Lodged at the Curate\'s, set out to see the Valley; heard an Avalanche fall, like thunder; saw Glacier – enormous. Storm came on, thunder, lightning, hail; all in perfection, and beautiful (Fig 1).
Byron described glaciers in Geneva as "neither mist nor water" in September 1816. (Photograph: John Mcconnico/AP)
He said that he was on horseback; Guide wanted to carry his cane; he was going to give it to him, when he recollected that it was a Swordstick, and he thought lightning might be attracted towards him; kept it himself; a good deal encumbered with it, and his cloak, as it was too heavy for a whip, and the horse was stupid, and stood still with every other peal," he records in Byron: Selections from Poetry, Letters & Journals (Nonesuch Press.)
Got in, not very wet; the cloak being staunch, H wet though. H took refuge in a cottage; sent man, umbrella and cloak (from the Curate\'s when he arrived) after him. He sees a torrent like the tail of a white horse streaming in the wind, such as it might be conceived would be that of the \'
With increases in the Earth\'s global mean temperature i.e., global warming, the various effects on climate change pose risks that increases. The IPCC (
Threats to endangered species and unique systems,
Damages from extreme climate events,
Effects that fall most heavily on developing countries and
The poor within countries, global aggregate impacts (i.e., various measurements of total social, economic and ecological impacts), and large-scale high-impact events.
The effects, or impacts, of climate change may be physical, ecological, social or economic. Evidence of observed climate change includes the instrumental temperature record, rising sea levels, and decreased snow cover in the Northern Hemisphere. According to the Intergovernmental Panel on Climate Change (IPCC, 2007a:10), "[most] of the observed increase in global average temperatures since the mid-20th century is
The phrase climate change is used to describe a change in the climate, measured in terms of its statistical properties, e.g., the global mean surface temperature. In this context, climate is taken to mean the average weather. Climate can change over period of time ranging from months to thousands or millions of years. The classical time period is 30 years, as defined by the World Meteorological Organization. The climate change referred to may be due to natural causes, e.g., changes in the sun\'s output, or due to human activities, e.g., changing the composition of the atmosphere. Any human-induced changes in climate will occur against the background of natural climatic variations.
Climate change reflects a change in the energy balance of the climate system, i.e. changes the relative balance between incoming solar radiation and outgoing infrared radiation from Earth. When this balance changes it is called "radiative forcing", and the calculation and measurement of radiative forcing is one aspect of the science of climatology. The processes that cause such changes are called "forcing mechanisms". Forcing mechanisms can be either "internal" or "external". Internal forcing mechanisms are natural processes within the climate system itself, e.g., the meridional turnover. External forcing mechanisms can be either natural (e.g., changes in solar output) or anthropogenic (e.g., increased emissions of greenhouse gases).
Whether the initial forcing mechanism is internal or external, the response of the climate system might be fast (e.g., a sudden cooling due to airborne volcanic ash reflecting sunlight), slow (e.g. thermal expansion of warming ocean water), or a combination (e.g., sudden loss of albedo in the arctic ocean as sea ice melts, followed by more gradual thermal expansion of the water). Therefore, the climate system can respond abruptly, but the full response to forcing mechanisms might not be fully developed for centuries or even longer.
The most general definition of
Increases in the frequency of intense rainfall,
Decreases in snow cover and sea ice,
More frequent and intense heat waves,
Rising sea levels, and
Widespread ocean acidification.
There are two studied made here to elaborate the risk of intense rain fall one by United States and other one by United Kingdom. They have warned that these risks are due to extreme climate change, thus we have to curb the global warming issues in phases. The summaries of study are given below:
The National Wildlife Federation says that to limit the magnitude of changes to the climate and the impacts on communities and wildlife, we must curb global warming pollution. The National Wildlife Federation recommends that policy makers, industry, and individuals take steps to reduce global warming pollution from today’s levels by 80 percent by 2050. That’s a reduction of 20 percent per decade or just 2 percent per year. Science tells us that this is the only way to hold warming in the next century to no more than 2°F. This target is achievable with technologies either available or under development, but we need to start taking action now to avoid the worst impacts (See: www.nwf.org/globalwarming).
There has been a two-part change in extreme rainfall event occurrence across the UK from 1961-2000. Little change is observed at 1- and 2-day duration, but significant decadal level changes are seen in 5- and 10-day events in many regions. In the south of the UK, growth curves have flattened and 5- and 10-day annual maxima have decreased during the 1990s. However, in the north, the 10-day growth curve has steepened and annual maxima have risen during the 1990s. This is particularly evident in Scotland. The 50-year event in Scotland during 1961-1990 has become an 8-, 11- and 25-year event in the Eastern, Southern and Northern Scotland pooling regions respectively during the 1990s. In northern England the average recurrence interval has also halved. This may have severe implications for design and planning practices in flood control.
Increasing flood risk is now recognised as the most important sectoral threat from climate change in most parts of the world, with recent repeated severe flooding in the UK and Europe causing major loss of property and life, and causing the insurance industry to threaten the withdrawal of flood insurance cover from millions of UK households. This has prompted public debate on the apparent increased frequency of extremes and focussed attention in particular on perceived increases in rainfall intensities. Climate model integrations predict increases in both the frequency and intensity of heavy rainfall in the high latitudes under enhanced greenhouse conditions. These projections are consistent with recent increases in rainfall intensity seen in the UK and worldwide.
Time-series of relative sea level for the past 300 years from Northern Europe: Amsterdam, Netherlands; Brest, France; Sheerness, UK; Stockholm, Sweden (detrended over the period 1774 to 1873 to remove to first order the contribution of post-glacial rebound); Swinoujscie, Poland (formerly Swinemunde, Germany); and Liverpool, UK. Data for the latter are of "Adjusted Mean High Water" rather than Mean Sea Level and include a nodal (18.6 year) term. The scale bar indicates ±100 mm.
A recent study shows that an increase in heat-absorbing greenhouse gases intensifies an unusual atmospheric circulation pattern already observed during heat waves in Europe and North America. As the pattern becomes more pronounced, severe heat waves occur in the Mediterranean region and the southern and western United States. Other parts of France, Germany and the Balkans also become more susceptible to severe heat waves. "Extreme weather events will have some of the most severe impacts on human society as climate changes, "says Meehl.
Heat waves can kill more people in a shorter time than almost any other climate event. According to records, 739 people died as a result of Chicago\'s July, 1995, heat wave. Fifteen thousand Parisians are estimated to have died from heat in August, 2003, along with thousands of farm animals. For the study, Meehl and Tebaldi compared present (1961-1990) and future (2080-2099) decades to determine how greenhouse gases and sulfate aerosols might affect future climate in Europe and the United States, focusing on Paris and Chicago. They assumed little policy intervention to slow the buildup of greenhouse gases. During the Paris and Chicago heat waves, atmospheric pressure rose to values higher than usual over Lake Michigan and Paris, producing clear skies and prolonged heat. In the model, atmospheric pressure increases even more during heat waves in both regions as carbon dioxide accumulates in the atmosphere.
Heat wave is based on the concept of exceeding specific thresholds, thus allowing analyses of heat wave duration and frequency. Three criteria were used to define heat waves in this way, which relied on two location-specific thresholds for maximum temperatures. Threshold 1 (T1) was defined as the 97.5th percentile of the distribution of maximum temperatures in the observations and in the simulated present-day climate (seasonal climatology at the given location), and T2 was defined as the 81st percentile. A heat wave was then defined as the longest period of consecutive days satisfying the following three conditions:
The daily maximum temperature must be above T1 for at least 3 days,
The average daily maximum temperature must be above T1 for the entire period, and
The daily maximum temperature must be above T2 for every day of the entire period.
Because the Chicago heat wave of 1995 and the Paris heat wave of 2003 had particularly severe impacts, we chose grid points from the model that were close to those two locations to illustrate heat wave characteristics. This choice was subjective and illustrative given that there are, of course, other well-known heat waves from other locations. Also, we are not suggesting that a model grid point is similar to a particular weather station; we picked these grid points because they represent heat wave conditions for regions representative of Illinois and France in the model, and therefore they can help identify processes that contribute to changes in heat waves in the future climate in those regions. We chose comparable grid points from the National Centers for Environmental Prediction (NCEP)/NCAR reanalyses that used assimilated observational data for comparison to the model results.
Heat waves in Chicago, Paris, and elsewhere in North America and Europe will become more intense, more frequent and longer lasting in the 21st century, according to a new modeling study by two scientists at the National Center for Atmospheric Research (NCAR) in Boulder, Colo. In the United States, heat waves will become most severe in the West and South. The findings appear in the August 13(2004) issue of the journal Science. Gerald Meehl and Claudia Tebaldi, both of NCAR, examined Earth\'s future climate using the Parallel Climate Model, developed by NCAR and the U.S. Department of Energy (DOE).
