Maternal factors affecting platelets in the newborn.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"3563",leadTitle:null,fullTitle:"Advanced Microwave Circuits and Systems",title:"Advanced Microwave Circuits and Systems",subtitle:null,reviewType:"peer-reviewed",abstract:"This book is based on recent research work conducted by the authors dealing with the design\nand development of active and passive microwave components, integrated circuits and\nsystems. 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From November 2000 to June 2005 he was a Metrology Engineer with the Laboratory of Metrology, Kharkiv, Ukraine. In 2004 he became a Junior Member of the Teaching Staff with the Kharkiv National University of Radio Electronics. In 2005 he joined the Technical University of Denmark, where he is currently an Assistant Professor. 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Pyshkin and John Ballato",coverURL:"https://cdn.intechopen.com/books/images_new/5709.jpg",editedByType:"Edited by",editors:[{id:"43016",title:"Prof.",name:"Sergei",surname:"Pyshkin",slug:"sergei-pyshkin",fullName:"Sergei Pyshkin"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],ofsBooks:[]},correction:{item:{id:"74918",slug:"corrigendum-to-a-hybrid-control-approach-based-on-the-combination-of-pid-control-with-lqr-optimal-co",title:"Corrigendum to: A Hybrid Control Approach Based on the Combination of PID Control with LQR Optimal Control",doi:null,correctionPDFUrl:"https://cdn.intechopen.com/pdfs/74918.pdf",downloadPdfUrl:"/chapter/pdf-download/74918",previewPdfUrl:"/chapter/pdf-preview/74918",totalDownloads:null,totalCrossrefCites:null,bibtexUrl:"/chapter/bibtex/74918",risUrl:"/chapter/ris/74918",chapter:{id:"74293",slug:"a-hybrid-control-approach-based-on-the-combination-of-pid-control-with-lqr-optimal-control",signatures:"Ibrahim K. Mohammed",dateSubmitted:"July 8th 2020",dateReviewed:"November 4th 2020",datePrePublished:"December 3rd 2020",datePublished:"June 16th 2021",book:{id:"9887",title:"Control Based on PID Framework",subtitle:"The Mutual Promotion of Control and Identification for Complex Systems",fullTitle:"Control Based on PID Framework - The Mutual Promotion of Control and Identification for Complex Systems",slug:"control-based-on-pid-framework-the-mutual-promotion-of-control-and-identification-for-complex-systems",publishedDate:"June 16th 2021",bookSignature:"Wei Wang",coverURL:"https://cdn.intechopen.com/books/images_new/9887.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"101176",title:"Prof.",name:"Wei",middleName:null,surname:"Wang",slug:"wei-wang",fullName:"Wei Wang"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"326786",title:"Dr.",name:"Ibrahim",middleName:null,surname:"Mohammed",fullName:"Ibrahim Mohammed",slug:"ibrahim-mohammed",email:"ibrahim.mohammed@uoninevah.edu.iq",position:null,institution:null}]}},chapter:{id:"74293",slug:"a-hybrid-control-approach-based-on-the-combination-of-pid-control-with-lqr-optimal-control",signatures:"Ibrahim K. Mohammed",dateSubmitted:"July 8th 2020",dateReviewed:"November 4th 2020",datePrePublished:"December 3rd 2020",datePublished:"June 16th 2021",book:{id:"9887",title:"Control Based on PID Framework",subtitle:"The Mutual Promotion of Control and Identification for Complex Systems",fullTitle:"Control Based on PID Framework - The Mutual Promotion of Control and Identification for Complex Systems",slug:"control-based-on-pid-framework-the-mutual-promotion-of-control-and-identification-for-complex-systems",publishedDate:"June 16th 2021",bookSignature:"Wei Wang",coverURL:"https://cdn.intechopen.com/books/images_new/9887.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"101176",title:"Prof.",name:"Wei",middleName:null,surname:"Wang",slug:"wei-wang",fullName:"Wei Wang"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"326786",title:"Dr.",name:"Ibrahim",middleName:null,surname:"Mohammed",fullName:"Ibrahim Mohammed",slug:"ibrahim-mohammed",email:"ibrahim.mohammed@uoninevah.edu.iq",position:null,institution:null}]},book:{id:"9887",title:"Control Based on PID Framework",subtitle:"The Mutual Promotion of Control and Identification for Complex Systems",fullTitle:"Control Based on PID Framework - The Mutual Promotion of Control and Identification for Complex Systems",slug:"control-based-on-pid-framework-the-mutual-promotion-of-control-and-identification-for-complex-systems",publishedDate:"June 16th 2021",bookSignature:"Wei Wang",coverURL:"https://cdn.intechopen.com/books/images_new/9887.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"101176",title:"Prof.",name:"Wei",middleName:null,surname:"Wang",slug:"wei-wang",fullName:"Wei Wang"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},ofsBook:{item:{type:"book",id:"11440",leadTitle:null,title:"Aggression and Violent Behaviour",subtitle:null,reviewType:"peer-reviewed",abstract:"
\r\n\tThe literature on violence and aggression is rich and scattered at the same time. From the days of Nietzsche’s moral philosophy on the opposition of master and slave; to Freud's psychoanalytic conception of Thanatos; and from the realm of social theory to affective neuroscience, researchers and clinicians agree on one thing: that aggression is at the core of the human condition.
\r\n\r\n\tThe purpose of this book is to advance existing knowledge on violence and aggression by synthesizing theories and empirical data from a variety of scientific paradigms to facilitate a constructive meta-dialogue about a topic that feels uncomfortably stimulating and perpetually consequential.
\r\n\r\n\tThe book is intended to be composed of an introductory overview chapter on the study of aggression and violent behavior, followed by distinct chapters on interdisciplinary approaches to aggression rooted in psychological, sociocultural, and contextual models. As an essential resource, this book will aim to attract scholars, researchers, and students, interested in studying the aetiology, intervention, and management of aggression and violent behavior.
",isbn:"978-1-80355-307-8",printIsbn:"978-1-80355-306-1",pdfIsbn:"978-1-80355-308-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,hash:"7f1d671b6a9e4df140f63d940ee2a1e1",bookSignature:"Dr. Catherine Athanasiadou-Lewis",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11440.jpg",keywords:"Childhood Adversity, Attachment Dysregulation, Neuropsychological Perspectives, Psychiatric Illness, Patriarchy, Discrimination, Technology, Social Injustice, Poverty, Political Change, Socioeconomic Adaptations, Psychological Therapies",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 22nd 2022",dateEndSecondStepPublish:"March 22nd 2022",dateEndThirdStepPublish:"May 21st 2022",dateEndFourthStepPublish:"August 9th 2022",dateEndFifthStepPublish:"October 8th 2022",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"A skillful researcher, academic, and practitioner Counselling psychologist in psychotherapy and clinical neuropsychology. Associate fellow of the British Psychological Society and Fellow of the Higher Education Academy.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"287692",title:"Dr.",name:"Catherine",middleName:null,surname:"Lewis",slug:"catherine-lewis",fullName:"Catherine Lewis",profilePictureURL:"https://mts.intechopen.com/storage/users/287692/images/system/287692.jpg",biography:"Catherine Athanasiadou-Lewis is an HCPC Counselling Psychologist, a BABCP Cognitive Behavioral Psychotherapist and an associate Fellow of the British Psychological Society. Academically she is based at London Metropolitan University where she holds a Senior Lecturer post in Counselling Psychology. Clinically, she is a Lead Psychologist in the NHS where she practices in the area of substance misuse and clinical neuropsychology. She has over 15 years of clinical experience in various clinical settings in the UK and she specializes in Psychodynamic, CBT and integrative models of practice. She has authored a number of papers in the fields of Counselling Psychology and psychotherapy, and she has also collaborated with other researchers on numerous projects.",institutionString:"London Metropolitan University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"London Metropolitan University",institutionURL:null,country:{name:"United Kingdom"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"21",title:"Psychology",slug:"psychology"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"453622",firstName:"Tea",lastName:"Jurcic",middleName:null,title:"Ms.",imageUrl:"//cdnintech.com/web/frontend/www/assets/author.svg",email:"tea@intechopen.com",biography:null}},relatedBooks:[{type:"book",id:"6494",title:"Behavior Analysis",subtitle:null,isOpenForSubmission:!1,hash:"72a81a7163705b2765f9eb0b21dec70e",slug:"behavior-analysis",bookSignature:"Huei-Tse Hou and Carolyn S. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"68113",title:"Platelets in the Newborn",doi:"10.5772/intechopen.86715",slug:"platelets-in-the-newborn",body:'Platelets are small discoid cellular particles, produced by megakaryocytes, and best known for their role in thrombus or platelet plug formation. Since their initial description in the mid-nineteenth century, further details have emerged about their structure and function. More recently, their roles in processes as wide ranging as tissue repair and wound healing, angiogenesis, tumor killing, tumor growth and metastasis, inflammation, and host defense have come to light [1, 2]. Platelets perform these varied functions and diverse interactions because of several receptors and ligands on their surface, and a store of over 300 proteins within their cytoplasm and granules. With newer technological advances, more platelet functions were discovered and the mechanisms for some of them are now clearer.
Platelets mediate primary hemostasis, a dynamic process involving several reactions resulting in thrombus formation. Initially, platelets aggregate to form a platelet plug at the site of injury [3, 4]. In secondary hemostasis, thrombin is generated after a cascade of enzymatic reactions. The generated thrombin subsequently cleaves fibrinogen to fibrin [5]. Fibrin spontaneously polymerizes forming a fibrous network which stabilizes the platelet plug [6]. The process of tertiary hemostasis, or fibrinolysis, restricts clot formation to the site of injury, dissolves clots after the damaged endothelium has been repaired, and prevents the formation of pathologic thrombi [7, 8]. These reactions are tightly regulated to minimize the risk of either bleeding or thrombosis. Components of the hemostatic system are usually preformed and circulate in their respective inactive forms. Apart from their role in hemostasis, some of these factors also play a role in other physiological processes such as embryonic development, angiogenesis, or immunity [9].
