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Quiroz, Erick R. Bandala and Carlos A. 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1. Introduction
Respiratory compromise due to embolization is one of the leading causes of death among hospitalized patients, a condition known as acute pulmonary embolism (PE). In the United States alone, for every 100,000 individuals, about 70 people will experience pulmonary embolism each calendar year [1].
Simply put, acute pulmonary embolism is a restriction of arterial blood flow in the lung that can be detrimental when misdiagnosed. When the cause of obstruction is blood itself, it is known as venous thromboembolism (VTE). This being the most common cause of pulmonary embolism. It is apropos to mention that blood flow is not the only substance that can cause mechanical lung obstructions. Other substances include, but not limited to fat (traumatic bone fracture, especially of long bones, leads to bone marrow/fat freely circulating systemically), amniotic fluid (as a complication of labor), air (a complication of central venous access), septic embolism (heart valve damage by micro-organism) or even tumor cells metastasizing. The broad array of materials that can lead to this obstructive shock makes it imperative for a clinician to put the clinical picture with the patient’s symptoms to make the diagnosis early. Failure to do so in a timely manner can lead to catastrophic cardiopulmonary compromise and even death.
When PE is caused by venous thromboembolism, greater than 50% of patients will have some clot burden in their lower extremities or a deep vein thrombosis (DVT). The culprit vessels being the femoral and popliteal veins. Some patients may present with symptoms of DVT without PE. Therefore, a thorough investigation is warranted to diagnose, treat and prevent future propagation.
2. Pathophysiology of acute pulmonary embolism
Acute pulmonary embolism is a mechanical obstruction of the blood flow to the lung vasculature and the functional unit involved in respiration, the parenchyma. The parenchyma being starved of oxygen leads to an inflammatory response and cellular death made evident by respiratory compromise and the compensatory respiratory alkalosis on patient presentation. It is imperative to note that both PE and DVT share a spectrum in the realm of VTE. The main difference between these two disease states lies in the location. The main mechanism that leads to PE and DVT, known as the Virchow’s triad, comprises of endothelial injury, venous statis and a hypercoagulable state.
Endothelial injury refers to damage to the vasculature which can lead to an inflammatory response in an attempt to heal with thrombus formation. Most commonly, this occurs in acute trauma, previous history of trauma or prior surgery. Venous stasis, which comprises of a no flow state of blood, can lead to thrombus formation as blood has an affinity to coagulate when not freely flowing. Venous stasis is mostly seen as a complication from immobility (postoperative states) or in patients with major strokes. Lastly, a hypercoagulable state can be a complication of disease states, such as active cancer, medications such as hormonal replacement therapy or oral contraceptives, and finally genetic mutations, most common being factor V Leiden. Other genetic mutations include: protein C and S deficiency, prothrombin gene mutation, antithrombin III deficiency.
Hemodynamically, there are many alterations that occur in the presence of an acute PE that is related to the size of the embolus, the duration of blood flow obstruction as well as the patient’s cardiopulmonary history. Large PEs tend to obstruct the main pulmonary artery along with its branches while smaller PEs are culprits of the smaller peripheral vessels. The obstructive burden coupled with neurohormonal release contribute to hemodynamic compromise and ischemic propagation is presence of neurohormonal release that progress propagate ongoing damage. Common neurohormones present include serotonin, thrombin and histamine [2].
Hypoxic vasoconstriction, a reflex response to acute PE, leads to increase in mean arterial pulmonary pressure. This increase is significantly high in patients with history of pulmonary hypertension. Increased pulmonary artery pressure contributes to increased right ventricular (RV) afterload causing right ventricular enlargement and a leftward bulging of the interventricular septum commonly found on echocardiography. Cardiac arrest is hence from the vascular compromise from increased pressure on the right coronary artery, causing myocardial ischemia.
Acute PE impairs efficient gas exchange. Hypoxemia and increase in the alveolar-arterial oxygen tension gradient are the most common gas exchange abnormalities. Total dead space increases. Ventilation and perfusion become mismatched, with blood flow from obstructed pulmonary arteries redirected to other gas exchange units [2]. The obstruction of blood flow in the pulmonary arteries leads to a redistribution of blood flow causing some alveoli to have low ratios of ventilation to perfusion, whereas others have excessively high ratios of ventilation to perfusion [2].