During the 1995 Chicago heat wave, the most severe health impacts resulted from the lack of cooling relief several nights in a row, according to health experts. In the model, the western and southern United States and the Mediterranean region of Europe experience a rise in nighttime minimum temperatures of more than 3 degrees Celsius (5.4 degrees Fahrenheit) three nights in a row. They will occur more often: The average number of heat waves in the Chicago area increases in the coming century by 25 percent, from "Heat Waves of the 21st Century: More Intense, More Frequent and Longer Lasting." (Source: PHYSorg.com. 12 Aug 2004, http://phys.org/news806.html Page 1/21.66 per year to 2.08).
In Paris, the average number increases 31percent, from 1.64 per year to 2.15. They will last longer: Chicago\'s present heat waves last from 5.39 to 8.85 days; future events increase to between 8.5 and 9.24 days. In Paris, present-day heat waves persist from 8.33 to 12.69 days; they stretch to between 11.39 and 17.04 days in future decades.(Source: National Science Foundation)
Based on tide gauge data, the rate of global mean sea level rise during the 20th century is in the range 1.0 to 2.0 mm/yr, with a central value of 1.5 mm/yr (the central value should not be interpreted as a best estimate.
Firstly, as ocean water warms, it expands. On the basis of observations of ocean temperatures and model results, thermal expansion is believed to be one of the major contributors to historical sea level changes. Further, thermal expansion is expected to contribute the largest component to sea level rise over the next hundred years. Deep ocean temperatures change only slowly; therefore, thermal expansion would continue for many centuries even if the atmospheric concentrations of greenhouse gases were to stabilise.
The amount of warming and the depth of water affected vary with location. In addition, warmer water expands more than colder water for a given change in temperature. The geographical distribution of sea level change results from the geographical variation of thermal expansion, changes in salinity, winds, and ocean circulation. The range of regional variation is substantial compared with the global average sea level rise.
Rise in sea Level: Sea level also changes when the mass of water in the ocean increases or decreases. This occurs when ocean water is exchanged with the water stored on land. The major land store is the water frozen in glaciers or ice sheets. Indeed, the main reason for the lower sea level during the last glacial period was the amount of water stored in the large extension of the ice sheets on the continents of the Northern Hemisphere. After thermal expansion, the melting of mountain glaciers and ice caps is expected to make the largest contribution to the rise of sea level over the next hundred years. These glaciers and ice caps make up only a few per cent of the world\'s land-ice area, but they are more sensitive to climate change than the larger ice sheets in Greenland and Antarctica, because the ice sheets are in colder climates with low precipitation and low melting rates. Consequently, the large ice sheets are expected to make only a small net contribution to sea level change in the coming decades.
A new study says the seas are acidifying ten times faster today than 55 million years ago when a mass extinction of marine species occurred. And, the study concludes, current changes in ocean chemistry due to the burning of fossil fuels may portend a new wave of die-offs. In other words, the vast clouds of shelled creatures in the deep oceans had virtually disappeared. Many scientists now agree that this change was caused by a drastic drop of the ocean’s pH level. The seawater became so corrosive that it ate away at the shells, along with other species with calcium carbonate in their bodies. It took hundreds of thousands of years for the oceans to recover from this crisis, and for the sea floor to turn from red back to white. The clay that the crew of the JOIDES Resolution dredged up may be an ominous warning of what the future has in store. By spewing carbon dioxide into the air, we are now once again making the oceans more acidic.
Approximately one millennium after the 7 Ka (32nd Century BCE) slowing of sea-level rise, many coastal urban centers rose to prominence around the world (Day, John W., et al. 2007). It has been hypothesized that this is correlated with the development of stable coastal environments and ecosystems and an increase in marine productivity (also related to an increase in temperatures), which would provide a food source for hierarchical urban societies.
The last written records of the Norse Greenlanders are from a 1408 marriage in the church of Hvalsey — today the best-preserved of the Norse ruins. Climate change has been associated with the historical collapse of civilizations, cities and dynasties. Notable examples of this include the Anasazi (Demenocal, P. B. 2001), Classic Maya (Hodell, David A., 1995), the Harappa, the Hittites, and Ancient Egypt (Jonathan Cowie, 2007). Other, smaller communities such as the Viking settlement of Greenland (transl. with introd. by Magnus Magnusson, 1983), have also suffered collapse with climate change being a suggested contributory factor (Diamond, Jared, 2005).
There are two proposed methods of Classic Maya collapse: environmental and non-environmental. The environmental approach uses paleoclimatic evidence to show that movements in the intertropical convergence zone likely caused severe, extended droughts during a few time periods at the end of the archaeological record for the classic Maya (Haug, Gh, et al., 2003). The non-environmental approach suggests that the collapse could be due to increasing class tensions associated with the building of monumental architecture and the corresponding decline of agriculture (Hosler D, et al., 1977), increased disease (Santley, Robert S.,et al., 1986) and increased internal warfare (Foias, Antonia E., et al.,1997). The Harappa and Indus civilizations were affected by drought 4,500–3,500 years ago. A decline in rainfall in the Middle East and Northern India 3,800–2,500 is likely to have affected the Hittites and Ancient Egypt.
Notable periods of climate change in recorded history include the medieval warm period and the little ice age. In the case of the Norse, the medieval warm period was associated with the Norse age of exploration and arctic colonization, and the later colder periods led to the decline of those colonies (Patterson, W.P., et al., 2007). Climate change in the recent past may be detected by corresponding changes in settlement and agricultural patterns. Archaeological evidence, oral history and historical documents can offer insights into past changes in the climate. Climate change effects have been linked to the collapse of various civilizations.
According to different levels of future global warming, impacts of climate has been used in the IPCC\'s Assessment Reports on climate change (Schneider DH, et al., 2007). The instrumental temperature record shows global warming of around 0.6 °C over the entire 20th century (IPCC 2007d.1). The future level of global warming is uncertain, but a wide range of estimates (projections) have been made (Fisher, BS et al., 2007). The IPCC\'s "SRES" scenarios have been frequently used to make projections of future climate change (Karl, 2009). Climate models using the six SRES "marker" scenarios suggest future warming of 1.1 to 6.4 °C by the end of the 21st century (above average global temperatures over the 1980 to 1999 time period as shown in Fig.3) (IPCC 2007d.3). The projected rate of warming under these scenarios would very likely be without precedent during at least the last 10,000 years (IPCC 2001-SPM). The most recent warm period comparable to these projections was the mid-Pliocene, around 3 million years ago (Stern N., 2008). At that time, models suggest that mean global temperatures were about 2–3 °C warmer than pre-industrial temperatures (Jansen E., et al., 2007).
Global Land-Ocean, mean surface temperature difference from the average for 1880–2009 (Courtesy: Wikipedia.com)
The most recent report IPCC projected that during the 21st century the global surface temperature is likely to rise a further1.1 to 2.9 °C (2 to 5.2 °F) for the lowest emissions scenario used in the report and 2.4 to 6.4 °C (4.3 to 11.5 °F) for the highest (Fig.4).
Working Group I\'s contribution to the IPCC Fourth Assessment Report, published in 2007, concluded that warming of the climate system was "unequivocal” (Solomon S, 2007a). This was based on the consistency of evidence across a range of observed changes, including increases in global average air and ocean temperatures, widespread melting of snow and ice, and rising global average sea level(Solomon S, 2007b).
Human activities have contributed to a number of the observed changes in climate (Hegerl GC, et. al., 2007). This contribution has principally been through the burning of fossil fuels, which has led to an increase in the concentration of GHGs in the atmosphere. This increase in GHG concentrations has caused a radiative forcing of the climate in the direction of warming. Human-induced forcing of the climate has likely to contributed to a number of observed changes, including sea level rise, changes in climate extremes (such as warm and cold days), declines in Arctic sea ice extent, and to glacier retreat (Fig.5 & 6).
Projected Global Temperature Rise 1.1 to 6.4 °C during 21st century (Courtesy: Wikipedia.com)
Decline in thickness of glaciers worldwide over the past half-century
Key climate indicators that show global warming (Courtesy: Wikipedia.com)
Human-induced warming could potentially lead to some impacts that are abrupt or irreversible. The probability of warming having unforeseen consequences increases with the rate, magnitude, and duration of climate change.