Most of the information about platelets is based on studies conducted in adults or in animal models. Despite recognized roles of platelets in processes as wide ranging as inflammation and angiogenesis, information about these roles of neonatal platelets is limited. However, clinical observations suggest that there likely are some functional differences between neonatal and adult platelets. Newborns are at greater risk of contracting infections and may not cope adequately with inflammatory stresses [10]. New blood vessels are formed to meet the demands of rapidly growing tissues. The roles of platelets in these processes and reactions in the newborn are not yet well described. Additionally, certain prematurity-related morbidities such as intraventricular hemorrhage, retinopathy of prematurity, and necrotizing enterocolitis are associated with bleeding and inflammation [11, 12]. Platelets or their functional deficits are believed to be involved in these disorders. Studying platelet function in the newborn is difficult, but emerging methodological approaches requiring small volumes of newborn’s blood are making such studies feasible. Following a general description of platelet structure and functions, this review will highlight documented differences in the newborn.
Platelets mediate primary hemostasis and play roles in procoagulant and fibrinolytic processes [13]. They are nonnucleated fragments derived from bone marrow megakaryocytes. The adult human produces about 1011 platelets daily, rising by more than 20-fold during increased need [14]. In the fetus and neonate, platelets are produced largely in the liver and spleen [15, 16]. Thrombopoietin maintains platelet homeostasis by regulating thrombopoiesis [17, 18]. The resting platelet is disk shaped with a diameter of about 1.5 μm and a lifespan of 7–10 days [19]. Its surface does not promote coagulation or aggregation. In circulation, the platelets’ resting state is further supported by the release of prostacyclin and nitric oxide from endothelial cells, by the expression of CD39 (an ADPase) on the endothelial surface, and by the inability of normal plasma vWF to bind spontaneously to the platelet surface [20].
Platelets have a complex internal structure with a series of organelles. Lacking a nucleus, they nevertheless contain some nucleic acid in the form of ribonucleic acid (RNA), which is used for synthesis of new proteins, especially during or after platelet activation [21]. The secretory granules comprise the α-granules and dense or δ-granules. The α-granules contain adhesion molecules important for platelet interactions with other platelets and blood cells, angiogenic and mitogenic factors, plasma proteins, and several factors relevant for coagulation and fibrinolysis [22]. The dense- or δ-granules contain non-protein molecules such as adenosine diphosphate (ADP), adenosine triphosphate (ATP), calcium and serotonin [22]. These play central roles in amplification of platelet activation and aggregation and in modulation of vascular endothelium and leukocyte functions. Within lysosomes are membrane proteins and acid hydrolases that digest the material in platelet aggregates through hydrolytic degradation [23]. Over 300 proteins are secreted from these granules during activation [24]. In the unstimulated platelets, the granule contents remain internalized. When stimulated, however, platelets release such contents through an open canalicular system [25].
A number of factors and agonists can stimulate platelets. These include shear stress during blood flow, agonists such as thrombin, collagen, or ADP, and recognition of and interaction with viruses, bacteria, or damaged vascular endothelium [26, 27]. Typically, platelet activation is triggered when there is a break in the vascular endothelium. The activated platelets first adhere to the damaged endothelium by binding to von Willebrand factor (vWF) through its surface membrane glycoprotein Ib (GPIb). Further interactions of platelet glycoprotein VI (GPVI) with fibrillary collagen and platelet β1 integrin with laminin, collagen, and fibronectin maintain platelet adhesion to exposed extracellular matrix [8].
Following activation, platelet membrane phospholipid distribution changes to include exposure of phosphatidylserine on the outer surface, thus promoting the condensation of vitamin K-dependent coagulation factors on this surface, and inducing the activation of the procoagulant cascade [28]. Additionally, a rearrangement of the cytoskeleton leads to a change in platelet structure [29] from the resting discoid form, via an intermediate spherical shape, to a fully activated amoeboid form with numerous extending pseudopodia able to interact with some nearby surfaces [29]. Meanwhile, the contents of α- and δ-granules are released into the immediate environment, further amplifying the original activation signal [23]. As a result, in response to a number of biological mediators, the activated platelets adhere to each other, to leukocytes and endothelial cells, and to components of the sub-endothelial matrix [30].
During extension of platelet plug formation, activated platelets accumulate on top of the initial monolayer of platelets bound to collagen of the sub-endothelium [3]. Expressed receptors on each platelet allow binding of agonists such as ADP, thrombin, and thromboxane A2, which are released from activated platelets [31]. Consequently, more platelets are recruited to the site of injury, thereby consolidating the initial hemostatic plug. Binding of fibrin to aggregated platelets through activated receptor glycoprotein GPIIb/IIIa (integrin αIIbβ3) helps to further stabilize the hemostatic plug [32].
Several proteins are released during platelet aggregation at a damaged blood vessel surface [22]. Some are believed to be responsible for repair of damaged blood vessels and development of new ones. Although precise mechanisms are not well understood, it was suggested that platelets are necessary for formation of new blood vessels [33]. Supporting this are observations of reduced retinal neovascularization in a mouse hypoxia-induced retinal angiogenesis model due to thrombocytopenia or in response to treatment with inhibitors of platelet aggregation [33]. In this context, platelet granules are believed to contain pro- and anti-angiogenic compounds [34, 35]. Similarly, platelet interactions with cancer cells appear to play a role in the development of metastases and tumor angiogenesis [36]. While cerebrovascular remodeling is known to occur in the newborn in the first few postnatal weeks [37], the roles of platelets in this developmental process are not yet well described.
Platelets may also play a role in newborn’s inflammatory processes and host defense. Neonates are generally believed to be at least partially immunologically incompetent and susceptible to a variety of infections. In this context, it is of interest that platelets have toll-like receptors (TLRs) that directly recognize and interact with a number of microorganisms or their products. Platelets may be responsible for killing microbes directly by phagocytosis, by release of microbicidal agents, or as sentinels communicating information about microbial encounters to cells of the innate immune system [15]. Bacterial infections, found in preterm newborns admitted to the neonatal intensive care unit (NICU), appear similar to infections found in adults with severe neutropenia [38]. This suggests reduced neutrophil functions in these babies. Neonates rely heavily on innate immunity for protection because their adaptive immunity is not yet fully developed [39]. Neutrophils are usually the first cells to be recruited to infection sites. They kill pathogens by various mechanisms including (a) direct phagocytosis and chemical killing by degranulation and (b) by formation of neutrophil extracellular traps (NETs) [40]. Recent studies showed that platelet interactions with neutrophils are important for optimal neutrophil functions [41, 42, 43, 44]. One such aspect of neutrophil function involves their chemotaxis and extravasation to sites of infection. Platelets were observed to act as “pathfinders” guiding neutrophils to infection sites, and platelet inhibition resulted in poor neutrophil chemotaxis [45, 46]. Interaction of platelets with leukocytes may induce inflammation. Understanding the role and mechanisms involved in platelet-leukocyte interactions in the newborn, particularly those born prematurely, could lead to development of more rational approaches to morbidities common to this group.
Thrombopoietin, a protein regulator of platelet synthesis and homeostasis [18], was detected in the fetal liver as early as the sixth week of gestation [18]. In turn, megakaryocytes, the precursor cells that form and release platelets into circulation, were detected in the liver and circulation at the eighth week [19]. The megakaryocyte numbers were observed to be, at least in part, inversely correlated to gestational age, so that healthy preterm newborns characteristically have higher levels, while levels in healthy full term newborns and adults are similar [47, 48]. Neonatal megakaryocyte progenitor cells are more sensitive and have higher proliferative potential in response to thrombopoietin compared to adult cells, and this sensitivity is even greater in preterm newborns [49]. However, neonatal megakaryocytes, tending to be smaller and with a lower ploidy than adult cells, produce fewer platelets per megakaryocyte [48, 50, 51]. Newborn and adult platelets are ultra-structurally similar [52, 53] and contain comparable membrane receptor glycoproteins (GPs) [54] and thromboxane receptors [55]. However, newborn platelets tend to include more immature forms, with the ability to form fewer pseudopods, fewer developed microtubular structures, and fewer α-granules [53]. Additionally, neonatal platelets have fewer adrenergic receptors [56]. Although they store comparably adult levels of ADP, ATP and serotonin in their dense granules, the overall dense granule release during platelet activation is lower in the newborn [57].
Platelet count is dependent on gestational age, increasing during fetal life, but usually reaches the expected adult range of 150,000 to 450,000/µL [58] from about 22 weeks of gestation [59]. The percentage of reticulated platelets, an indication of newly produced platelets, is higher in the newborn circulation [60], while the mean platelet volume (MPV), a measure of platelet size, tends to be comparable to adults.
Platelet adhesion to, and coverage of, sub-endothelial extracellular matrix is higher in the newborns than in adults [61, 62]. This is in spite of comparable collagen binding or platelet aggregation [61]. The enhanced neonatal platelet adhesion is believed to be mediated by the neonatal plasma von Willebrand factor (vWF) [61], which was reported to include unusually large multimers [63, 64]. Nevertheless, compared to full-term newborns, platelet adhesion tended to be lower in earlier gestational age neonates [62]. In part, these observations could help to explain how hemostatic function is usually maintained in full-term newborns, despite decreased intrinsic platelet activation, and why the preterm neonates are progressively decompensated the earlier their gestational age.
The phospholipid content and baseline exposure of platelet surface phosphatidylserine is comparable in adults and newborns [65, 66]. However, more platelet microparticles are generated and more phosphatidylserine molecules are exposed in the term and preterm platelets when thrombin or calcium ionophores were used as activators [67]. Microparticles or exposed phosphatidylserine is expected to induce a procoagulant state. Yet, the procoagulant activity, especially in the preterm newborn, is generally lower despite the higher levels of generated microparticles and exposed phosphatidylserine [67]. Supplementing neonatal plasma with coagulation factors improves its procoagulant activity so that it becomes comparable to adults. This implies that newborn platelets can often present adequate procoagulant surface, but the apparent poor activity may in part be due to a deficiency of humoral factors [68].
P-selectin expression, as an index of α-granule secretion, was reported lower in newborn platelets compared to adults, especially in the <30 week gestation group [69, 70]. Neonatal dense granule secretion, measured by secreted serotonin, was similar to that in adults when inositol triphosphate, 1-oleoyl-2-acetyl-glycerol, or thrombin was used as an agonist. Collagen-mediated stimulation, however, resulted in lower serotonin secretion in cord blood, although the number of dense granules in adults and neonates was found to be similar [57, 68]. GPIIb/IIIa receptors are expressed early during gestation. Yet, the fraction of active GPIIb/IIIa in neonatal cord and peripheral blood is lower compared to adults [69].