3. Clinical manifestations
Assessment of PE in patients can be challenging as symptoms can be nonspecific. The patient could present with an array of different possibilities but a history of dyspnea, progressive or sudden onset in nature is a common complaint. Other complaints include pleuritic chest pain, cough and hemoptysis mostly in patients with pulmonary infarction. Due to the nonspecific symptoms that acute PE could present with, it is imperative to garner the appropriate risk factors that could lead to the suspicion. Another complaint that should increase the index of suspicion is a patient with dyspnea coupled with recent onset lower extremity tenderness or swelling.
Most patients with PE have tachypnea and tachycardia associated with hypoxemia. Similar findings can occur in disorders such as heart failure, pneumonia, or chronic obstructive pulmonary disease [2]. A good clinical examination is apropos to ascertain any other possible disease pathology that may mimic PE.
4. Diagnosis
The diagnosis of PE relies on a high clinical suspicion along with the patient’s history and physical exam. After suspicion, confirmation with appropriate testing leads to the final diagnosis. Diagnostic tests alone are not the reflex course of action with a high index of suspicion due to the fact that there are many disease states that could present similarly. In patients with a high index of suspicion, the Wells criteria, developed by Wells et al., is a simple clinical model to predict the likelihood of PE. Scoring system has a maximum of 12.5 points, based on 7 variables: 3 points each for clinical evidence of DVT and an alternative diagnosis being less likely than PE, 1.5 points each for heart rate > 100 per minute, immobilization/surgery within 4 weeks, and previous deep vein thrombosis/PE, and 1 point each for hemoptysis or cancer [2, 3]. The pretest probability for PE after utilization of the Wells scoring system categorizes PE into low (score < 2), moderate (score between 2 and 6) or high risk (score > 6). This will then guide a clinician on subsequent tests such as a D-dimer assay, a byproduct of ineffective fibrinolysis released into systemic circulation. D-dimer elevation has high sensitivity for acute PE, as high as 98%, albeit poor sensitivity. Instances such as malignancy, advanced age and chronic inflammatory conditions are all reasons for an elevated d-dimer besides PE. Therefore, the benefit of a d-dimer assay lies in its high negative predictive value and its ability to effectively reduce further diagnostic testing in patients with an already low to moderate pretest probability with Wells scoring [4, 5].
Imaging studies in patients with acute PE in recent times have been with computed tomography pulmonary angiography (CT-PA). The benefit of CT-PA is direct thrombi visualization in the pulmonary arteries and effectively ruling out patients without PE [2]. The use of radiocontrast dye should be taken into consideration in patients with a suspicion of PE, but in patients with decompensation coupled with a high index of suspicion, the benefits of imaging clearly outweigh the risk. Furthermore, CT-PA with evidence of thrombus in the pulmonary arteries up to the segmental level provides strong evidence of PE. When negative, it does exclude PE but the presence of PE in the subsegmental regions, sometimes missed by CT-PA, does not alter patient outcome as these patients have at least as good an outcome as patients with a negative lung scan [2, 6].
There are indeed other modalities for investigation of acute PE, though by far a CT-PA has emerged as the more favorable option. Other modalities include a ventilation-perfusion (V/Q) scan, a two-part exam with a ventilation phase and perfusion phase. Diagnosis of PE based on a V/Q scan is made when PE-associated lung areas fail to enhance on the perfusion phase using technetium-labeled albumin macroaggregates. Magnetic resonance imaging (MRI) with gadolinium-enhancement has been shown to have similar efficacy to that of CT-PA.
5. Management of acute pulmonary embolism
Anticoagulation has become the mainstay treatment for acute PE though the degree of severity influences the length of treatment. The severity of acute PE depends on parameters such as hemodynamics, right ventricular dysfunction, presence of troponin and/or brain natriuretic peptide (BNP). Risk stratification using the appropriate criteria not only guides the choice of treatment, but also provides outpatient management options. It is also highly important to know if the patient has any contraindications to anticoagulation prior to initiation of treatment. Massive (high-risk) PE is the presence of hemodynamic compromise, right ventricular dysfunction and increased troponin and/or BNP levels. In such patients, the most common cause of death is not the PE, but the complication of acute right ventricular failure. To mitigate this complication, hemodynamic and respiratory support early is crucial. Due to the dependence of preload in right ventricular failure, both fluid expansion and inotropic agents, such as dobutamine, dopamine and/or norepinephrine, are needed to manage shock [2]. In patients with presence of right ventricular dysfunction and increased troponin and/or BNP levels without hemodynamic compromise, are classified as sub-massive (intermediate-risk) PE with consideration of fibrinolytic therapy if very symptomatic. Lastly, low-risk PE classification is in the group of patients with no hemodynamic compromise, right ventricular dysfunction or increased troponin or BNP levels. In such patients, a consideration of outpatient management is acceptable.