Observations show that there have been changes in weather (Le Treut H, et. al., 2007). As climate changes, the probabilities of certain types of weather events are affected. Changes have been observed in the amount, intensity, frequency, and type of precipitation. Widespread increases in heavy precipitation have occurred, even in places where total rain amounts have decreased. IPCC (2007d) concluded that human influences had, more likely than not (greater than 50% probability, based on expert judgment), contributed to an increase in the frequency of heavy precipitation events. Projections of future changes in precipitation show overall increases in the global average, but with substantial shifts in where and how precipitation falls. Climate models tend to project increasing precipitation at high latitudes and in the tropics (e.g., the south-east monsoon region and over the tropical Pacific) and decreasing precipitation in the sub-tropics (e.g., over much of North Africa and the northern Sahara).
Evidence suggests that, since the 1970s, there have been substantial increases in the intensity and duration of tropical storms and hurricanes. Models project a general tendency for more intense but fewer storms outside the tropics.
Since the late 20th century, changes have been observed in the trends of some extreme weather and climate events, e.g., heat waves. Human activities have, with varying degrees of confidence, contributed to some of these observed trends. Projections for the 21st century suggest continuing changes in trends for some extreme events (Fig.7). Solomon et al. (2007), for example, projected the following likely (greater than 66% probability, based on expert judgment) changes:
an increase in the areas affected by drought;
increased tropical cyclone activity; and
increased incidence of extreme high sea level (excluding tsunamis).
Projected changes in extreme events will have predominantly adverse impacts on ecosystems and human society.
Scientists are to outline dramatic evidence that global warming threatens the planet in a new and unexpected way – by triggering earthquakes, tsunamis, avalanches and volcanic eruptions. It is assessed that the Melting glaciers will set off avalanches, floods and mud flows in the Alps and other mountain ranges; torrential rainfall in the UK is likely to cause widespread erosion; while disappearing Greenland and Antarctic ice sheets threaten to let loose underwater landslides, triggering tsunamis that could even strike the seas around Britain.
At the same time the disappearance of ice caps will change the pressures acting on the Earth\'s crust and set off volcanic eruptions across the globe. Life on Earth faces a warm future – and a fiery one.
Accumulated cyclone energy in the Atlantic Ocean and the sea surface temperature difference which influences such, measured by the U.S. NOAA.
Not only are the oceans and atmosphere conspiring against us, bringing baking temperatures, more powerful storms and floods, but the crust beneath our feet seems likely to join in too, said Professor Bill McGuire, director of the Benfield Hazard Research Centre, at University College London (UCL).
Maybe the Earth is trying to tell us something, added McGuire, who is one of the organisers of UCL\'s Climate Forcing of Geological Hazards. Some of the key evidence will come from studies of past volcanic activity. These indicate that when ice sheets disappear the number of eruptions increases, said Professor David Pyle, of Oxford University\'s earth sciences department.
The last ice age came to an end between 12,000 to 15,000 years ago and the ice sheets that once covered central Europe shrank dramatically, added Pyle. The impact on the continent\'s geology can be measured by the jump in volcanic activity that occurred at this time.
In the Eiffel region of western Germany a huge eruption created a vast caldera, or basin-shaped crater, 12,900 years ago, for example. This has since flooded to form the Laacher See, near Koblenz. Scientists are now studying volcanic regions in Chile and Alaska – where glaciers and ice sheets are shrinking rapidly as the planet heats up – in an effort to anticipate the eruptions that might be set off.
Recently scientists from Northern Arizona University reported in the journal Science that temperatures in the Arctic were now higher than at any time in the past 2,000 years. Ice sheets are disappearing at a dramatic rate – and these could have other, unexpected impacts on the planet\'s geology.
According to Professor Mark Maslin of UCL, one is likely to be the release of the planet\'s methane hydrate deposits. These ice-like deposits are found on the seabed and in the permafrost regions of Siberia and the far north. These permafrost deposits are now melting and releasing their methane, said Maslin. You can see the methane bubbling out of lakes in Siberia. And that is a concern, for the impact of methane in the atmosphere is considerable. It is 25 times more powerful than carbon dioxide as a greenhouse gas.
Earthquake
A build-up of permafrost methane in the atmosphere would produce a further jump in global warming and accelerate the process of climate change. Even more worrying, however, is the impact of rising sea temperatures on the far greater reserves of methane hydrates that are found on the sea floor. It was not just the warming of the sea that was the problem, added Maslin. As the ice around Greenland and Antarctica melted, sediments would pour off land masses and cliffs would crumble, triggering underwater landslides that would break open more hydrate reserves on the sea-bed. Again there would be a jump in global warming. These are key issues that we will have to investigate over the next few years, he said.
There is also a danger of earthquakes, triggered by disintegrating glaciers, causing tsunamis off Chile, New Zealand and Newfoundland in Canada, NASA scientist Tony Song said recently (Fig.8). The last on this list could even send a tsunami across the Atlantic, one that might reach British shores. From other experts, it is said that the risk posed by melting ice in mountain regions, which would pose significant dangers to local people and tourists. The Alps, in particular, face a worryingly uncertain future, said Jasper Knight of Exeter University. Rock walls resting against glaciers will become unstable as the ice disappears and so set off avalanches. In addition, increasing melt-waters will trigger more floods and mud flows.
For the Alps this is a serious problem. Tourism is growing there, while the region\'s population is rising. Managing and protecting these people was now an issue that needed to be addressed as a matter of urgency, Knight said. "Global warming is not just a matter of warmer weather, more floods or stronger hurricanes. It is a wake-up call to Terra Firma," McGuire said.
Sea-level rise due to climate change could cripple the city in Irene-like storm scenarios, new climate report claims Irene-like storms of the future would put a third of New York City streets under water and flood many of the tunnels leading into Manhattan in under an hour because of climate change, a new state government report warns Wednesday 16th Nov’ 2011 (Fig.9).
Sea level rise due to climate change would leave lower Manhattan dangerously exposed to flood surges during major storms, the report, which looks at the impact of climate change across the entire state of New York, warns. The risks and the impacts are huge, said Art deGaetano, a climate scientist at Cornell University and lead author of the ClimAID study. Clearly areas of the city that are currently inhabited will be uninhabitable with the rising of the sea.
Factor in storm surges, and the scenario becomes even more frightening, he said. Subway tunnels get affected, airports - both LaGuardia and Kennedy sit right at sea level - and when you are talking about the lowest areas of the city you are talking about the business districts. The report, commissioned by the New York State Energy Research and Development Authority, said the effects of sea level rise and changing weather patterns would be felt as early as the next decade.
The Manhattan skyline as Hurricane Irene approached
By the mid-2020s, sea level rise around Manhattan and Long Island could be up to 10 inches, assuming the rapid melting of polar sea ice continues. By 2050, sea-rise could reach 2.5ft and more than 4.5ft by 2080 under the same conditions. In such a scenario, many of the tunnels - subway, highway, and rail - crossing into the Bronx beneath the Harlem River, and under the East River would be flooded within the hour, the report said. Some transport systems could be out of operation for up to a month.
The report, which was two years in the making, was intended to help the New York state government take steps now to get people out of harm\'s way - and factor climate change into long-term planning to protect transport, water and sewage systems. New York mayor Michael Bloomberg was so concerned that he went on to commission an even more detailed study of the city after receiving early briefings on the report. That makes him an outlier among his fellow Republicans, who blocked funds for creating a new climate service in budget negotiations in Congress this week.
DeGaetano said climate change would force governments to begin rethinking infrastructure. Most of New York City\'s power plants, water treatment plants, and sewage systems are right at sea level. City planners are also going to have to help people adapt. More than half a million people live in the New York flood plain, and, as the report noted, a significant portion of them are African American and Latinos. And floods are not the only potential danger of climate change. The report notes that New York could face average annual temperature rises of up to 5 degrees Fahrenheit by the middle of this century and by as much as 9 degrees by 2080.
In summer months, this could subject New Yorkers to power shortages and the risk of black-outs because of the extra need for air conditioning. Those without air conditioning - or who cannot afford the higher electricity bills - would be at greater risk of heat stroke. Those hotter conditions would have effects right across the state, playing havoc with New York State’s wine and agricultural industries. Spruce and Fir trees would disappear from the Catskills and West Hudson River Valley, dairy cows would suffer heat stress, and popular apple varieties would decline, the report said.
Climate change is likely to cause more storms, floods, droughts, heatwaves and other extreme weather events, according to the most authoritative review yet of the effects of global warming. Report likely to conclude that man-made emissions are increasing the frequency of storms, floods and droughts on Thursday- 17 November 2011 16.32 GMT from New York. The Intergovernmental Panel on Climate Change will publish on 18 November 2011, its first special report on extreme weather, and its relationship to rising greenhouse gas emissions. The final details are being fought over by governments, as the "summary for policymakers" of the report has to be agreed in full by every nation that chooses to be involved. But the conclusions are expected to be that emissions from human activities are increasing the frequency of extreme weather events. In particular, there are likely to be many more heatwaves, droughts and changes in rainfall patterns.