During the first few days of life, platelet activation appears to be less effective, as indicated by flow cytometric studies [69]. However, these activation profiles approach the adult patterns between the tenth and the fourteenth day of life [71]. Proposed explanations for this observed hypo-responsiveness include: relative deficiencies of phospholipid metabolism including thromboxane production, differential regulation of GPIIb/IIIa activation, impaired mobilization of calcium and intracellular signaling, impaired granule secretion, and lower aggregation [72]. These could result from lower intrinsic signal transduction in neonatal platelets [72]. Such effects are further enhanced by lower expression of protease-activated receptor-1 (PAR-1) and PAR-4 [73, 74], which mediate thrombin-dependent platelet activation.
Various components of the hemostatic system in the fetus and neonate are qualitatively and quantitatively different from those in adults [8]. Such differences could be explained either by lower synthesis, higher clearance, or higher consumption [75, 76]. Although the hemostatic system is sometimes thought to be incomplete at birth [72], it nevertheless appears to be adequate for the majority of healthy full-term newborns.
Acquired platelet dysfunctions are common during the neonatal period especially in preterm newborns. These disorders are usually secondary to perinatal or neonatal conditions such as maternal and neonatal state of health, presence of infections, medications given to mother or to newborn, or interventions for the newborn (Tables 1 and 2). Platelet count and function are usually restored several hours or days after the triggering condition is removed.
Factor | Effect on newborn platelet |
---|---|
Hypertension in mother | |
Magnesium sulfate (prenatal) |
|
Low dose aspirin (prenatal) | |
Indomethacin | |
Ibuprofen |
|
Maternal factors affecting platelets in the newborn.
Neonatal factor | Effect on newborn platelet |
---|---|
Nitric oxide | |
Therapeutic hypothermia | |
Asphyxia and RDS | |
Mechanical ventilation |
|
Extracorporeal membrane oxygenation (ECMO) |
Neonatal factors affecting platelets in the newborn.
RDS, respiratory distress syndrome; MPV, mean platelet volume; PDW, platelet distribution width.
There are several maternal factors that can impact neonatal platelet function especially during the days preceding delivery. These include maternal hypertensive disorders and prenatal use of aspirin, magnesium sulfate, or antibiotics.
Hypertensive disorders of pregnancy are associated with platelet dysfunctions in the newborn. Pregnancy-induced hypertension (PIH) is a risk factor for early onset thrombocytopenia in the newborn [77]. This is especially true for babies born prior to 36 weeks of gestation [78, 79]. Neonatal platelet counts tend to be inversely correlated to maternal blood pressure [79]. These platelets also exhibited lower adhesion properties [80]. Babies with low birth weight, meconium aspiration, or infections are also at greater risk for thrombocytopenia [81, 82]. Flow cytometric analyses of platelets from premature newborns from preeclamptic mothers demonstrated lower expression of CD62P (P-selectin), CD63 (platelet activation marker), or CD36 (platelet glycoprotein IV (GPIV)) after thrombin stimulation, compared to full-term neonates [83]. However, when compared to other similar preterms, the expression of platelet CD62P and CD63 was relatively higher in newborns from preeclamptic mothers [84]. Additionally, this cohort was also characterized by lower platelet and megakaryocyte counts [84], implying possible disturbances in platelet production [85]. Infants born to hypertensive mothers tend to be hypoxic [86]. Animal model studies suggest that hypoxia tends to favor erythropoiesis over megakaryopoiesis, leading to lower platelet counts [87].
Low dose aspirin (LDA), about 60–100 mg, is sometimes given to pregnant women, who are at risk of developing a hypertensive disorder, or whose fetus has intrauterine growth restriction [88, 89]. Aspirin inhibits cyclooxygenase, which catalyzes the initial steps in conversion of arachidonic acid to prostaglandins and thromboxanes [90]. Thromboxane A2 (TxA2) serves to amplify the signal during platelet activation [91]. Nevertheless, while some reports suggest that prenatal aspirin does not alter cord blood platelet count and aggregation [92] or thromboxane B2 (TxB2) inhibition [93], others challenge this with clear TxB2 differences in newborns of mothers exposed to LDA even several days after the medication was stopped [94]. This apparent contradiction may be resolved by taking into account the actual timing of LDA treatment prior to delivery. It was noted that newborn platelet dysfunction, including reduced collagen-stimulated platelet aggregation, is generally observable if the mother had aspirin within a week of delivery [95]. In this context, aspirin also increases the risk for mucocutaneous bleeding in the newborn, especially if the mother took it within five days of delivery [72, 95].
While aspirin is perhaps the best described with respect to its potential to alter platelet functions, it is not the only drug to do so. Indomethacin, given to the mother as a tocolytic, increased the risk of subsequent neonatal intraventricular hemorrhage (IVH) [96], presumably by affecting cerebral blood flow and by altering platelet and neutrophil functions. Similarly, platelets in newborns, from mothers receiving tocolytic magnesium sulfate, tended to be less effective in forming aggregates in response to ADP-mediated activation, but not so in response to collagen stimulation [97].
Neonatal infections tend to lead to platelet consumption. This is implied by the observed upregulation of thrombopoietin and elevated megakaryocyte progenitor cells in septic newborns [98]. Reduced platelet adhesion was also reported in such neonates [99]. However, enhanced granule secretion and aggregate formation in response to agonists during experimental conditions [100] suggest that these circulating platelets may already be to some extent primed and not in their resting state. Furthermore, neonates born following chorioamnionitis had significantly higher levels of soluble P-selectin and higher CD40L (CD40 ligand, able to bind CD40 protein on antigen presenting cells) on their platelets [101].
Antibiotics are often used to treat infections and sepsis, and some of them could alter hemostatic responses. Prolonged template bleeding and PFA-100 closure times were correlated with duration and dosage of neonatal ampicillin treatment [102, 103].
Nonsteroidal anti-inflammatory drugs (NSAIDs) are known to affect platelet function in adults. Yet, they are sometimes given to newborns as a treatment for patent ductus arteriosus (PDA). Indomethacin is associated with prolonged bleeding time and gastrointestinal bleeding in preterm newborns [104]. These effects tend to last up to 48 h [105], but normal platelet values are restored about the tenth day [106]. Nevertheless, in preterm newborns with intracranial hemorrhage, indomethacin administration for treatment of PDA did not extend the hemorrhage [107]. In contrast, ibuprofen treatment is associated with prolonged PFA-100 closure time, but not with altered bleeding time [108].
Inhaled nitric oxide (NO) is used as a selective pulmonary vasodilator to treat hypoxemic respiratory failure or pulmonary hypertension in newborns (≥34 week gestation) [109]. Inhaled NO prolongs bleeding time in adults [110]. Persistent pulmonary hypertension and treatment with inhaled NO were reported to alter neonatal platelet thromboelastogram (TEG) values [109]. Bleeding time was also prolonged in such babies [111]. These clinical tests, however, returned to normal after about 24 h of stopping therapy. It is of interest that newborns receiving NO therapy did not experience increased risk of intracranial hemorrhage [72]. Nitric oxide is known to inhibit platelet adhesion and aggregation by inhibiting GPIIb/IIIa activation [110]. A reduction in expressed P-selectin and activated GPIIb/IIIa on collagen-stimulated platelets was reported after NO treatment in adults and newborns [112].
Term newborns who were small for gestational age tended to have lower platelet counts but higher mean platelet volumes (MPVs) [113, 114]. A similar pattern was also observed in asphyxiated term newborns [113]. MPV is a measure of average platelet size [115] and may serve as a marker of platelet production, consumption, or severity of some disorder of bone marrow, thrombosis, or infection [116, 117]. For example, MPV was elevated in preterm newborns with respiratory distress [117], suggesting potential issues in platelet production, consumption, or both. Asphyxia is associated with upregulation of thrombopoietin concentration, which in turn is negatively correlated to platelet count up to the 7th day of life [118]. Thrombocytopenia, however, when associated with perinatal asphyxia, does not tend to resolve until about the 19th to 21st day of life [119]. Increased thromboxane levels in asphyxiated newborns [120] suggest platelet activation, and possibly consumption, as an explanation for the observed thrombocytopenia. Hypoxia leads to preferential upregulation of erythropoiesis over megakaryopoiesis [87, 114], consistent with elevated thrombopoietin observed [118].
Mechanical ventilation is generally used to resuscitate hypoxic or asphyxiated newborns. It was reported that mechanical ventilation led to reduced platelet counts in newborns with respiratory distress, or in rabbit models, regardless of the oxygen concentration used [121]. However, using newborn piglet models of hypoxia, it was found that various platelet indices were affected particularly by high oxygen level used [122]. Resuscitation with 100% oxygen led to enhanced collagen-stimulated platelet aggregation, while using 18–21% oxygen did not do so [122].
To prevent permanent brain damage following perinatal asphyxia, the newborns are sometimes treated with therapeutic hypothermia. The hypothermia treatment, in turn, led to decreased platelet counts, but had an overall protective effect by reducing risk of cerebral hemorrhage [123] and restoring other hemostatic parameters [124]. Similarly, extracorporeal membrane oxygenation (ECMO) is used to rescue term newborns with persistent pulmonary hypertension, asphyxia, or congenital diaphragmatic hernia [125]. Platelet counts and rates of activation were reduced during ECMO therapy, and were not fully restored with transfusion, until several hours post-ECMO [125, 126].
Sepsis is a complex syndrome characterized by disordered immune, endocrine, and metabolic responses to infection [127]. The exaggerated responses can lead to multi-organ failure (MOF), shock, and death [127]. Sepsis is generally considered if a documented or suspected infection is present with at least one additional finding (e.g., fever/hypothermia, elevated heart rate, and leukocytosis/leukopenia). In contrast to infection, however, sepsis is defined by additional evidence of organ dysfunction and a dysregulated host immune response [127], its key features. Notably, interactions between the innate immune system and the hemostatic system, including platelets and coagulation factors, were identified as principal steps in the pathogenesis of sepsis. Progressive thrombocytopenia and coagulopathy are strong negative prognostic findings in severe sepsis and have recently been included in the updated definition of the disease [127]. Platelets are able to release cytokines, recruit leukocytes, interact with bacteria and the endothelium, and contribute to formation of microthrombi [128]. These processes are adaptive and protective in the context of a localized infection, but may become dysregulated and “maladaptive” during sepsis, contributing to organ damage [129]. A low platelet count is a well-known biomarker for disease severity. More recently, attention has been focused on the active role of platelets in the pathogenesis of multi-organ failure.