5.1 Anticoagulation
Anticoagulation has become the cornerstone modality of treatment in patients with acute PE. In patients with a very high index of suspicion or massive PE, anticoagulation should be initiated prior to confirmatory test. The most extensively studied anticoagulant in PE is heparin. Heparin, an anti-thrombin III inhibitor, acts mainly by inactivation of factor Xa in the clotting cascade, preventing the conversion of prothrombin to thrombin. Other options include low molecular weight heparin (LMWH), fondaparinux or the direct factor Xa inhibitors, rivaroxaban and apixaban. Dosing for heparin is usually 80 U/kg bolus followed by an infusion at the rate of 18 U/kg per hour with subsequent doses based on aPTT results [4]. Additionally, it is important to monitor platelet count while heparin is administered due to the risk of heparin-induced thrombocytopenia (HIT). After the initial heparinization phase, continued treatment is with an oral direct thrombin inhibitor, factor Xa inhibitor or warfarin.
The duration of treatment of PE is directly related to the precipitating factors that led to the PE. In other words, whether the PE was provoked or unprovoked. Special considerations in terms of treatment modality and duration are made for certain populations such as pregnant females or patients with active cancer. For all other patient populations with who present with a first time PE, the minimum duration of treatment is 3 months. If the PE is provoked and the factors are withdrawn such as a female stopping hormonal treatment, then a 3-month period of oral anticoagulation is sufficient. In patients with an unprovoked or life-threatening PE, indefinite anticoagulation is ideal due to a higher risk of recurrence. There must be a risk and benefit analysis when indefinite anticoagulation is being pursued, especially in patients with a higher bleeding risk [4].
5.2 Thrombolytic therapy
Systemic thrombolytic therapy is an effective therapy in preventing deaths from PE, however it markedly increases bleeding risks, including intracranial and fatal bleeding [7]. The PEITHO (Pulmonary Embolism Thrombolysis Study), which compared tenecteplase with placebo in 1000 PE patients without hypotension but with right ventricular dysfunction, found no clear net benefit from systemic thrombolytic therapy; the reduction in cardiovascular collapse (odds ratio: 0.30) was offset by the increase in major bleeding (odds ratio: 5.2) [8]. Consequently, systemic thrombolytic therapy is usually reserved for PE patients with hypotension. Catheter-directed thrombolysis (CDT) was initially developed for treatment of arterial, dialysis graft, and deep vein thromboses (leg or arm). When used to treat acute PE, a wire is usually passed through the embolus, followed by placement of a multi-sidehole infusion catheter through which a thrombolytic drug is infused over 12–24 h. The delivery of the drug directly into the thrombus is expected to be as effective as systemic therapy but to cause less bleeding because a much lower dose of the drug is used.
SEATTLE II is a single-arm prospective cohort study in which 150 patients with lobar artery or more central PE (31 with and 119 without hypotension) were treated with ultrasound-assisted CDT using a standardized protocol [9]. Tissue plasminogen activator was infused into each treated lung at a rate of 1 mg/h, to a total dose of 24 mg (over 12 h for bilateral lung infusions), and no additional mechanical maneuvers were used to disrupt or aspirate thrombus. When computed tomography pulmonary angiography was repeated after 48 h, the right ventricular to left ventricular ratio was decreased by 27% and thrombus burden was reduced by 30%. Pulmonary artery pressure also decreased by 27% between the start to the end of CDT. These 3 improvements were each highly statistically significant. There were 17 episodes of major bleeding in 15 patients (10%): one was associated with hypotension; all required transfusion; none was intracranial; and none was fatal.
5.3 Mechanical thrombectomy
Acute pulmonary ischemia due to pulmonary embolism results in a cascade of events, from decreasing lung compliance to increasing pulmonary resistance ultimately resulting in RV dysfunction and hemodynamic collapse. Thus, in certain cases more rapid thrombus removal is required, and mechanical techniques are now available.