Jake Schmidt of the US-based Natural Resources Defense Council said: This report should be a wake-up call to those that believe that climate change is some distant issue that might impact someone else. The report documents that extreme weather is happening now and that global warming will bring very dangerous events in the future. From the report you can see that extreme weather will impact everyone in one way or another. This is a window into the future if our political response doesn\'t change quickly.
This special report - one of only two that the IPCC is publishing before its 2014 comprehensive assessment of the state of climate change science - is particularly controversial as it deals with the relationship between man-made climate change and damaging events such as storms, floods and droughts. Some climate change skeptics and scientists cast doubt on whether the observed increase in extreme weather events can be attributed directly to human actions, or whether much of it is due to natural variability in the weather (Fig. 10).
The IPCC, a body of the world\'s leading climate scientists convened by the United Nations, is likely to conclude that extreme weather can be linked to man-made climate change, but that individual weather events can at present only rarely be linked directly to global warming.
The Red Cross warned that disaster agencies were already dealing with the effects of climate change in vulnerable countries across the world. "The findings of this report certainly tally with what the Red Cross Movement is seeing, which is a rise in the number of weather-related emergencies around the world," said Maarten van Aalst, director of the Red Cross / Red Crescent Climate Centre and coordinating lead author of the IPCC report. "We are committed to responding to disasters whenever and wherever they happen, but we have to recognise that if the number of disasters continues to increase, the current model we have for responding to them is simply impossible to sustain."
A Pakistani mother carries her children through flood waters in 2010. The IPCC report deals with the relationship between man-made climate change and extreme weather. (Photograph: K.M.Chaudary/AP)
Insurers are also worried. Mark Way, of the insurance giant Swiss Re, told the Guardian that the massive increase in insurance claims was causing serious concern. He said that between 1970 and 1989, the insurance industry globally had paid out an average of $5bn a year in weather-related claims, but that this had increased enormously to $27bn a year. Although not all of this was attributable to climate change - increasing population, urbanisation and prosperity also play a major part - he said insurers wanted governments to get to grips with the effects of climate change in order to prepare for likely damage and tackle the causes of global warming.
Mike Hulme at the Tyndall Centre said it would be dangerous for governments to use this report in order to justify directing overseas aid only to those countries that could be proved to be suffering from climate change, rather than other problems. In that scenario, he said: "Funding will no longer go to those who are most at risk from climate-impacts and with low adaptive capacity, but will go to those who are lucky enough to live in regions of the world where weather extremes happen to be most attributable by climate models to human agency. These regions tend to be in mid-to-high latitudes, with lots of good weather data and well calibrated models. So, goodbye Africa."
From the various studies and reports, it is evident that the with the current rate of carbon dioxide release in the atmosphere there would not only be the increase in the global temperature, but it will also cause rise in sea, level and increase the frequency of disasters. The following major challenges are noticed from the above study:
Emissions from human activities are increasing the frequency of extreme weather events. In particular, there are likely to be many more heatwaves, droughts and changes in rainfall patterns.
The temperature is estimated to increase by 2 to 6o Celsius within year 2100, which is a tremendous increase from our current average temperature of 1.7o Celsius (IPCC).
By the mid-2020s, sea level rise around Manhattan and Long Island could be up to 10 inches, assuming the rapid melting of polar sea ice continues. By 2050, sea-rise could reach 2.5ft and more than 4.5ft by 2080 under the same conditions.
Global warming threatens the planet in a new and unexpected way – by triggering earthquakes, tsunamis, avalanches and volcanic eruptions.
Irene-like storms of the future would put a third of New York City streets under water and flood many of the tunnels leading into Manhattan in under an hour because of climate change.
These are few glimpses of future suspects; there may be much more bad implications of evils of climate change globally and humanity will be at high risk, developments will get shattered and rescue efforts will gain higher priorities
Authors indebted to extend their thanks to the School of Management Sciences, Technical Campus, Lucknow and Harcourt Butler Technological Institute, Kanpur for providing the support of Library.
There are a number of factors that influence patient outcome in trauma and orthopedic surgery in relation to hemorrhage. These can include patient factors, for example anticoagulant and antiplatelet medications, coagulopathies and other conditions, as well as surgical factors such as bony bleeding, large surgical incisions, diffuse venous bleeding and unseen sources of bleeding [1, 2].
Trauma still remains a leading worldwide cause of morbidity and mortality [3] and despite various developments over the years, hemorrhagic shock from trauma continues to form one part of the terrible triad contributing to mortality in both the military and civilian settings [4].
Effective hemostasis during surgery is advantageous to the surgeon as it prevents diffuse bleeding from capillaries and venules obscuring the surgical field and adding to operation time and infection risk [5, 6].
Significant blood loss has been associated with increased need for allogeneic and autologous blood transfusion [2, 7, 8]. These are associated with attendant risks including nosocomial infections [9], transfusion-related injury and fluid overload [10, 11]. In fact blood transfusion is an independent risk factor for infection, respiratory complications and the need for critical care support in traumatic injuries and resulted in a twofold increase in complications and critical care admissions, with more than two units of blood transfusion [7]. The risk of major perioperative complications is also increased with high intraoperative blood loss [2, 12, 13]. Therefore, patient outcome is optimal when the balance between bleeding and clotting is maintained during surgery such that tissue perfusion is adequate without excessive blood loss [5, 6].
Hemostasis in regard to trauma and surgery is a highly regulated process, maintaining flow through vessels at the same time as the thrombotic response to tissue damage is occurring [14], thereby ensuring tissue perfusion and limiting blood loss. The process is a complex interaction between vascular endothelium, platelets, the coagulation and fibrinolytic systems [15, 16].
Following injury, a temporary vascular smooth muscle contraction occurs in an attempt to stem blood flow. Endothelial disruption exposes the subendothelial layer and circulating Von Willebrand factor attaches to the site of injury. Surface glycoproteins also adhere to platelet surfaces. The subendothelial collagen activates adhering platelets and their surface receptors then bind circulating fibrinogen, forming a soft platelet plug comprising aggregated platelets and fibrinogen [14]. The adhering platelets secrete humoral factors including serotonin, prostaglandins and thromboxane that maintain a reduced blood flow, creating an environment that is conducive to clot formation at the site of bleeding. At the same time, circulating coagulating factors produced by the liver are activated in a series of precisely controlled sequential and dependant reactions [14, 17].
The final common pathway is the activation of thrombin that leads to conversion of soluble plasma fibrinogen to insoluble fibrin. The complex of activated factor XIII and fibrin results in cross-linking of fibrin monomers to form a stable clot [17].
Broadly speaking, there are mechanical, thermal, pharmacological and topical methods of hemorrhage control [2, 6, 8, 17, 18, 19, 20].
Mechanical methods include direct pressure, ligating clips and staples, sutures, fabric pads and gauze while hemostatic scalpels and lasers also reduce bleeding during surgery [6, 7, 17]. However, these methods have their drawbacks with respect to certain situations. The location of bleeding is particularly important with respect to orthopedics and in particular trauma. Bony surface bleeding and bleeding from the intramedullary canals are almost impossible to control with mechanical methods. Inflamed or friable tissues may contain a dense network of friable capillaries may prove a challenge [1, 2, 7]. Junctional bleeding in trauma may be potentially catastrophic and its control may not be amenable to the above methods.
The use of pharmacological methods can be a useful adjunct to other methods in these circumstances [7]. These may include epinephrine, desmopressin, tranexamic acid, vitamin K, aminocaproic acid and others.
In some situations though, even the above methods are ineffective or impractical [15] and hence the development of topical hemostatic agents. These are a diverse group of agents of varying composition and mechanisms of action. They can be versatile in the sense that when blood loss is minimal, they can be used sparingly and when there is severe blood loss then more liberal application could be an option [2]. They may be applied directly to the bleeding site and prevent or reduce continuous and unrelenting bleeding intraoperatively and postoperatively [2] and their topical nature broadly avoids the systemic adverse effects associated with systemic hemostatic medications including thrombosis [8].
Topical hemostasis is defined as a process that acts locally to stop bleeding from damaged vessels [21]. Recent and continuing developments have focused on agents that can be used as adjuncts to control bleeding during surgical procedures and control residual problematic bleeding if conventional methods fail. Broadly speaking, topical hemostats can be divided into three types [17, 20].
Passive—where the mechanism of action is to provide a physical scaffold around which platelets can aggregate. These act through contact activation and promote platelet aggregation so a clot can form. Examples include collagen, cellulose and gelatins.
Active—these have biological activity and their mechanism of action is actively influencing the clotting cascade to promote clot formation [17, 20]. These usually contain thrombin in one form or another [14].