The correlation between thrombocytopenia and sepsis is well documented [130]. Platelet count below <50,000/μL is a strong negative prognostic marker in patients with sepsis and is thought to result from platelet activation and consumption [131, 132]. A number of platelet function markers were proposed as biomarkers for sepsis correlating with its severity [133] (Table 3).
Biomarker | Association | References |
---|---|---|
Thrombocytopenia | Mortality | [133] |
Impaired platelet function | MOF, mortality | [132, 133] |
Impaired platelet aggregation | ALI | [133] |
P-selectin | MOF | [133] |
Platelet-neutrophil aggregates | Sepsis progression | [132, 133] |
Immature platelet fraction | MOF | [133] |
Platelet-related biomarkers of sepsis severity in human studies.
MOF, multi-organ failure; ALI, acute lung injury; TPO, thrombopoietin.
Moreover, platelets interact with neutrophils in the formation of NETs (neutrophil extracellular traps) resulting in the trapping and killing of pathogens [133]. They also play a central role in driving and modulating host inflammatory and immune responses, influencing directly the function of endothelial cells, neutrophils, and lymphocytes [134]. Platelets are the most numerous blood cells with immune function, able to interact with bacteria in several ways: (1) direct interaction between platelet glycoproteins and bacterial surface proteins, as occurs between GPIb and
In addition to hemostasis, platelets actively participate in the innate immune defense system. Participating in the recognition of pathogens, signal transduction, or the release of cytokines/chemokines, they reveal a functional similarity with leucocytes in sepsis and septic shock. There is abundant evidence that platelets can influence key host responses to sepsis. Further studies are needed to address the effects of platelet transfusion or inhibition toward sepsis prevention and treatment particularly in the newborn.
Extracorporeal membrane oxygenators are used to provide gas exchange in severe respiratory failure employing venovenous (VV) circuits or, increasingly, if associated with concurrent cardiac failure, veno-arterial (VA) circuits, while waiting for organ recovery to occur. Support by cardiopulmonary bypass (CPB) systems decreased the morbidity and mortality of children, especially those who require surgery for life-threatening anatomical heart defects [135, 136]. ECMO contributed to decreased mortality for children with severe cardiac or respiratory failure [137, 138]. While annually thousands of neonates are helped by ECMO support, thromboembolic complications also frequently occur [139]. Nevertheless, for many neonatal patients, survival is made possible only because of ECMO support [136]. ECMO is used to treat a variety of conditions in neonatal patients, including respiratory and cardiac failure as a result of persistent pulmonary hypertension (PPHN), congenital diaphragmatic hernia (CDH), meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), pneumonia, severe air-leak syndromes, or sepsis [140].
Both bleeding and clotting complications can occur during ECMO support, often coexist in the same patient, and are associated with significant morbidity and mortality [141]. Moreover, patients requiring ECMO are critically ill, thus making it difficult to distinguish the relative contributions of the underlying pathology from that of the ECMO circuit as such. Rates of reported ECMO-associated venous thromboembolism (VTE) in general population, ranging from 18 to 85% in various centers, may be at least partly dependent on anticoagulation regimens [141]. Severe hemorrhage is reported in nearly 40% and intracranial hemorrhage in 16–21% of patients [142, 143]. At the same time, there is broad variation in practice, without clear consensus, on the administration and monitoring of anticoagulation during ECMO, or the management of ECMO-related hemorrhage and VTE [144].
Activation of the coagulation system is initiated by the exposure of blood to foreign synthetic surfaces and by shear stresses of the circuit, especially from device pumps. The shift to a pro-coagulant state appears to be mediated primarily by thrombin, while an excessive fibrinolytic tendency is mediated by plasmin, resulting in a consumption of clotting factors, impaired platelet function, thrombocytopenia, and fibrinolysis [145]. Initial fibrinogen deposition and subsequent activation of coagulation and complement factors allow platelets and leukocytes to adhere to oxygenator surfaces further enhancing thrombin generation. Such changes contribute to higher rates of thrombosis in these patients [145]. Meanwhile, several of a series of processes contribute to higher bleeding rates. (a) Primary hemostasis is impaired because of platelet dysfunction and loss of key adhesive molecules. (b) Shear stress causes the development of an acquired von Willebrand defect. (c) Widespread fibrin deposits on surfaces trigger an enhanced fibrinolytic response. (d) Administration of systemic anticoagulation, required to maintain circuit patency, raises bleeding risks [146].
Balancing the relative risks of bleeding and thrombosis can be difficult. Factors related to patient’s illness, the extracorporeal support, and the interplay between pro-inflammatory and anti-inflammatory processes vary among patients.
If the ECMO circuit is primed only with crystalloid or RBCs and plasma, then dilutional coagulopathy and dilutional thrombocytopenia develop as the ECMO is initiated. Dilutional coagulopathy is generally not severe, but will complement the systemic anticoagulation. Dilutional thrombocytopenia, however, may further aggravate any preexisting thrombocytopenia or platelet dysfunction, frequently present in premature neonates. Accurate assessment of platelet function under these circumstances can be difficult, further complicating evaluation of patient’s bleeding or thrombotic potential. Impairment of platelets can occur as early as 15 min after starting ECMO and last until it is discontinued [125].
Platelets adhere to the protein-coated monolayer of the ECMO circuit surfaces and interact with activated components of the coagulation and complement systems [147]. Elevated shear flow from the ECMO circuit causes some platelet receptor shedding. Of particular interest are the losses of key platelet adhesion glycoproteins GPI and GPVI, and the associated reduction of high molecular weight vWF multimers. GPI serves as a receptor for vWF and GPVI as a receptor for collagen [126]. Adhesive proteins, vWF, and fibrinogen assist platelets to bind to damaged vessel wall surface and to other platelets [148]. As platelet thrombus is being formed, the prothrombinase enzyme complex assembles on the activated platelet surfaces to produce thrombin. In turn, thrombin cleaves fibrinogen to form fibrin, which spontaneously polymerizes to form the fibrin meshwork, which further strengthens the thrombus [149]. Consequently, shedding of GPI and loss of high molecular weight vWF lead to dysfunctional platelet responses to vascular injury. This persists despite platelet transfusion and throughout the period of ECMO use [126]. Subsequently, lower levels of platelet aggregation are observed by light aggregometry using various agonists including ADP, ristocetin, collagen, or epinephrine [150]. Such decreased potential for platelet aggregation may lead to increased bleeding risk particularly when combined with the effects of anticoagulants or antiplatelet agents. Flow cytometry of blood, from those receiving ECMO support, showed severely reduced membrane-bound P-selectin (CD62P) and CD63, both of which modulate platelet spreading [151].
Despite reduced aggregation and lower expression of key platelet adhesion and structural molecules, there is a time-dependent platelet activation marked by increased levels of circulating matrix metalloproteinase-2 (MMP-2) and soluble P-selectin [126]. This is not associated with significant activation of the endothelium [126], but may be due to the release of platelet granules [152]. Furthermore, this time-dependent platelet activation is also accompanied by platelet receptor shedding and the release of platelet microparticles (PMPs) [153]. These are small cell-derived particles, typically 0.1–1 μm in size, that are produced from activated platelets in situations of shear stress [154]. While these PMPs can present a prothrombotic surface, it is not clear whether they are a major contributor to the prothrombotic phenotype or to the pathogenesis of ECMO-associated coagulopathy [153].
Thrombocytopenia is common in critically ill patients. A constant shear force, caused by the ECMO pump, is implicated in acquired platelet dysfunctions. Appropriate anticoagulation is difficult to achieve during ECMO since severe thrombocytopenia of <50,000/μL may be present even prior to ECMO. This situation increases the practice of platelet transfusions [155]. Minimal target platelet counts vary from 25,000 to 100,000/μL between hospitals. However, if bleeding occurs or is expected, then target platelet counts are increased to 150,000/μL or higher, particularly if platelet dysfunction is suspected. As in any setting of thrombocytopenia, it is important to try and identify the cause and treat appropriately [156, 157]. Bleeding in critically ill patients with a platelet count of 30,000/μL is believed to be associated with additional disturbances of hemostasis [158]. Platelet transfusion is recommended in bleeding patients with either primary or secondary platelet abnormalities regardless of platelet counts [158]. Required thresholds for prophylactic platelet transfusions, however, are generally at platelet levels above 20,000/μL, given the requirements of invasive procedures and potential bleeding risk [158]. Many centers describe targeting a platelet count of >100,000/µL during an ECMO [159]. Research to support this practice, however, is lacking and urgently needed.
Unfractionated heparin is the most widely used anticoagulant during ECMO [160]. Heparin levels tend to be monitored primarily indirectly by activated clotting time (ACT) [159]. While there are a number of devices that promise to describe certain characteristics of platelet function, it is not yet clear to what extent the data produced by them actually reflect the physiological platelet interactions and roles. Viscoelastic tests using rotational thromboelastometry (ROTEM) assess whole blood coagulation, and thus provide information on the dynamics of clot development, stabilization, and dissolution. Several reports suggest that ROTEM-guided coagulation management could reduce bleeding episodes in ECMO patients [160, 161]. Similarly, whole blood platelet aggregometry using the Multiplate (Roche Diagnostics, Munich, Germany) demonstrated decreased platelet aggregation in ECMO patients [161].
Other intravenous anticoagulants, such as bivalirudin and argatroban, are used increasingly, particularly if heparin-induced thrombocytopenia (HIT), heparin resistance, or allergy is suspected [162, 163]. At present, there is no clear consensus on administration and monitoring of anticoagulation during ECMO or on management of ECMO-related hemorrhage and VTE [164]. The current aim of anticoagulation is to reduce thrombin generation. This, however, increases the risk of hemorrhage. The ideal therapeutic agent, which would reduce thrombotic risk without increasing the risk of bleeding, remains elusive.