The FlowTriever System (Figure 1) is a mechanical thrombectomy device indicated for use in the peripheral vasculature and pulmonary arteries (PAs). FlowTriever received U.S. Food and Drug Administration 510(k) clearance for PE in May 2018—the first mechanical thrombectomy device to receive that indication. The FlowTriever System includes Triever aspiration catheters (16-F, 20-F, 24-F) capable of removing large amounts of thrombus via aspiration with a 60 cc syringe. The FlowTriever System also includes FlowTriever catheters with three self-expanding nitinol mesh disks of different sizes designed to aid in extraction, if needed, by engaging and disrupting thrombus. Anticoagulation with heparin is recommended per routine catheterization laboratory practice to prevent thrombosis of the catheter. The aspiration catheter is advanced over a 0.035-inch wire to the level of the right or left PA, just proximal to the occlusive thrombus. Once engaged, the clot is extracted via aspiration through the catheter. The procedure can be repeated several times per side at the discretion of the physician, depending on the amount of clot retrieved and the improvement in distal flow on repeat angiography.
Figure 1.
The FlowTriever® system. The Triever aspiration catheter is shown in purple, and the optional FlowTriever® catheter with nitinol disks is shown emerging from the distal end of the Triever catheter.
The FlowTriever System has been evaluated in several clinical studies both prospectively and retrospectively. The first of these was a prospective multi-center study, the FLARE (FlowTriever Pulmonary Embolectomy Clinical Study) trial, which was the largest systematic evaluation of the effectiveness of mechanical thrombectomy for PE at the time [10]. From April 2016 to October 2017, 106 patients were treated with the FlowTriever System at 18 U.S. sites. Two patients (1.9%) received adjunctive thrombolytics. The mean procedural time was 94 min, and the mean intensive care unit stay was 1.5 days. Forty-three patients (41.3%) did not require any intensive care unit stay. At 48 h post-procedure, average RV/LV ratio reduction was 0.38 (25.1%; p < 0.0001). Four patients (3.8%) experienced 6 major adverse events, with 1 patient (1.0%) experiencing major bleeding. One patient (1.0%) died from undiagnosed breast cancer through 30-day follow-up. The trial concluded that percutaneous mechanical thrombectomy with the FlowTriever System appears safe and effective in patients with acute intermediate-risk PE, achieved significant improvement in RV/LV ratio, and resulted in minimal major bleeding.
Large-bore aspiration mechanical thrombectomy with the FlowTriever System was also evaluated in two retrospective single-arm clinical studies. The first of these [11] was a single-center study of 46 patients with both massive (high-risk) and submassive (intermediate-risk) PE. The authors reported a significant reduction in mean PA pressure from 33.9 ± 8.9 mmHg to 27.0 ± 9.0 mmHg (p < 0.0001) immediately following thrombectomy. The majority of patients experienced intraprocedural reductions in mean PA pressure (88%) and supplemental oxygen requirements (71%). All patients survived to discharge, and there were no procedure-related complications or deaths within the 30 days following discharge. The second retrospective study [12] was a multi-center study of 34 patients with massive and very-high-risk submassive PE. All patients were either hemodynamically unstable, intubated, or normotensive but with low cardiac index (< 1.8 L/min/m2). In this very sick population, cardiac index improved significantly immediately following thrombectomy (2.0 ± 0.1 L/min/m2 vs. 2.4 ± 0.1 L/min/m2, p = 0.1), as did mean PA pressure (33.2 ± 1.6 mmHg vs. 25.0 ± 1.5 mmHg, p = .01). Two patients deteriorated during the procedure, one who expired and one who was stabilized on ECMO. All other patients survived through a mean follow-up of 205 days. These two retrospective studies provide clinical evidence supporting the safety and effectiveness of mechanical thrombectomy with the FlowTriever System for PE treatment.
More recently, the FlowTriever System was studied in a nonrandomized two-arm retrospective analysis versus routine care [13]. This single-center study compared outcomes for 28 patients who underwent mechanical thrombectomy with the FlowTriever System to those for 30 patients who received routine care, which consisted of anticoagulation alone, anticoagulation with CDT, or systemic thrombolysis. In-hospital mortality was significantly lower for patients undergoing mechanical thrombectomy versus routine care (3.6% vs. 23.3%, p < 0.05). Furthermore, the average intensive care unit length of stay was also significantly shorter for patients undergoing mechanical thrombectomy (2.1 ± 1.2 days vs. 6.1 ± 8.6 days, p < 0.05). Total hospital length of stay and 30-day readmission rates were similar between the two groups. This study provides initial comparative data suggesting that mechanical thrombectomy can improve in-hospital mortality and decrease ICU length of stay for PE patients with elevated risk profiles.