Combined—combination of passive product with thrombin.
Contact activation occurs between receptors on platelets and collagen, promoting platelet aggregation [15, 17]. Preparation includes collagen sponges, pastes and powders [15, 17] and is obtained mainly from bovine sources [15], making it potentially immunogenic. In fact a 2–4% allergy in the total population to bovine collagen has been reported in the literature [22] (Table 1).
Hemostatic agent | Examples | Manufacturer |
---|---|---|
Collagen-based products | Avitene | Davol/BD BARD |
Helistat/Helitene | Integra Lifesciences | |
Instat/Ultrafoam | Ethicon. Johnson & Johnson | |
Oxidized cellulose | Surgicel Fibrillar | Ethicon, Johnson & Johnson |
Surgicel Nu-Knit | Ethicon, Johnson & Johnson | |
Gelatin-based products | Gelfoam | Pharmacia Corp, Pfizer |
Surgifoam | Johnson & Johnson | |
Polysaccharide spheres | Arista AH | BD BARD |
Passive hemostats.
The active ingredient in this product is oxidized regenerated cellulose (ORC). Its exact mechanism of action is poorly understood but contact activation is thought to play a part [15]. Often at reoperation, previously used ORC is visible, indicating reduced absorption and poor biodegradability, although this may be related to the amount used and the site of implantation [8]. For this reason, only the minimum possible amount to be used is indicated and it is recommended that the product be removed once hemostasis is achieved and before definitive closure [6, 8].
Their mechanism of action involves swelling while in contact with blood, providing a tamponade effect in confined spaces and restoring blood flow, and thereby producing a stable scaffold around which clots can form [17]. This does make it suitable for irregular wounds [6] and confined spaces [17]. However, it tends to stick to instruments when soaked with blood, making it difficult to handle and does not form a tight bond with the bleeding surface and can hence easily be dislodged [17].
Active agents have biological activity and actively participate in the coagulation cascade to induce clot formation at the site of bleeding [20]. They include thrombin, which comes into play in the last stages of the clotting cascade, converting circulating fibrinogen to a fibrin clot [17, 23]. Hence a significant advantage of thrombin is that its action is less susceptible to coagulopathies caused by clotting factor or platelet dysfunction [17]. Its activity constitutes the final steps in the clotting cascade and therefore it bypasses the initial steps in the cascade. Therefore, other aspects of the clotting cascade can be dysfunctional without significantly impairing the local hemostatic activity of thrombin [20].
Thrombin-based products are therefore excellent adjuncts in the presence of congenital and acquired coagulation and platelet disorders and in the presence of pharmacological and antiplatelet agents that are increasingly being used in the general population [5, 17]. Circulating fibrinogen is necessary for hemostasis to occur by active agents as thrombin converts it into insoluble fibrin that forms part of the clot. Therefore in rare cases of fibrinogen deficiency, clotting by thrombin-based products is impaired [17, 23].
These accomplish their action by bypassing the coagulation cascade to the final steps and converting fibrinogen to fibrin [24]. A fibrin precursor and thrombin stored in two separate adjacent syringes (dual syringe kit) with a single lumen enables delivery and mixing of these agents in the lumen and onto the surgical site, causing thrombin to cleave the fibrin precursor, resulting in fibrin monomers that polymerize at the site into a soluble mesh stabilized into a stable clot by factor XIII at the tissue surface [25]. Previously, bovine thrombin was used, which has recently been replaced by human thrombin [26] and more recently autologous human thrombin. Autologous fibrin sealants overcome the risk of allogeneic blood products, for example one is a patient-derived fibrin sealant utilizing the patient’s own blood as a source of fibrinogen and prothrombin and mixing it with an alkaline buffer solution to lower the pH, activating endogenous prothrombin [24] (Table 2).
Biosurgical | Examples | Manufacturer |
---|---|---|
Liquid fibrin adhesives | Tiseel | Baxter |
Evicel | Ethicon, Johnson & Johnson | |
Crosseal | Ethicon, Johnson & Johnson | |
Floseal | Baxter | |
Fibrin patches | Tachosil | Takeda |
Platelet gels | Vitagel | Orthovita |
Glutaraldehyde cross-linked albumin | BioGlue | Cryolife |
Sealants and adhesives.
These are a combination of thrombin, calcium and platelet-rich plasma, usually obtained from autologous sources using centrifugation systems that produce platelet-rich plasma. Platelets provide growth factors to stimulate wound healing and contribute to the strength of the clot [27].
These systems however rely on an intact coagulation system and may not be as effective in patients on antiplatelet or anticoagulant medications [27]. Also the extraction systems are expensive and there is a risk of contamination.
In addition to not requiring normal clotting mechanisms to work as mentioned before, active hemostats may offer other advantages. With many passive hemostatic agents, degeneration and reabsorption are a problem. This necessitates their removal from the surgical site prior to closure. With thrombin, this is not the case as degeneration and resorption of the resulting fibrin clot is achieved as part of wound healing [1, 8]. Thrombin and combination products also have a rapid onset of action with hemostasis being achieved within 10 min in most patients [7, 17, 28, 29]. Studies have shown that combining an active hemostat within a hemostatic product accelerates clotting. In a comparison of collagen-based products at different bleeding sites after surgical tumor resection, the combination of a collagen-thrombin product (n = 23) achieved complete hemostasis three times faster than the collagen sponge alone (n = 30). The median time to hemostasis was 78 seconds versus 243 seconds respectively (p < 0.001) [30]. Furthermore, approximately 80% achieved complete hemostasis within 2 min with an active topical hemostatic agent compared with only one-third of patients receiving a passive topical hemostatic agent [31]. Active hemostats are also very versatile and can come in various forms. These include sprays that can be advantageous in covering large bleeding surfaces quickly without the need for tamponade [31], and the concentration of thrombin in the formulation can also be varied depending on the severity and type of bleeding. Surgeons can use them in multiple ways during a single procedure due to their flexibility and range of delivery options [20]. Although bovine sources of thrombin may induce antibodies in hosts, this has not manifest itself as a major problem in the clinical setting [1, 32].
It has been shown that the terrible triad of hypothermia, coagulopathy and acidosis are associated with increased mortality in multiple trauma patients and that infection and multiple organ failure are other potential complications arising from severe blood loss [33, 34]. About a quarter of patients presenting to trauma centers have an established coagulopathy secondary to hemorrhage [35] with attendant risks of significant complications. Multiple defects in hemostasis can occur in combat injuries and as such, conventional methods of hemostasis may not be possible. Time is of the essence in these situations and non-transfusional approaches to hemostasis and the use of biosurgicals may be indicated [36, 37, 38, 39].
The combat setting has proved a challenging environment in many different ways in terms of management of hemorrhage. The tissue available for controlling life-threatening hemorrhage may be limited, the wound severity and the possibility of multiple injuries make the situation uniquely challenging [40]. Most combat injuries are penetrating in nature and a large proportion are limb wounds. Mortality from hemorrhage from these kinds of wounds is potentially preventable [36, 41, 42].
In the combat setting, the three principal sites of lethal hemorrhage are truncal (67%), junctional (19%) and extremity (14%). A report from the National Trauma Database suggests that the mortality from isolated lower limb extremity trauma with arterial injury is 2.8% with a 6.6% amputation rate [38]. Tourniquets can be used for these isolated injuries and their use in the military and civilian setting is supported by the Hartford consensus [39] and by the American College of Surgeons Committee on Trauma [38].
Junctional injuries (neck, axilla, groin and perineum) form a significant proportion of trauma in a combat setting and may damage the large vascular structures. These types of injuries are difficult to compress and are not amenable to tourniquet control [43, 44]. Topical hemostatic agents that have been developed in the last two decades [36, 45] can play a vital role in controlling severe bleeding in these situations and increase survival [33, 46] and have thus been listed as optional basic equipment for ambulances [39]. In addition, in a combat setting, more complex types of wound patterns are encountered than in a civilian setting, including blast injuries, which may be more amenable to topical hemostasis.
In 2003, USAIR [47] introduced guidelines of what should constitute the perfect hemostatic agent for use in the prehospital and battlefield settings [33, 41, 47, 48, 49] that included the following: being able to stop large vessel and arterial bleeding within 2 min of application, ability to be delivered through a pool of blood when applied, ready to use with no need for on-site preparation, simple enough to use by the wounded victim or a paramedic with minimal training, light weight and durable with a minimum 2-year shelf life in extreme environmental conditions, safe to use with no risk of injury to tissues or transmission of infection and inexpensive [41, 45, 50, 51]. In addition, hemostatic dressings need to be conformable and flexible enough due to the irregular shape, depth and wound configurations caused by modern explosive devices [40, 48].