Heparin-induced thrombocytopenia (HIT) is an immune-mediated coagulation side effect of heparin therapy characterized by a prothrombotic state mediated by platelets, leukocytes, and antibodies against complexes of platelet factor 4 (PF4) with long chain heparins [165]. Rapid platelet consumption leads to thrombocytopenia. HIT was considered to be very rare in the pediatric population. However, more recent reports indicate that it occurs in children receiving unfractionated heparin therapy with an incidence similar to that seen in adults [166]. The highest incidence of pediatric HIT was found in pediatric intensive care units supporting patients following cardiac surgery [167].
At least 70 cases of reported HIT were documented in pediatric patients [168], with the majority occurring during care following cardiac surgery. HIT in children was reported to occur in all age groups, but with a bimodal distribution. The higher incidences occur a) early in life, between 0–2, and b) during puberty, between 11–17 years of age [168, 169]. The balance between the risk of procoagulant and thromboembolic events on one hand and the risk of severe, sometimes fatal, bleeding on the other hand can be very challenging in ECMO patients with HIT. Pollak et al. reported a case of HIT with evidence of small vessel arterial thrombosis in a 5-day-old newborn receiving ECMO for congenital diaphragmatic hernia. It was assumed that the leading cause of death in this patient was massive disseminated intravascular coagulation. In this case, however, it is more likely that repeated platelet transfusions proved fatal and, retrospectively speaking, should have been avoided [170]. Although HIT is a recognizable and treatable complication, its relative infrequency increases the risk for delayed diagnosis leading to significant morbidity.
Diagnostic studies for HIT tend to be unreliable. Therefore, early intervention using alternative anticoagulants is a crucial step when HIT is suspected. This can hopefully lead to improved outcomes in these patients. Treatment of confirmed or suspected HIT in patients on ECMO includes removing unfractionated heparin, and possibly the entire ECMO circuit. Certain modern ECMO circuit components are heparin bonded in an effort to reduce immune reactivity to foreign surfaces [171, 172, 173]. If platelet recovery does not occur after withdrawal of heparin, it is possible that ongoing exposure to heparin bonding may be a factor [173]. Options for alternative anticoagulation if HIT is suspected include direct thrombin inhibitors (argatroban and bivalirudin) as well as short heparinoids (fondaparinux and danaparoid) [162, 174].
The predominant challenge for the clinician caring for a patient on ECMO is making an informed assessment of bleeding and clotting risks. The goal is to minimize bleeding and transfusion requirements while avoiding formation of micro or macro thrombi either in the circuit or within the patient’s cardiovascular system [175]. Assessment of the patient’s hemostasis includes consideration of the pathophysiology, type and severity of organ failure, and extent of tissue trauma during cannulation. A holistic approach to hemostatic management is needed to balance all these factors. ROTEM and whole blood platelet aggregometry provide rapid information on whole blood coagulation, and may be helpful in providing blood product support, factor replacement, anti-coagulation therapy and anti-fibrinolytics. Further research using ROTEM and whole blood platelet aggregometry in ECMO patients is needed to demonstrate efficacy in support of real-time hemostatic management in this cohort.
Transfusion of blood products in neonates is not an uncommon practice in neonatal intensive care units. Extremely premature neonates (<28 week gestation) or extremely low birth weight (ELBW) infants (<1000 g) receive at least one packed red blood cell (pRBC) transfusion per hospital admission [176]. Platelet transfusions are also quite prevalent in ELBW infants, occurring in up to 90% of those weighing less than 750 g [177]. Unfortunately, while platelet transfusions for thrombocytopenia may be helpful, they are not without risk. Further, because the guidelines for transfusion thresholds in neonates are not based on a well-developed body of evidence, there is considerable variability in circumstances for such transfusions, and in particular clinical scenarios triggering them.
Thrombocytopenia is defined by a platelet count of less than 150,000/μL, and is further sub-classified as mild (100,000–149,000/µL), moderate (50,000–99,000/µL), or severe (<50,000/μL) [178]. The reference values for very low birth weight (VLBW) babies (<1500 g), however, remain controversial [179]. Thrombocytopenia affects 18–35% of all neonates in the neonatal intensive care unit [180, 181] and up to 73% of ELBW infants [182]. While clinical significance of platelet counts between 100,000 and 150,000/µL is debatable, it is well known that platelet counts below 20,000/µL are associated with increased risk of hemorrhage, at least in the adult population [183]. The relationship between thrombocytopenia and hemorrhage, however, remains one of the associations. It is not clear that neonatal thrombocytopenia directly causes hemorrhagic events [184].
Thrombocytopenia may be described by time of onset, where early onset (occurring in the first 72 h of life) is distinguished from late onset (occurring after the first 72 h of life) [179, 184]. In the premature population, the early onset thrombocytopenia is most often mild to moderate, develops gradually, and tends to be related to causes of chronic fetal hypoxia, as seen with intra-uterine growth restriction (IUGR), pregnancy-induced hypertension (PIH), hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome, or preeclampsia [185]. In term neonates, however, platelet destruction tends to be antibody-mediated [184]. In contrast to early onset, late onset thrombocytopenia tends to be more severe, more acute, and most frequently associated with infections (NEC, sepsis, and viral infections) [184].
Due to limited understanding of neonatal platelet functions, transfusion practice in the newborn is generally extrapolated from what is recognized as beneficial within the pediatric and adult populations. However, neonates are vulnerable to particular illnesses with varying underlying disease processes. Moreover, they tend to have developmental differences in regulation of primary hemostasis [178]. Nevertheless, platelet transfusions are typically given in two distinct clinical scenarios: (a) acutely, as a life-saving procedure and (b) prophylactically, under the presumption that they diminish the risk for hemorrhage. Surprisingly, an overwhelming majority of neonatal transfusions are done prophylactically, accounting for 98% of platelet transfusions [59]. Yet, it is not clear that this practice is beneficial. Prophylactic platelet transfusion in clinically stable neonates with no active bleeding remains controversial at best [186], consistent with the wide range of national and international clinical practices by neonatologists [177]. In this context, the severity of thrombocytopenia does not correlate with increased risk of intraventricular hemorrhage (IVH), and platelet transfusion for mild to moderate thrombocytopenia does not appear to prevent or reduce the incidence of intracranial hemorrhage [183, 187].
Although adequate quantities of platelets are necessary for hemostasis, increased risk of hemorrhage appears to be dependent on factors other than thrombocytopenia alone. Additional relevant platelet parameters include functional competency, immature platelet fraction, and developmental differences in neonatal thrombopoiesis [49, 188, 189]. Underlying clinical conditions associated with increased risk of hemorrhage include: preterm premature rupture of membranes, low birth weight, sepsis, shock, pulmonary hypertension, respiratory distress, NEC, and premature gestational age [182, 190, 191, 192]. Thus, recommendations to transfuse platelets should not be solely based on thrombocytopenia, but also on the presence of such other contributory factors [178, 190]. In spite of such considerations, it appears that management of thrombocytopenia in the newborn still lacks adequately rigorous scientific basis [179].
In the United States, there are currently no national guidelines for neonatal platelet transfusion and only two published randomized controlled trials assessing prophylactic transfusions [183, 193]. Most countries recommend therapeutic transfusion in actively bleeding neonates when platelets fall below 50,000/μL. However, there is no agreement regarding prophylactic transfusions when platelets are anywhere between 20,000 and 90,000/μL [184, 194, 195]. A wide range of thrombocytopenia thresholds are employed, tending to be markedly higher in the United States, between 50,000 and 149,000/µL [187, 196, 197]. Nonetheless, such trends are based on clinical experience and judgment, rather than on reliable and consistent data.
A growing number of adverse effects of platelet transfusions are being documented, including but not limited to increased risk of infection, transfusion-related injuries in various organs, alloimmunization, hemolytic reactions, febrile reactions, allergic reactions, anaphylaxis, and NEC [177, 185]. Randomized controlled trials comparing thresholds for platelet transfusion in thrombocytopenic neonates concluded that the frequency of IVH is not reduced by more aggressive thresholds [183]. Additionally, platelet transfusions, themselves, are implicated in increased mortality, linking the number of transfusions with death rate [198]. This was further supported by a recent large, multicenter, randomized clinical trial suggesting that significant hemorrhage and death could be prevented by lowering thrombocytopenia transfusion thresholds from 50,000 to 25,000/μL [193].
Platelets are best known for their role in hemostasis. But beyond forming a platelet plug, they are also important in several processes such as recognition and elimination of invading microorganisms, inflammation and interaction with leukocytes, wound healing and tissue repair, angiogenesis, and even tumor growth. These are emerging areas of investigation and there is little to no information on the roles of platelets in such processes in the newborn. Although current understanding suggests that newborn platelets may be somewhat different from adult platelets, they nonetheless protect the healthy newborn adequately. Certain perinatal factors were identified to affect platelet counts and function, but the platelet dysfunctions induced by them are acquired and transitory in nature. Premature neonates are likely at greatest risk for reduced platelet counts and functions, and by extension, at greatest risk of hemorrhage, particularly if prematurity is in combination with antenatal infections or postnatal respiratory disorders. There is, however, still a lot that is not known about platelets in the newborn. Such information is critical to improving the standard of care, intervention, and therapy.
This work was supported in part by NIH grant R01 NR011209-08.
The authors declare that they have no conflict of interest.
The Internet of Things (IoT) is a developing and promising innovation, which were able to revolutionize the world [1]. IoT manages low-powered gadgets, using the internet by interacting with one another. IoT interconnect “Things” and also helps in machine-to-machine (M2M) communication, which is a way of data communication between varied gadgets without human intercession [2].
IoT applications can be classified into six main categories, such as [1]: smart cities, smart business, smart homes, healthcare, security and surveillance. Regarding these different applications, several requirements should be maintained, like [2]: (1) high scalability, (2) security and privacy, (3) high capacity, (4) security and privacy, (5) energy saving, (6) reduced latency, (7) quality of service (QoS), (8) built-in redundancy, (9) heterogeneity and (10) efficient network and spectrum.
The 5G enabled IoT contains a number of key communication techniques for IoT applications, in order to make the network with faster speeds and greater accessibility. A network that reaches all over the world and is accessible to all. Since 5G technology offers greater connectivity, more and more applications for this technology are likely to come to the field. Four main categories can be cited in the this context: (1) Wireless Network Function Virtualization, (2) Architecture of 5–IoT, (3) Heterogeneous Network (HetNet) and (4) Device to Device (D2D) Communication.