5.4 Technical aspects of mechanical thrombectomy
Pre procedure planning\t\t
Patient Information
Prior to any pulmonary embolism procedure several patient conditions must be made clear. Several questions that all operators should ask include, what are the current hemodynamics and does that patient require vasopressor support? What is the current respiratory status (Ie O2 supplementation or on mechanical ventilation)? What is the bleeding risk and can the patient be anticoagulated? During our procedure we maintain and actual clotting time (ACT) of >250 secs.
Pre case Imaging
CT is the most rapid and common imaging tool used. Specific items to look for include, location and size of clot, RV/LV Ratio, and pulmonary infarct.
Echocardiography will not only show LV and RV size but RV systolic function.
Additional things to consider:
History or current DVT
IVC Filter in Place
Clot in Transit (is TEE or TTE available urgently)
Conscious sedation is recommended. General Anesthesia has a risk of worsening hypotension and reducing preload to the RV. If systemic pressure is tenuous, a rapid reduction in RV filling can result in immediate hemodynamic collapse.
Patient Selection
Avoidance of thrombolytics
There are several advantages to the decision making for who would benefit from thrombolytic therapy for pulmonary embolism. The immediate decision is to determine who is at highest risk and thus has the largest to gain. Any patient with right ventricular (RV) dysfunction, we feel should be considered for thrombolytic therapy. Patients with an elevated RV: LV ratio; greater than 0.9, elevated pro-bnp, elevated troponins, and hemodynamics suggestive of reduced cardiac output, should be considered for thrombolytic therapy.
Patients need to be able to lay either supine or prone for a minimum of 30 minutes, thus taking oxygen requirements and body habitus into consideration.
Any patient with a relative contraindication to thrombolytic therapy, or felt to be at elevated risk, immediately should be considered for thrombotic intervention.
Access
US guidance
Access to venous circulation, when using large bore sheaths should always be performed with ultrasound guidance. It is advantageous in the venous system to evaluate for upper or lower extremity deep venous thrombosis, prior to starting the procedure, as well as avoidance of an arterial puncture.
Femoral
The most common access site for pulmonary thrombectomy is the common femoral vein
Jugular
When an alternative access is required another option is the internal jugular vein.
Pulmonary angiogram
Difficulties
Image quality tends to be the dis-advantage. Morbid obesity, patient movement, as well as variations in imaging acquisition (ie dye load, manual vs. power injection), can result in wide range of image quality.
Aspiration thrombectomy catheters
Inari Medical
Twenty-four french aspiration guide catheter that navigates through the right heart and delivers the catheter directly into the pulmonary artery. Aspiration is performed by a manual pull. The large bore catheter maximizes aspiration and collection of thrombus. The 24 F catheter creates an aspiration flow rate of 143 mLs/second.
Sixteen french curve
Due to the natural curvature of the pulmonary artery to the right, the 24 F catheter takes a turn to the right pulmonary artery typically with little difficulty. The catheter when placed in the left pulmonary artery, typically does not engage the left lower lobe. The 16 french curve catheter is placed within the 24F catheter and is preshaped to point down into the left pulmonary artery for selective thrombus aspiration.
Bloodloss technology
The FlowSaver blood return system is designed to be used with the FlowTriever aspiration catheter to reduced blood loss by filtering aspirated thrombi and blood for reinfusion back to the patient, thus enabling bloodless thrombectomy for pulmonary embolism procedure. The filtration system includes a 40-micro filter. Filtered blood can be reintroduced using a 60-cc collection syringe.
Penumbra, Inc.
The Indigo aspiration system is indicated for use in the peripheral arterial system and the pulmonary arteries, receiving U.S. Food and Drug Administration 510(k) clearance for PE in December 2019.
The Indigo system lightning 12 aspiration catheter that navigates through the right heart and into the selected pulmonary artery. The 12F system, unlike the manual aspiration of the Inari device, is connected to the Penumbra aspiration pump, resulting in a continuous vacuum system at −28.5 mmHg. If thrombus is not aspirated, the system also has a separator wire that can be advanced through the catheter to disrupt thrombus at the distal tip.