These include gelatin [52], oxidized cellulose [53] and collagen and plant-derived polysaccharide spheres [54]. These agents are not biologically active and rely on the patients’ endogenous fibrin production for hemostasis. They provide a scaffold for platelet activation and aggregation, absorbing fluid several times their own weight to form a matrix at the site of hemorrhage, activating the extrinsic coagulation pathway and allowing clotting to occur. This makes them suitable only for patients in whom the coagulation system is intact [55, 56]. In fact in the absence of some coagulation factors, these agents may not be effective [53, 56]. They can be used as first line due to their ready availability and favorable cost-effectiveness, mostly as adjuncts with direct pressure at bleeding sites to control minimal residual hemorrhage [56].
These agents act by forming a physical matrix that stimulates platelet aggregation and degranulation to release factors that encourage clot formation [55].
Cellulose is a homopolysaccharide made by polymerization of glucopyranose molecules through glucosidic bonds. Surgical oxidized cellulose is either regenerated where organized fibers are formed prior to oxidation (regenerated ORC), or non-regenerated, with unorganized fibers prior to oxidation [55]. ORC conforms more rapidly to the surrounding environment. Surgical oxidized cellulose offers several favorable properties in hemostasis including bactericidal activity, good biocompatibility and ease of use [55]. It is usually resorbed but can take anywhere between 2 and 6 weeks depending on the amount used, the degree of saturation with blood and the tissue bed. The excess material may also cause foreign body reactions and granuloma formation without biodegradation and complicate radiological and clinical diagnoses of abscess, residual or recurrent tumor and granuloma [55, 57, 58]. For this reason, the minimal effective amount should be used and excess material removed prior to definitive closure. In addition, these products should not be used or left in place close to nerves, ureters, intestinal and vascular structures due to the risk of local inflammatory reactions and ischemia [55].
These can be used in combination with active agents such as thrombin in adhesives, or in a stand-alone manner. They are usually of bovine or porcine origin and act at the terminal stages of clotting to facilitate fibrin clot formation and are highly absorptive, forming a mechanical matrix for the clot to adhere to [55, 59]. They are quite versatile and available as sponges, powders or granules and are usually completely resorbed in 4–6 weeks [59]. It is important to use the minimum amount necessary to achieve hemostasis and to remove excess because part of the mechanism of action is swelling to cause a tamponade effect and this could potentially cause compression and necrosis in surrounding tissues if packed in tight spaces. This is particularly important around neural tissue and in bony spaces [59]. They are also useful in irregular wounds and surgical cavities as they can expand and fill these irregular spaces.
Mucoporous polysaccharide hemispheres are among a relatively new class of hemostatic agents derived from plant starch. Their mechanism of action includes absorbing water and the low-molecular weight components of blood, hence concentrating platelets and clotting factors in the vicinity, thereby enhancing local clotting processes [58, 60]. They have been used safely in cardiothoracic and neurospinal surgery.
These are active formulations containing mostly two agents—human purified fibrinogen and thrombin. They may also have added other compounds such as factor XIII, fibronectin and antifibrinolytics such as aprotinin used previously and tranexamic acid currently [61]. However, formulations without tranexamic acid or aprotinin are available to avoid hypersensitivity associated with aprotinin and neurotoxicity associated with tranexamic acid [62, 63] (Table 2).
These products are available in liquid or low-viscosity forms (fibrin glues) or as part of stiff collagen fleece (fibrin patches) [55]. Once applied, their mechanism of action is cleavage of fibrinogen to fibrin monomers by thrombin, which also activates factor XIII and the complex fibrin matrix forms the clot [55]. Calcium is required in both these steps and then the clot is eventually resorbed via the fibrinolytic pathway [25]. Generally, they connect atraumatically to tissues and form a barrier to leakage and bleeding through covalent polymerization between themselves and adjacent tissue [55]. Chiara et al. set out the properties of an sealant as being strong, rapid to adhere, flexible, sterile, without toxicity, biologically inert, biocompatible and able to be used in relatively wet environments with low thrombogenicity [55].
True sealants are of two types: synthetic (PEG-based or cyanoacrylates) [53, 60, 64, 65, 66, 67] or semisynthetic glutaraldehyde [68] (Table 2).
True sealants are cross-linking sealants that polymerize through nonenzymatic reactions, free of the need for the presence of blood or coagulation factors although some do have some coagulation factors within them. Both can be used to control residual ooze [53, 67].
PEG sealants are composed of polyethylene glycol and come in both flowing form as well as pads or fleeces. They should be avoided in kidney disease due to the renal clearance of polyethylene glycol and may contain allergenic components such as human albumin that can also lead to the theoretical risk of disease transmission [55].
Cyanoacrylates are products generally used for skin closure or lacerations in areas of low skin tension, for example scalp wounds. They are synthetic sealants that rapidly polymerize with water acting as the catalyst. There are two formulations: octyl-2-cyanocrylate and N-Butyl-2-cyanoacrylate. In a systematic review looking at octyl-2-cyanoacrylate, there were no differences in infections, wound dehiscence or cosmetic appearance when compared with other methods of closure [65]. Polymerization generates heat and therefore the amount used should be just enough and should certainly be avoided in delicate areas such as the spinal canal and neural tissue [55, 65]. Below the skin, a foreign body reaction may occur [65] and intravascular use is contraindicated due to the risk of systemic embolization [55].
Semisynthetic sealants otherwise known as bioglues are compounds of semisynthetic glutaraldehyde—bovine albumin-based sealant. Proteins on the surface of bleeding human tissue link with those of bovine albumin in the bioglue, causing a sealant effect [55]. Within synthetic graft materials, bioglue permeates interstices within the graft matrix [69], making it suitable for sealing anastomotic sites and decreasing postop bleeding [70].
These can be used as an adjunct to surgical hemostasis to improve residual moderate bleeding [55]. They are usually applied by double syringe systems. Each component is located in a separate section of the syringe, which then combine in a single lumen. They subsequently are applied using a blunt needle or spray tips in cases of large bleeding surface areas to the bleeding surgical site [25, 61]. Since the components bypass the initial steps in the extrinsic coagulation pathway, they can be used in achieving hemostasis in patients with congenital or acquired bleeding disorders such as hemophilia and patients on anticoagulants or antiplatelet medications [25, 62, 71] (Table 2).
They do have some drawbacks including the risk of thrombosis if injected intravascularly, hypotension and death and the risk of air embolization with the use of gas-driven sprayers [55]. In addition, the cost of sealants is significant and hence they are not recommended for use except in particular situations where indicated, for example in those with coagulation disorders [61]. One cost-effectiveness analysis done in the United Kingdom in patients undergoing total knee replacement on Quixil, one of the commercial brands, in addition to conventional hemostatic agents estimated that the use of a 5-ml dose of Quixil in addition to conventional hemostatic methods was cost saving in comparison to conventional methods alone. But the use of a 10-ml dose increased the cost substantially and they recommended that liquid fibrin adhesives only be used in selected cases [25]. They have however been found to be effective. Echave et al. [59] carried out a systematic review of 27 studies on the effectiveness of human gelatin-thrombin matrix sealant in different surgical fields including orthopedics. All 27 studies demonstrated that this sealant was associated with a significantly higher rate of successful hemostasis, and a shorter time to achieve it (p < 0.001) in comparison to other alternatives when conventional methods failed.
These products are also available as patches, for example Tachosil. They may have slightly different components but all of them have essentially the same mechanism of action, offering mechanical support with either collagen, oxidized cellulose/polyglactin 910 matrix, binding coagulation factors, allowing better adherence to bleeding tissue even in the presence of brisk bleeding, preventing the so-called “streaming effect” observed with fluid adhesives [72, 73, 74]. Tachosil is a ready-to-use fixed combination of equine collagen patch on one side and coated with coagulation factors, human fibrinogen and human thrombin on the other side [55]. Fibrin-pad and PGA-felt are absorbable hemostats composed of polyglactin 910, oxidized regenerated cellulose, thrombin and fibrinogen shown to be effective in a variety of tissue types [25, 72] and can rapidly achieve hemostasis in brisk bleeding in the retroperitoneum and pelvis, compared with the standard of care [72, 73] (Table 2).
Junctional hemorrhage is a significant problem in major trauma especially on the battlefield and often conventional methods such as tourniquets are ineffective [55]. In this respect, science has led to the development of products that are effective options in these circumstances and they can be divided into factor concentrators [75], procoagulants [76] and mucoadhesives [77] (Table 3).