In this chapter, we mainly focus on the last type especially on D2D Communication [3, 4, 5, 6, 7, 8], which allows the exchange of data between user equipment without the use of the base station. The short distance communication between two devices (D2D) becomes a challenging way to transmit data, since it benefits the 5–IoT with low power consumption, load balancing and better QoS for edge users. Indeed, in IoT over
Several approaches have already been proposed in the literature in order to achieve MS and PC management, these approaches can be: (1) Centralized management: where the base station (BS) allocates directly to the designated DUE and require the knowledge of D2D links’ Channel State Information (CSI) at the BS level and (2) Distributed (or decentralized) management, in which the BS informs D2D users which Resource Blocks (RBs) they can use. In this chapter, we focus on the RRM algorithms in underlay D2D communication, for both centralized and distributed MS and PC, in order to improve the overall of the system using game theory tools. In [3, 4, 5, 6, 7, 9, 11, 13, 14, 15, 16, 17, 19, 20, 21, 22], the authors have proposed centralized and distributed PC approaches with perfect channel state information (CSI) using powerful mathematical tools, such as game theory [7, 8, 9], stochastic approximation [20], mechanism design [21] etc.
In fact, Game theory (GT) is a branch of applied mathematics that provides models and tools for analyzing situations where multiple rational users interact to achieve their goals [23, 24]. Several examples based on Wireless Communications are investigated in the literature, as in PC, congestion control, load balancing, etc. In [6], a centralized and distributed PC algorithms are developed and evaluated for a D2D underlaid cellular system using stochastic geometry. The authors in [9] have focused on maximizing the total sum-rate in an heterogeneous network (HetNet) via game theoretic approaches. The authors in [11] have proposed a distributed PC, based on an appropriate interference management scheme in D2D underlaid Cellular Network by using GT approach. An iterative distributed power allocation algorithm for the two kinds of game: pure and mixed has investigated. Distributed vs. centralized MS and PC approaches have been suggested in [25] using GT tools.
This chapter investigates both MS and PC in D2D communications using centralized and distributed approaches based on GT tools. In the proposed MS approach, the CUE and DUE list, the minimum and maximum quantities of power are derived according to CUE and DUE signal-to-interference plus-noise-ratio (SINR) thresholds. The expression of the minimum amount of power known in the literature as the Pareto power [6, 9, 11], has always been used until now without mathematical proof. We propose in this chapter to show mathematically this Pareto power, which is considered as a key of the PC process. Then, a pure strategy non-cooperative game between the two kind of users is modeled as a distributed PC approach, based on the derived minimum and maximum power, where two utility functions are investigated for both type of users. This chapter reviews the work previously published by the authors in [12]. For this, all the proofs and demonstrations of the different results stated in this chapter will not be provided since they are already explained in [12].
The structure of this chapter is given as: In Section 2, the system model of a D2D communication and CUE and DUE SINR and coverage probability expressions are defined. In Section 3, the closed form expression of both minimum and maximum amounts of power with a mathematical demonstration are provided, based on the predetermined CUE and DUE SINR thresholds. In Section 4, our proposed centralized MS and PC approaches are investigated, which consists of generalizing a classical centralized MS and PC approaches. The Section 5, outlines an iterative NE distributed power approach which is proposed for both CUE and DUE and is based on the minimum and maximum amounts of power, derived from Section 3 and on the GT tools. This proposed distributed approach aims to achieve a better compromise between different users in terms of allocated powers is presented in Section 6. Several simulations are provided in order to assess the performance of the allocation approaches of the MS and PC thus proposed in Section 7. Section 8 is followed with conclusion and future scope.
In this section, a D2D uplink underlaid cellular network is considered illustrated in this section, which is shown in Figure 1. A system which is composed by a single-cell cellular network, where
CUE mode: if
DUE mode: if
System model of D2D communication.
Let
In order to ensure a QoS in terms of
where
where,
Let us define for each user
In order to simplify the notations used in the chapter, we will consider vector rather than analytical expressions. According to each kind of user, we define the coverage probabilities expressions denoted as
where,
This section investigates the study of the existence of the two minimum and maximum powers
To do this, we start by providing another vector form of the (1) system to build this Pareto power.
Let us take into consideration the following definition and proposition (1),
where
All previous works [6, 8, 9, 11] have dealt with the resolution of the problem presented in (9) by using a minimum power
The authors in [6, 8, 11] have shown that: if
To do this, we propose theorems, definitions and propositions in order to outline all the necessary steps which allow to build this sufficient condition. Obviously, to make reading easier, all the demonstrations relating to these theorems and propositions are already detailed in [11, 12].
Hence,
To let
where,
Likewise, we consider the following notation
Hence,
This section investigates centralized MS and PC approaches, which aims to select CUE and DUE from a predetermined list and to minimize the consumed amount of power, in order to satisfy the QoS depicted in Eq. (1). A centralized approach is proposed in this section, which is a generalized version of the algorithm CPCA (denoted GCPCA) to more than one CUE.
The condition assumed during the MS process is
Unlike the CPCA algorithm which is based on a MS relating to a system containing only one CUE, the GCPCA (see algorithm 1) generalizes this latter for several CUEs, based on the same condition
As shown in step 1 from algorithm 1, we first test if the matrix
Thus, this user
his most annoying user elimination strategy is repeated until the constraint is verified. Finally, the matrix obtained satisfies the sufficient condition
All these steps are more detailed in algorithm 1.
Step 1: if
Step 3. remove the
Step 4. update:
Step 5. evaluate the power
This GCPCA algorithm converges after an iteration number, since the condition
The maximum power
The power control problem proposed in this paper is considered as a distributed strategies non-cooperative game, where the utility functions as well as the strategies adopted by each user are defined and justified.
Several utility functions have suggested in [3, 9, 27, 28], using a pricing coefficient to enhance both efficiency and fairness among users. The proposed CUE and DUE utility functions considered in this section are defined as follows [6, 11],
where
The reward function
The penalty function,
where,
and
From which it follows
Afterwards, we denote the utility function vector as:
We denote our game
where,
The two powers
The NE is a strategy profile in which the strategy used by each user is at least as good a reply as any other strategy available to him to the strategies played by the other users. In this sense, to derive the NE of our proposed game, we propose in the following paragraph to study the best response relative to each user
Hence, each element of the best-response function
Hence, a PSNE
We assume that (
In this case, the feasible region of the power is defined as a region where the amount of power
So, the expression of
After simplification, the
The two best-response
Best-response
R | |
D2D link range | |
D2D link density ( | |
Path loss exponent ( | |
from | |
from | |
Iterations number |
Simulation parameters.
In the next section, we propose to extend this study for a system which contains
A NE Distributed PC Algorithm (NEDPCA) relative to both CUE and DUE is investigated in this section, in which our proposed game and CUE and DUE utility functions already defined in the previous section are considered. First, to do this, the SINR NE expressions for each user (CUE and DUE) are presented. Afterwards, the amount of power allocated to each user (CUE and DUE) relative to the derived NE are also studied. Thirdly, a power allocation algorithm will be suggested, based on the obtained results to derive the NE power quantities and the power limitation already discussed in Section 3.
The authors in [11] have shown that for a CUE and DUE
where
In fact, if:
The unique NE power
where,
We propose in the next step a distributed PC algorithm for the mentioned pure strategy game, which is based on the allocated power
The algorithm depicted in 2 outlines the different steps of the proposed algorithm NEDPCA offered to each CUE and DUE, which is based on the previous pure strategy game. In fact, this algorithm NEDPCA offers a NE power for the two kinds of users, based on both the previous constraints (1) and on the power expression depicted in Eq. (40). First, the MS process is derived from the GCPCA, in order to guarantee the constraints imposed by the CUEs and the DUEs in terms of SINR thresholds (see Eq. (1)). This is shown in step 1 of the Algorithm 2. Second, the SINR NE
Step 1: Evaluate from the Algorithm 1 GCPCA:
1) the CUE and DUE set of users:
2)
2. for each CUE
Step 3. for each DUE
Step 4. Derive for each CUE and DUE
Step 5: update
Step 6. if
All the NEDPCA steps relative to the distributed MS and PC for both CUE and DUE are detailed in Algorithm 2. Indeed, the first step of NECPCA makes it possible to realize the MS approach and all the other steps allow to deduce the PC approach.
Like the GCPCA algorithm, the NEDPCA algorithm converges after an iteration number, since it is based on the same condition
In order to evaluate the performance of the algorithms already mentioned and proposed in the following sections, we consider in this section to study the simulations of these algorithms: GCPCA and NEDPCA. A Monte Carlo simulation is applied according to the Table 1, already given in the previous section.
The CUE and DUE Total powers are evaluated in Figures 3 and 4 versus
We remain that the CPCA algorithm considers only one CUE and possibly several DUE. The GCPCA allocates to the different users the minimum power derived from Eq. (11), while respecting the condition
First, we can notice from Figure 3 that all the curves relative to GCPCA and NEDPCA algorithms are decreasing when
CUE Total power vs.
DUE Total power vs.
As it is shown from these two figures, the DUE coverage probability is significantly improved compared to that of DUE, because the DUEs benefit much more from TG compared to CUE, by using the NEPCA.
Second, the proposed centralized approach GCPCA which is a generalization of the CPCA approach offers less total power compared to the NEPCA, for both types of users CUE and DUE. This is due to the fact that when we want to reach a NE, by increasing the utility functions of each type of user, we should increase the total power consumed. Moreover, the difference between the two types of curves represents the power gain that must be added in order to reach this NE. From Figures 3 and 4, it is clear that for DUEs, this difference in terms of power is smaller compared to that of the CUEs. This is explained by the fact that the DUEs require less power to transmit. Third, by limiting the power consumed in
This chapter allows to invoke the problem of selection mode and power control for a D2D underlaid cellular networks in 5G. The basic idea of this chapter is to generalize the classic allocation algorithms by applying Game Theory, for many CUEs and DUEs in system.
First, we assume that the amount of power allocated to each kind of user should be between two amounts of power: a minimum power defined as a Pareto solution and a maximum power. Thus, a mathematical demonstration was provided in this chapter, in order to prove the expressions of these two powers, based on constraints imposed by the users in terms of SINR thresholds to be respected.
Second, our proposed system is modeled as a non-cooperative pure game between the different types of users, where the utility functions should be maximized. From the built-in utility functions, NE SINR and PC solution existence and uniqueness are investigated and studied.