Intraprocedural complications
Perforation
The most common cause of pulmonary artery perforation is due to a wire complication. Wire perforation causes include treating distal clot, poor wire positioning and overlapping vessel (specifically on the left side)
Avoidance and Management
Limit use of guide wires, and always use Amplatz wire to work over
Use multiple shots to confirm location of wire and catheter
Use multiple angles of monitor to confirm locations
If Perforation does occur, increase supplemental oxygen, stop and reverse anticoagulation and consider placing a occlusion balloon proximal to the perforation.
Right heart trauma
If the tricuspid valve crossed safely with angled pigtail catheter or balloon tip catheter, typically not as concerned. If a end hold catheter was used, through a chordae tendinea of the tricuspid valve.
Always advance with caution as advancing through heart monitoring pain, excessive tension advancing catheter, and any arrhythmias happening
Never advance large bore catheters without dilators
Use buddy wires to assist stability in accessing multiple vessels to avoid kick back
Shock/RV failure
There are several methods of determining right ventricular systolic function. A calculated PAPi in the cardiac cath lab can determine who would benefit from RV mechanical support (ie Abiomed Impella RP). If the PAPi is calculated to be less than 1, and you have achieved enough thrombolytic therapy to allow for distal perfusion, mechanical support should be considered. Extracorporeal membrane oxygenation (ECMO) can also be considered for both hemodynamic support and oxygenation.
Closure
Most venous access sites can be closed with manual pressure alone. However, with large bore access we have using the Abbott Medical proglide perclose suture mediated closure. This device has been shown to reduce time to hemostasis, ambulation and discharge compared to manual compression
Post Procedure management
ICU avoidance
The use of thrombolysis for the treatment of PE at some institutions requires ICU level care.
Mechanical thrombectomy is a means of direct therapy which can result in immediate clinical response and will commonly not require intensive care management.
Additionally with the avoidance of tissue plasminogen activator (tPA), ICU admission post procedure is commonly unnecessary.
Venous dopplers
The most common source of PE is DVT. Thus, all patients require bilateral venous duplex for confrontation of rescheduled disease.
Based on these results, it is a clinical decision whether therapy is required for DVT.
Hypercoagulable work up
Patients who benefit from this work up include:
those with/without a family history of VTE
patients age < 45 years
recurrent thrombosis or thrombosis in unusual sites
arterial thrombosis
history of warfarin-induced dermatologic necrosis
These patients will benefit from testing: activated protein C resistance, factor V Leiden, Prothrombin gene mutation, Protein C and S deficiency, Antithrombin deficiency.
DOAC
DOACS such as Factor Xa inhibitors, Apixaban or Rivaroxaban, have become more favorable than Warfarin for anticoagulation due to lower bleeding risk, monitoring for therapeutic INR levels and easier dosing. Apixaban is dosed twice daily while Rivaroxaban is daily dosing. A lower dose is required based on age ≥80, weight ≤60kg and creatinine ≥1.5
Follow up Echo
A follow up echo is used to determine RV dimensions, RV dysfunction and residual pulmonary hypertension.
It is our practice that if there is residual elevation of pulmonary systolic pressure, we refer the patient to a pulmonary hypertension specialist.
5.5 Mechanical thrombectomy case reports
Case 1
A 33-year-old woman with no significant past medical history presented to our emergency department after multiple syncopal episodes. An ambulance service was called by family and the patient arrived hypotensive and poorly responsive. She required 6 L of supplemental oxygen and vasopressor support to keep a mean arterial pressure greater than 60 mmHg and oxygen saturation greater than 92%. A bedside anterior-posterior chest X-ray showed a normal cardiac silhouette and clear lung fields. A 12-lead electrocardiogram was consistent with a sinus tachycardia and right bundle branch block. Initial laboratory data was positive for an elevated d-dimer (> 5000 ng/mL), positive troponin (0.4 ng/mL), and pro-brain natriuretic peptide (> 10,000 pg/mL). A stat CT angiogram of the chest demonstrated a massive PE with complete occlusion of the left lower lobe and a RV/LV ratio of 1.5.