Biosurgical | Examples | Manufacturer |
---|---|---|
Zeolite dressings | QuikClot & QuikClot ACS | Z-Medica |
Smectite dressings | WoundStat | TraumaCure Inc. |
Kaolin dressings | QuikClot Combat Gauze | Z-Medica |
Rapid Deployment Hemostat | Marine Polymer Technologies | |
Celox | Med Trade Products, UK | |
Trauma Stat | OreMedix | |
Fibrin dressings | Dry fibrin sealant dressing (DFSD) | American Red Cross |
Hemostatic dressings.
These are compounds of either zeolite (microporous crystalline aluminum silicate) or smectite (a nonmetallic clay mineral sodium, calcium and aluminum silicate). Examples include QuikClot (Z-Medica LLC, CT,USA) and QuikClot ACS (advanced clotting sponge), Traumadex (Medafor Inc., MN, USA) and self-expanding hemostatic polymer (SEHP) [35]. As the group name suggests these agents rapidly absorb the fluid content of blood. The resulting effect is an increase in relative concentration of its cellular and protein content and therefore clot formation. Water molecules are held in its pores by hydrogen bonds and this results in a relative local increase in concentration of platelets and clotting factors [35]. The first generation of QuikClot was designed as granules that were poured onto the bleeding wound. A high efficiency rate of 92% was demonstrated in a series of 103 patients in the military and civilian setting. There were eight patients in which hemorrhage was not effectively controlled with QC in coagulopathic patients where it was used as a last resort [75]. There were also some side effects of QC including intense exothermic reaction and scar formation from foreign body reaction [75]. Animal and early human studies on QC revealed thermal injury, poor biodegradability and foreign body reactions as the main drawbacks of QC [78, 79, 80]. In fact temperature generated by QuikClot in contact with aqueous components of blood at bleeding wounds has been measured to reach and average of 61°C with a potential rise to 76°C [78].
QuikClot has been compared to other hemostatic agents including HemCon (HemCon Medical Technologies Inc., OR, USA) in a military setting in multiple patients injured after explosions and gunshot wounds [81]. In this study, QC was effective but thermal injury was an issue. This has also been investigated in other studies by McMannus et al. [82] in the combat setting and evidence suggests that the greater the amount of blood and the more the QC applied, the greater is the risk of thermal injury. Thus currently it is only recommended for external use and the minimum amount required to achieve effective hemostasis is recommended.
QuikClot ACS is a newer generation of product made by larger zeolite beads packaged into mesh bags. This makes it easier to pack into cavities and irregular wounds often found on the battlefield and at junctional sites of hemorrhage and in cavities [55] and is claimed to produce much less of an exothermic reaction [75, 78] although there is a lack of studies with sufficient numbers to confirm this unequivocally [41].
Self-expanding hemostatic polymer (SEHP) is a dual action factor concentrator. Its mechanism of action results from its extremely potent absorptive capacity following absorption of the fluid component of blood and its ability to expand to conform to large irregular cavities and spaces, exerting a tamponade effect [35]. The other action is the effect of the polymer absorbing the liquid phase of blood into its matrix, thereby leading to a relative increase in concentration of platelets and coagulation factors at the site of bleeding, thereby promoting clotting [83, 84].
Woundstat is a compound of smectite granules that come in granular form. Its mechanism of action is absorption of the aqueous phase of blood, forming a clay substance that adheres to bleeding tissue and acts as a sealant and also concentrates clotting factors and blood cells locally, contributing to hemostasis. Granules are negatively charged and activate the intrinsic pathway as well [85, 86, 87].
These are products where the basic component is chitosan, which is a polymer derived from crustacean chitin. It is a complex biodegradable carbohydrate [55]. The mechanism of action appears to be related to highly positively charged chitosan interacting electronically with negatively charged cell membranes of erythrocytes. The product adheres strongly to tissues and seals bleeding wounds [77, 88, 89]. Examples include HemCon (HemCon Med Tech, Portland, OR) and Celox (Med. Trade Products, UK).
Celox is a chitosan-based adhesive, which is biodegradable and causes absorption of the aqueous phase and the advancement of red blood cell bonding. The positively charged Celox binds negatively charged red blood cells independently of the body’s clotting system, resulting in clot formation without the exothermic reaction associated with certain factor concentrators like QuikClot [35]. Its action is independent of the body’s clotting system, a property that makes it useful in patients requiring antiplatelet or anticoagulant medications or in the presence of coagulopathy and its local action means that it is not associated with distant clot formation. It is also reported to be very versatile, being available in granular and bandage forms and easy to remove from the wound after its clot formation activity is complete [49, 90, 91, 92]. HemCon, however, does have a hard consistency and is made in a square shape. Therefore, it works best on flat bleeding surfaces rather than deep irregular wounds [79, 83]. Wedmore et al. [77] looked at a series of patients with prehospital combative injuries where chitosan-based products had been used externally in chest, groin, buttock and abdominal wounds in 25 patients, 35 extremity wounds and neck and facial wounds in 4 cases. In about two-thirds of cases, the chitosan dressings were used following failure of hemostasis using only gauze with 100% success. In 97% of cases, bleeding stopped or hemostasis was improved, with failure only occurring in two cases attributed to blind stuffing of bandages into large cavitational injuries [77].
Trauma Stat is another chitosan-based derivative that was developed in collaboration with the United States Army, in which the mechanism of action involves positive charges in the amine groups on the chitosan molecule interacting with negative charges on the red blood cell membranes and in addition the adsorption of chitosan for fibrinogen and plasma proteins [79, 93].
Te Grotenhuis carried out a study of 66 patients in which conventional treatment with gauze and compression failed to control excessive bleeding or where conventional treatment was unlikely to achieve hemostasis. Complete cessation of hemorrhage including arterial hemorrhage occurred in 70% using the HemCon ChitoGauze, and reduction in hemorrhage occurred in 20% of patients despite 21 patients being on anticoagulants or having a clotting disorder and no adverse events occurred [88].
Due to the fact that chitosan is derived from crustaceans, there is a theoretical risk of allergenic reactions in patients allergic to shellfish. However in a study of 19 patients who had a positive IgE test to shellfish, none of the patients demonstrated a positive skin prick test to chitosan powder or expressed a reaction to HemCon bandage during serial bandage challenges, indicating favorable but not completely risk-free use of these products [94].
Chitosan-based dressings are also easy to remove after hemostasis has been achieved [41] and are known to have some antimicrobial properties [41, 95].
Their mechanism of action is mainly to deliver factors that promote coagulation into the bleeding wound. Examples are dry fibrin sealant dressing (DFSD) and QuikClot Combat Gauze (QCG) [70, 96, 97]. QCG is a surgical gauze coated with kaolin. On contact with injured endothelium, kaolin activates the extrinsic pathway, enhancing coagulation and promoting hemostasis. It is not degradable and needs to be removed from the wound following achievement of hemostasis [76].
Kaolin-based products have been used in a military setting and have demonstrated good results in both junctional and non-junctional hemorrhage [76]. In the above study, Shina et al. retrospectively reviewed 133 kaolin-based dressings applied to 122 military patients. 27% were for junctional hemorrhage with a success rate of 88% while the rest were extremity trauma where the success rate was 92%.
In addition to problems specific to certain types of hemostatic agents, there are also general drawbacks.
The hemostats that contain biological agents, usually the active hemostats, can be associated with the risk of disease transmission. For example, DFSD has the theoretical risk of viral disease transmission and hence has not achieved FDA approval.
Some agents have handling characteristics that are beneficial in certain situations. For example agents that have a granular nature can be used for complex irregular wounds with multiple bleeding points. However, the handling characteristics are difficult and they are difficult to apply in combat situations [89]. In addition, many agents are nonabsorbable and need to be removed after hemostasis is achieved. This may be difficult with some agents and require multiple washouts. Granular agents also have the potential to enter the vascular system and occlude the distal parts of vessels, causing endothelial injury and intravascular coagulation [41]. This has been demonstrated by Kheirabadi et al. [89] in their study, and for these reasons a bandage/gauze form of hemostatic agent is preferable as being safer for hemorrhage control, avoiding intravascular complications [38].
Any chapter on hemostasis in trauma and orthopedics is incomplete without the mention of tranexamic acid. This drug has been shown to be effective in reducing mortality due to bleeding in both the military and civilian setting.
The CRASH-2 (Clinical Randomization of an Antibrinolytic in Severe Hemorrhage-2) trial was a multicenter trial involving 40 centers looking at 20,211 adult trauma patients with significant bleeding who were randomized to two arms. One arm received TA within the first 3 hours of trauma and the other received placebo. The study demonstrated a reduction in mortality risk due to any cause from 14.5% compared with 16% in the placebo group (p < 0.001), with no increase in vasoocclusive events such as pulmonary embolism or myocardial infarction (0.3% versus 0.5% p-0.096) [98].