Third, simulations have been established in this context, in order to assess the performance of the algorithms thus proposed in terms of total powers relative to both users CUE and DUE. Through these simulations which compare these results without and with GT, we noticed that by applying the TG, the total power consumed increases in order to reach the NE for the two types of users: CUE and DUE. This is due to the fact that to increase the utility functions relating to the two types of users, a power margin must be added. However, this difference in terms of power becomes less important for the DUEs, since they require less power relative to the DUEs.
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Biosensors, Biomaterials and Tissue Engineering",value:9,count:1},{group:"subseries",caption:"Bioinspired Technology and Biomechanics",value:8,count:2},{group:"subseries",caption:"Bioinformatics and Medical Informatics",value:7,count:9}],publicationYearFilters:[{group:"publicationYear",caption:"2021",value:2021,count:4},{group:"publicationYear",caption:"2019",value:2019,count:5},{group:"publicationYear",caption:"2018",value:2018,count:3}],authors:{paginationCount:302,paginationItems:[{id:"198499",title:"Dr.",name:"Daniel",middleName:null,surname:"Glossman-Mitnik",slug:"daniel-glossman-mitnik",fullName:"Daniel Glossman-Mitnik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/198499/images/system/198499.jpeg",biography:"Dr. Daniel Glossman-Mitnik is currently a Titular Researcher at the Centro de Investigación en Materiales Avanzados (CIMAV), Chihuahua, Mexico, as well as a National Researcher of Level III at the Consejo Nacional de Ciencia y Tecnología, Mexico. His research interest focuses on computational chemistry and molecular modeling of diverse systems of pharmacological, food, and alternative energy interests by resorting to DFT and Conceptual DFT. He has authored a coauthored more than 255 peer-reviewed papers, 32 book chapters, and 2 edited books. He has delivered speeches at many international and domestic conferences. He serves as a reviewer for more than eighty international journals, books, and research proposals as well as an editor for special issues of renowned scientific journals.",institutionString:"Centro de Investigación en Materiales Avanzados",institution:{name:"Centro de Investigación en Materiales Avanzados",country:{name:"Mexico"}}},{id:"76477",title:"Prof.",name:"Mirza",middleName:null,surname:"Hasanuzzaman",slug:"mirza-hasanuzzaman",fullName:"Mirza Hasanuzzaman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/76477/images/system/76477.png",biography:"Dr. Mirza Hasanuzzaman is a Professor of Agronomy at Sher-e-Bangla Agricultural University, Bangladesh. He received his Ph.D. in Plant Stress Physiology and Antioxidant Metabolism from Ehime University, Japan, with a scholarship from the Japanese Government (MEXT). Later, he completed his postdoctoral research at the Center of Molecular Biosciences, University of the Ryukyus, Japan, as a recipient of the Japan Society for the Promotion of Science (JSPS) postdoctoral fellowship. He was also the recipient of the Australian Government Endeavour Research Fellowship for postdoctoral research as an adjunct senior researcher at the University of Tasmania, Australia. Dr. Hasanuzzaman’s current work is focused on the physiological and molecular mechanisms of environmental stress tolerance. Dr. Hasanuzzaman has published more than 150 articles in peer-reviewed journals. He has edited ten books and written more than forty book chapters on important aspects of plant physiology, plant stress tolerance, and crop production. According to Scopus, Dr. Hasanuzzaman’s publications have received more than 10,500 citations with an h-index of 53. He has been named a Highly Cited Researcher by Clarivate. He is an editor and reviewer for more than fifty peer-reviewed international journals and was a recipient of the “Publons Peer Review Award” in 2017, 2018, and 2019. He has been honored by different authorities for his outstanding performance in various fields like research and education, and he has received the World Academy of Science Young Scientist Award (2014) and the University Grants Commission (UGC) Award 2018. He is a fellow of the Bangladesh Academy of Sciences (BAS) and the Royal Society of Biology.",institutionString:"Sher-e-Bangla Agricultural University",institution:{name:"Sher-e-Bangla Agricultural University",country:{name:"Bangladesh"}}},{id:"187859",title:"Prof.",name:"Kusal",middleName:"K.",surname:"Das",slug:"kusal-das",fullName:"Kusal Das",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSBDeQAO/Profile_Picture_1623411145568",biography:"Kusal K. Das is a Distinguished Chair Professor of Physiology, Shri B. M. Patil Medical College and Director, Centre for Advanced Medical Research (CAMR), BLDE (Deemed to be University), Vijayapur, Karnataka, India. Dr. Das did his M.S. and Ph.D. in Human Physiology from the University of Calcutta, Kolkata. His area of research is focused on understanding of molecular mechanisms of heavy metal activated low oxygen sensing pathways in vascular pathophysiology. He has invented a new method of estimation of serum vitamin E. His expertise in critical experimental protocols on vascular functions in experimental animals was well documented by his quality of publications. He was a Visiting Professor of Medicine at University of Leeds, United Kingdom (2014-2016) and Tulane University, New Orleans, USA (2017). For his immense contribution in medical research Ministry of Science and Technology, Government of India conferred him 'G.P. Chatterjee Memorial Research Prize-2019” and he is also the recipient of 'Dr.Raja Ramanna State Scientist Award 2015” by Government of Karnataka. He is a Fellow of the Royal Society of Biology (FRSB), London and Honorary Fellow of Karnataka Science and Technology Academy, Department of Science and Technology, Government of Karnataka.",institutionString:"BLDE (Deemed to be University), India",institution:null},{id:"243660",title:"Dr.",name:"Mallanagouda Shivanagouda",middleName:null,surname:"Biradar",slug:"mallanagouda-shivanagouda-biradar",fullName:"Mallanagouda Shivanagouda Biradar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243660/images/system/243660.jpeg",biography:"M. S. Biradar is Vice Chancellor and Professor of Medicine of\nBLDE (Deemed to be University), Vijayapura, Karnataka, India.\nHe obtained his MD with a gold medal in General Medicine and\nhas devoted himself to medical teaching, research, and administrations. He has also immensely contributed to medical research\non vascular medicine, which is reflected by his numerous publications including books and book chapters. Professor Biradar was\nalso Visiting Professor at Tulane University School of Medicine, New Orleans, USA.",institutionString:"BLDE (Deemed to be University)",institution:{name:"BLDE University",country:{name:"India"}}},{id:"289796",title:"Dr.",name:"Swastika",middleName:null,surname:"Das",slug:"swastika-das",fullName:"Swastika Das",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/289796/images/system/289796.jpeg",biography:"Swastika N. Das is Professor of Chemistry at the V. P. Dr. P. G.\nHalakatti College of Engineering and Technology, BLDE (Deemed\nto be University), Vijayapura, Karnataka, India. She obtained an\nMSc, MPhil, and PhD in Chemistry from Sambalpur University,\nOdisha, India. Her areas of research interest are medicinal chemistry, chemical kinetics, and free radical chemistry. She is a member\nof the investigators who invented a new modified method of estimation of serum vitamin E. She has authored numerous publications including book\nchapters and is a mentor of doctoral curriculum at her university.",institutionString:"BLDEA’s V.P.Dr.P.G.Halakatti College of Engineering & Technology",institution:{name:"BLDE University",country:{name:"India"}}},{id:"248459",title:"Dr.",name:"Akikazu",middleName:null,surname:"Takada",slug:"akikazu-takada",fullName:"Akikazu Takada",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/248459/images/system/248459.png",biography:"Akikazu Takada was born in Japan, 1935. After graduation from\nKeio University School of Medicine and finishing his post-graduate studies, he worked at Roswell Park Memorial Institute NY,\nUSA. He then took a professorship at Hamamatsu University\nSchool of Medicine. In thrombosis studies, he found the SK\npotentiator that enhances plasminogen activation by streptokinase. He is very much interested in simultaneous measurements\nof fatty acids, amino acids, and tryptophan degradation products. By using fatty\nacid analyses, he indicated that plasma levels of trans-fatty acids of old men were\nfar higher in the US than Japanese men. . He also showed that eicosapentaenoic acid\n(EPA) and docosahexaenoic acid (DHA) levels are higher, and arachidonic acid\nlevels are lower in Japanese than US people. By using simultaneous LC/MS analyses\nof plasma levels of tryptophan metabolites, he recently found that plasma levels of\nserotonin, kynurenine, or 5-HIAA were higher in patients of mono- and bipolar\ndepression, which are significantly different from observations reported before. In\nview of recent reports that plasma tryptophan metabolites are mainly produced by\nmicrobiota. He is now working on the relationships between microbiota and depression or autism.",institutionString:"Hamamatsu University School of Medicine",institution:{name:"Hamamatsu University School of Medicine",country:{name:"Japan"}}},{id:"137240",title:"Prof.",name:"Mohammed",middleName:null,surname:"Khalid",slug:"mohammed-khalid",fullName:"Mohammed Khalid",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/137240/images/system/137240.png",biography:"Mohammed Khalid received his B.S. degree in chemistry in 2000 and Ph.D. degree in physical chemistry in 2007 from the University of Khartoum, Sudan. He moved to School of Chemistry, Faculty of Science, University of Sydney, Australia in 2009 and joined Dr. Ron Clarke as a postdoctoral fellow where he worked on the interaction of ATP with the phosphoenzyme of the Na+/K+-ATPase and dual mechanisms of allosteric acceleration of the Na+/K+-ATPase by ATP; then he went back to Department of Chemistry, University of Khartoum as an assistant professor, and in 2014 he was promoted as an associate professor. In 2011, he joined the staff of Department of Chemistry at Taif University, Saudi Arabia, where he is currently an assistant professor. His research interests include the following: P-Type ATPase enzyme kinetics and mechanisms, kinetics and mechanisms of redox reactions, autocatalytic reactions, computational enzyme kinetics, allosteric acceleration of P-type ATPases by ATP, exploring of allosteric sites of ATPases, and interaction of ATP with ATPases located in cell membranes.",institutionString:"Taif University",institution:{name:"Taif University",country:{name:"Saudi Arabia"}}},{id:"63810",title:"Prof.",name:"Jorge",middleName:null,surname:"Morales-Montor",slug:"jorge-morales-montor",fullName:"Jorge Morales-Montor",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/63810/images/system/63810.png",biography:"Dr. Jorge Morales-Montor was recognized with the Lola and Igo Flisser PUIS Award for best graduate thesis at the national