The MATTER (Military Application of Tranexamic Acid in Trauma) study looked at 896 patients with severe combat injuries and demonstrated a 6.5% absolute risk reduction in mortality in these patients with the use of tranexamic acid [99].
Both these studies have recommended incorporation of intravenous tranexamic acid into clinical practice [24].
Joint replacements are major procedures in elective orthopedics and can be associated with significant blood loss and increased transfusion requirements if appropriate steps are not taken to mitigate against this. In addition to the conventional methods of blood management including preoperative optimization, tourniquets if appropriate, intraoperative techniques such as cell saver and cauterization, topical and pharmacological hemostats and biosurgicals may offer some excellent solutions to reduce the transfusion requirements and achieve hemostasis.
A few studies have looked at human-derived fibrin sealants in total knee replacement [100, 101, 102]. A multicenter randomized control trial looking at 58 patients who underwent total knee replacement demonstrated a reduced postoperative blood loss, reduced postoperative decrease in hemoglobin and calculated blood loss in patients in whom fibrin sealant was used compared with that in the standard group (20% compared with the standard 83% p = 0.004) [100]. Another study that showed benefit was done by Dhillon et al. [25]. Results from other studies have been equivocal and have not demonstrated any clear difference.
In total hip arthroplasty, the use of fibrin sealants has been associated with reducing blood loss but inconsistent results have been demonstrated with regard to reduction in postoperative transfusion requirements [24, 103, 104, 105].
Multiple studies have looked at platelet gels in arthroplasty surgery. The evidence has been inconsistent in many. One randomized control trial looking at 100 total knee replacements did demonstrate significantly lower transfusion requirements in patients in whom platelet gels were used [106].
Desmopressin is a synthetic analog of anti-diuretic hormone. Its mechanism of action is to increase the levels of factor VIII and Von Willebrand factor, thereby enhancing primary hemostasis and platelet aggregation and adherence. This makes it suitable as a blood management strategy in patients with platelet dysfunction or other clotting disorders such as Von Willebrand’s disease and hemophilia A [107, 108]. It has also been used in healthy individuals for reducing postoperative bleeding in total hip and knee replacement surgery [109]. Six randomized placebo-controlled trials addressing the use of desmopressin in total hip and knee arthroplasty have been undertaken [110, 111, 112, 113, 114, 115]; however, evidence suggests that desmopressin is not significantly effective in reducing blood loss or transfusion requirements in these patients [24].
There are a number of good-quality randomized control trials that support the use of tranexamic acid in reducing blood loss and transfusion requirements in both knee and hip arthroplasty surgery [24]. There is however considerable amount of heterogeneity between the trials with regard to methods of delivery including single intravenous bolus dose, repeated boluses, prolonged infusion or intraarticular injection [116], and also differing dosing regimes [117]. In total knee arthroplasty, it has been shown that one intraoperative dose is sufficiently effective in reducing transfusion requirements and postoperative bleeding [118]. With the theoretical risk of intravascular thrombosis, intraarticular injection of tranexamic acid was investigated and compared to placebo and the studies showed reduction in blood loss but no reduction in transfusion rates [101, 119, 120]. Only one RCT by Seo et al. [121] showed a reduction in transfusion requirements with intraarticular (20%) rather than intravenous (34%) or placebo (94%). The evidence in total hip replacement with regard to intraarticular tranexamic acid is less convincing than in knee arthroplasty and more studies are needed.
With regard to aminocaproic acid, three RCTs did demonstrate benefit in hip and knee replacement surgery in terms of reducing blood loss in comparison with placebo. However, with regard to reducing transfusion requirements the evidence is much less convincing [24, 122, 123, 124].
Spine surgery presents a few unique challenges that limit the products that can be used for hemostasis in these situations. One of them is the friability of neural tissue and secondly the fact that the spinal cord and nerve roots are enclosed in rigid bony spaces that limit the kinds of hemostats that can be used due to the potential of swelling and compression of neural tissue in a rigid space. In addition, there is the potential for neurotoxicity with certain agents.
Cerebrospinal fluid leaks are a common source of postoperative morbidity in patients who have undergone spinal surgery. The morbidity burden includes severe postural headaches, vomiting, dizziness, photophobia, tinnitus, pseudomeningoceles and the risk of meningitis. It is therefore important that when dural tears occur or when an iatrogenic durotomy is created a water tight repair is essential. PEG hydrogel sealant has been found to be a safe effective way to augment dural closure and prevent these complications. A prospective study by Kim et al. [66] demonstrated that augmentation of standard dural closure techniques with this sealant in patients had significantly higher rates of watertight closure than with controls (100% and 64.3% respectively), without statistical differences in cerebrospinal fluid leaks, infections or wound healing. Complications due to swelling of polyethylene glycol and nerve compression were not demonstrated in this study but this remains a possibility. This led to the development of low-swell PEG hydrogel sealant (Duraseal) [55] and has been found to be safe and effective in a 3-to-1 randomized single-blind multicenter trial in which 100% of patients who had this low-swell formulation achieved watertight dural closure. Another study has also shown that BioGlue (semisynthetic glutaraldehyde-bovine albumin sealant) is safe and cost-effective in proximity to neurological structures despite previous concerns. Miscusi et al. [125] demonstrated a watertight dural closure in 23 patients requiring dural repair, with no incidence of neurological or infection related complications.
Collagen and gelatin-based products can be used to achieve hemostasis in spinal surgery. Xu et al. [64] carried out a study on 92 patients undergoing spinal fusion surgery and concluded that collagen-based products are superior to gelatin-based products in achieving hemostasis in spine surgery, with lower blood loss and postoperative drain volume.
Oxidized regenerated cellulose has been used for hemostasis in spine surgery. However when used around or in foramina with rigid bony walls, the swelling of small portions of the cellulose material may lead to significant mass effect and neural compression 1 day after surgery as demonstrated by Menovsky et al. [126] and may lead to rapid neurological deterioration. Therefore this material should be removed after hemostasis has been achieved prior to closure.
As mentioned before, liquid fibrin sealants can be used in spine surgery for hemostasis, but those containing tranexamic acid may be associated with neurotoxicity and should not be used if CSF leak or dural tear is present [55].
Topical hemostats and biosurgicals are a diverse group of compounds that have been developed and can be used in different situations as part of a comprehensive blood management program to limit the amount of blood loss. Trauma and orthopedics as a specialty also presents some unique challenges, with operations having significant blood loss and in trauma, junctional injuries on the battlefield with hemorrhage that is hard to control by conventional means. In addition, patients may be complex and frequently have platelet or coagulation disorders that preclude the use of certain classes of hemostatic agents. As mentioned before, these compounds are diverse, with different mechanisms of actions and indications, both in an elective and an emergency trauma setting. A comprehensive knowledge of these products is essential in modern-day trauma and orthopedic practice.
Despite recent developments, the perfect hemostatic or biosurgical agent still remains elusive and each of these products has their own drawbacks, side effects and unique indications and future research will hopefully continue to improve on these.
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\n\nHowever, as Open Access becomes a more commonly used publishing option for the dissemination of scientific and scholarly content, in addition to institutions, there are a growing number of funders who allow the use of grants for covering OA publication costs, or have established separate funds for the same purpose.
\n\nPlease consult our Open Access Funding page to explore some of these funding opportunities and learn more about how you could finance your IntechOpen publication. Keep in mind that this list is not definitive, and while we are constantly updating and informing our Authors of new funding opportunities, we recommend that you always check with your institution first.
\n\nFor Authors who are unable to obtain funding from their institution or research funding bodies and still need help in covering publication costs, IntechOpen offers the possibility of applying for a Waiver.
\n\nOur mission is to support Authors in publishing their research and making an impact within the scientific community. Currently, 14% of Authors receive full waivers and 6% receive partial waivers.
\n\nWhile providing support and advice to all our international Authors, waiver priority will be given to those Authors who reside in countries that are classified by the World Bank as low-income economies. In this way, we can help ensure that the scientific work being carried out can make an impact within the worldwide scientific community, no matter where an Author might live.
\n\nThe application process is open after your submitted manuscript has been accepted for publication. To apply, please fill out a Waiver Request Form and send it to your Author Service Manager. If you have an official letter from your university or institution showing that funds for your OA publication are unavailable, please attach that as well. The Waiver Request will normally be addressed within one week from the application date. All chapters that receive waivers or partial waivers will be designated as such online.
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\n\nFeel free to contact us at oapf@intechopen.com if you have any questions about Funding options or our Waiver program. If you have already begun the process and require further assistance, please contact your Author Service Manager, who is there to assist you!
\n\nNote: All data represented above was collected by IntechOpen from 2013 to 2017.
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