level in the field of parasitology. He received a fellowship from the Fogarty Foundation to perform postdoctoral research stay at the University of Georgia. He has 153 journal articles to his credit. He has also edited several books and published more than fifty-five book chapters. He is a member of the Mexican Academy of Sciences, Latin American Academy of Sciences, and the National Academy of Medicine. He has received more than thirty-five awards and has supervised numerous bachelor’s, master’s, and Ph.D. students. Dr. Morales-Montor is the past president of the Mexican Society of Parasitology.",institutionString:"National Autonomous University of Mexico",institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}},{id:"217215",title:"Dr.",name:"Palash",middleName:null,surname:"Mandal",slug:"palash-mandal",fullName:"Palash Mandal",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217215/images/system/217215.jpeg",biography:null,institutionString:"Charusat University",institution:null},{id:"49739",title:"Dr.",name:"Leszek",middleName:null,surname:"Szablewski",slug:"leszek-szablewski",fullName:"Leszek Szablewski",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49739/images/system/49739.jpg",biography:"Leszek Szablewski is a professor of medical sciences. He received his M.S. in the Faculty of Biology from the University of Warsaw and his PhD degree from the Institute of Experimental Biology Polish Academy of Sciences. He habilitated in the Medical University of Warsaw, and he obtained his degree of Professor from the President of Poland. Professor Szablewski is the Head of Chair and Department of General Biology and Parasitology, Medical University of Warsaw. Professor Szablewski has published over 80 peer-reviewed papers in journals such as Journal of Alzheimer’s Disease, Biochim. Biophys. Acta Reviews of Cancer, Biol. Chem., J. Biomed. Sci., and Diabetes/Metabol. Res. Rev, Endocrine. He is the author of two books and four book chapters. He has edited four books, written 15 scripts for students, is the ad hoc reviewer of over 30 peer-reviewed journals, and editorial member of peer-reviewed journals. Prof. Szablewski’s research focuses on cell physiology, genetics, and pathophysiology. He works on the damage caused by lack of glucose homeostasis and changes in the expression and/or function of glucose transporters due to various diseases. He has given lectures, seminars, and exercises for students at the Medical University.",institutionString:"Medical University of Warsaw",institution:{name:"Medical University of Warsaw",country:{name:"Poland"}}},{id:"173123",title:"Dr.",name:"Maitham",middleName:null,surname:"Khajah",slug:"maitham-khajah",fullName:"Maitham Khajah",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/173123/images/system/173123.jpeg",biography:"Dr. Maitham A. Khajah received his degree in Pharmacy from Faculty of Pharmacy, Kuwait University, in 2003 and obtained his PhD degree in December 2009 from the University of Calgary, Canada (Gastrointestinal Science and Immunology). Since January 2010 he has been assistant professor in Kuwait University, Faculty of Pharmacy, Department of Pharmacology and Therapeutics. His research interest are molecular targets for the treatment of inflammatory bowel disease (IBD) and the mechanisms responsible for immune cell chemotaxis. He cosupervised many students for the MSc Molecular Biology Program, College of Graduate Studies, Kuwait University. Ever since joining Kuwait University in 2010, he got various grants as PI and Co-I. He was awarded the Best Young Researcher Award by Kuwait University, Research Sector, for the Year 2013–2014. He was a member in the organizing committee for three conferences organized by Kuwait University, Faculty of Pharmacy, as cochair and a member in the scientific committee (the 3rd, 4th, and 5th Kuwait International Pharmacy Conference).",institutionString:"Kuwait University",institution:{name:"Kuwait University",country:{name:"Kuwait"}}},{id:"195136",title:"Dr.",name:"Aya",middleName:null,surname:"Adel",slug:"aya-adel",fullName:"Aya Adel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/195136/images/system/195136.jpg",biography:"Dr. Adel works as an Assistant Lecturer in the unit of Phoniatrics, Department of Otolaryngology, Ain Shams University in Cairo, Egypt. Dr. Adel is especially interested in joint attention and its impairment in autism spectrum disorder",institutionString:"Ain Shams University",institution:{name:"Ain Shams University",country:{name:"Egypt"}}},{id:"94911",title:"Dr.",name:"Boulenouar",middleName:null,surname:"Mesraoua",slug:"boulenouar-mesraoua",fullName:"Boulenouar Mesraoua",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94911/images/system/94911.png",biography:"Dr Boulenouar Mesraoua is the Associate Professor of Clinical Neurology at Weill Cornell Medical College-Qatar and a Consultant Neurologist at Hamad Medical Corporation at the Neuroscience Department; He graduated as a Medical Doctor from the University of Oran, Algeria; he then moved to Belgium, the City of Liege, for a Residency in Internal Medicine and Neurology at Liege University; after getting the Belgian Board of Neurology (with high marks), he went to the National Hospital for Nervous Diseases, Queen Square, London, United Kingdom for a fellowship in Clinical Neurophysiology, under Pr Willison ; Dr Mesraoua had also further training in Epilepsy and Continuous EEG Monitoring for two years (from 2001-2003) in the Neurophysiology department of Zurich University, Switzerland, under late Pr Hans Gregor Wieser ,an internationally known epileptologist expert. \n\nDr B. Mesraoua is the Director of the Neurology Fellowship Program at the Neurology Section and an active member of the newly created Comprehensive Epilepsy Program at Hamad General Hospital, Doha, Qatar; he is also Assistant Director of the Residency Program at the Qatar Medical School. \nDr B. Mesraoua's main interests are Epilepsy, Multiple Sclerosis, and Clinical Neurology; He is the Chairman and the Organizer of the well known Qatar Epilepsy Symposium, he is running yearly for the past 14 years and which is considered a landmark in the Gulf region; He has also started last year , together with other epileptologists from Qatar, the region and elsewhere, a yearly International Epilepsy School Course, which was attended by many neurologists from the Area.\n\nInternationally, Dr Mesraoua is an active and elected member of the Commission on Eastern Mediterranean Region (EMR ) , a regional branch of the International League Against Epilepsy (ILAE), where he represents the Middle East and North Africa(MENA ) and where he holds the position of chief of the Epilepsy Epidemiology Section; Dr Mesraoua is a member of the American Academy of Neurology, the Europeen Academy of Neurology and the American Epilepsy Society.\n\nDr Mesraoua's main objectives are to encourage frequent gathering of the epileptologists/neurologists from the MENA region and the rest of the world, promote Epilepsy Teaching in the MENA Region, and encourage multicenter studies involving neurologists and epileptologists in the MENA region, particularly epilepsy epidemiological studies. \n\nDr. Mesraoua is the recipient of two research Grants, as the Lead Principal Investigator (750.000 USD and 250.000 USD) from the Qatar National Research Fund (QNRF) and the Hamad Hospital Internal Research Grant (IRGC), on the following topics : “Continuous EEG Monitoring in the ICU “ and on “Alpha-lactoalbumin , proof of concept in the treatment of epilepsy” .Dr Mesraoua is a reviewer for the journal \"seizures\" (Europeen Epilepsy Journal ) as well as dove journals ; Dr Mesraoua is the author and co-author of many peer reviewed publications and four book chapters in the field of Epilepsy and Clinical Neurology",institutionString:"Weill Cornell Medical College in Qatar",institution:{name:"Weill Cornell Medical College in Qatar",country:{name:"Qatar"}}},{id:"282429",title:"Prof.",name:"Covanis",middleName:null,surname:"Athanasios",slug:"covanis-athanasios",fullName:"Covanis Athanasios",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/282429/images/system/282429.jpg",biography:null,institutionString:"Neurology-Neurophysiology Department of the Children Hospital Agia Sophia",institution:null},{id:"190980",title:"Prof.",name:"Marwa",middleName:null,surname:"Mahmoud Saleh",slug:"marwa-mahmoud-saleh",fullName:"Marwa Mahmoud Saleh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/190980/images/system/190980.jpg",biography:"Professor Marwa Mahmoud Saleh is a doctor of medicine and currently works in the unit of Phoniatrics, Department of Otolaryngology, Ain Shams University in Cairo, Egypt. She got her doctoral degree in 1991 and her doctoral thesis was accomplished in the University of Iowa, United States. Her publications covered a multitude of topics as videokymography, cochlear implants, stuttering, and dysphagia. She has lectured Egyptian phonology for many years. Her recent research interest is joint attention in autism.",institutionString:"Ain Shams University",institution:{name:"Ain Shams University",country:{name:"Egypt"}}},{id:"259190",title:"Dr.",name:"Syed Ali Raza",middleName:null,surname:"Naqvi",slug:"syed-ali-raza-naqvi",fullName:"Syed Ali Raza Naqvi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259190/images/system/259190.png",biography:"Dr. Naqvi is a radioanalytical chemist and is working as an associate professor of analytical chemistry in the Department of Chemistry, Government College University, Faisalabad, Pakistan. Advance separation techniques, nuclear analytical techniques and radiopharmaceutical analysis are the main courses that he is teaching to graduate and post-graduate students. In the research area, he is focusing on the development of organic- and biomolecule-based radiopharmaceuticals for diagnosis and therapy of infectious and cancerous diseases. Under the supervision of Dr. Naqvi, three students have completed their Ph.D. degrees and 41 students have completed their MS degrees. He has completed three research projects and is currently working on 2 projects entitled “Radiolabeling of fluoroquinolone derivatives for the diagnosis of deep-seated bacterial infections” and “Radiolabeled minigastrin peptides for diagnosis and therapy of NETs”. He has published about 100 research articles in international reputed journals and 7 book chapters. Pakistan Institute of Nuclear Science & Technology (PINSTECH) Islamabad, Punjab Institute of Nuclear Medicine (PINM), Faisalabad and Institute of Nuclear Medicine and Radiology (INOR) Abbottabad are the main collaborating institutes.",institutionString:"Government College University",institution:{name:"Government College University, Faisalabad",country:{name:"Pakistan"}}},{id:"58390",title:"Dr.",name:"Gyula",middleName:null,surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/58390/images/system/58390.png",biography:"Gyula Mózsik MD, Ph.D., ScD (med), is an emeritus professor of Medicine at the First Department of Medicine, Univesity of Pécs, Hungary. He was head of this department from 1993 to 2003. His specializations are medicine, gastroenterology, clinical pharmacology, clinical nutrition, and dietetics. 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