The patient was moved emergently to the cardiac catheterization laboratory for immediate therapeutic aspiration thrombectomy. Access was obtained in the right femoral vein using ultrasound guidance. Initial systolic PA pressure was 60 mmHg and the mean PA pressure was 35 mmHg. A pulmonary angiogram confirmed complete occlusion of the left lower lobe (Figure 2). The 24-F Triever aspiration catheter (Triever24) was positioned in the left pulmonary artery. A 20-F Triever Curve catheter, capable of curving up to 260° to aid in navigating in difficult anatomies, (Figure 3) was used coaxially with the Triever24 catheter to angle to the lower lobe where two aspirations were performed. A large amount of thrombus was removed (Figure 4) and repeat pulmonary angiography showed almost complete pulmonary artery opacification and large reduction in thrombus burden (Figure 5). Within minutes there was hemodynamic improvement and oxygen requirements returned to room air alone. Post-thrombectomy pulmonary artery systolic pressure was 33 mmHg. The patient was transferred to the general medical ward and started on oral Factor Xa inhibitor and discharged home the following day.
Case 2
A 75-year-old man with a past medical history of metastatic prostate cancer with known spinal involvement, presented to our emergency room with acute onset of shortness of breath and chest tightness. Initial oxygen saturation was 82% requiring high flow oxygen with a non-rebreather mask. Initial blood pressure was 110/80 mmHg and heart rate of 110 bpm. The pretest probability of PE was high thus the first diagnostic test was a CT pulmonary angiogram, which confirmed a saddle pulmonary embolism and large thrombus burden in the left and right lobes. The RV/LV ratio was 1.4.
Pulmonary angiography was consistent with CT findings (Figure 6). With a known history of spinal metastasis, thrombolytic therapy was contraindicated. The femoral vein access site was dilated to accommodate a 24-F sheath, the Flowtriever System was positioned into the mainstem pulmonary artery and a single aspiration was performed. The catheter was then positioned into the left pulmonary artery performing a single aspiration, followed by the right pulmonary artery, again requiring a single aspiration. Repeat angiography confirmed thrombus resolution and large clot removal (Figure 7). The patient was transferred to the general medical floor on room air. An echocardiogram performed the next day demonstrated normal right ventricular size and function with normal pulmonary pressures. The patient was discharged home the following day.
Case 3
A 44-year-old woman with a recent history of COVID-19 pneumonia presented from home with acute worsening of dyspnea and new pleuritic chest pain. Prior to this admission she required no supplemental oxygen, however, now was on 10 L of oxygen to maintain a saturation > 96%. A CT angiogram of the chest was consistent with a massive right middle lobe pulmonary embolism. The patient was taken to the cardiac catheterization laboratory for emergent intervention. Due to rapid decline in respiratory status and acute hypoxic respiratory failure, the patient was placed on mechanical ventilation. In order to provide rapid therapy, aspiration thrombectomy was performed in the right pulmonary artery. Initial pulmonary angiogram clearly demonstrated large thrombus burden of the right pulmonary artery (Figure 8, left). After a single aspiration was performed, repeat angiogram confirmed almost complete resolution (Figure 8, right), and large thrombus debulking (Figure 9). At the conclusion of the procedure, the patient required <40% fraction of inspired oxygen (Fio2) and positive end-expiratory pressure (PEEP) of 5, maintaining an oxygen saturation > 99%. That evening while in the intensive care unit she was successfully extubated and required 2 L of oxygen by nasal cannula. Seventy-two hours after her initial presentation, she was discharged home on room air.
Figure 2.
Pre-treatment pulmonary angiogram showing complete occlusion of the left lower lobe in a patient with massive pulmonary embolism.
Figure 3.
Intra-procedure pulmonary angiogram showing the Triever20 curve catheter coaxial within the larger Triever24 catheter in the left lower lobe of the lung in a PE patient.
Figure 4.
A large amount of thrombus extracted with the FlowTriever® system from a PE patient.
Figure 5.
Post-thrombectomy pulmonary angiogram showing almost complete pulmonary artery opacification and large reduction in thrombus burden.
Figure 6.
Pre-thrombectomy pulmonary angiography of the right and left lungs demonstrating a saddle pulmonary embolism with large thrombus burden.
Figure 7.
Thrombus extracted using the FlowTriever® system.
Figure 8.
Pre- (left) and post-thrombectomy (right) pulmonary angiograms demonstrating large thrombus burden prior to thrombectomy with the FlowTriever® system and subsequent resolution post-thrombectomy.
Figure 9.
Large amount of thrombus extracted with the FlowTriever® system in a patient with history of COVID-19.
\n',keywords:"pulmonary embolism, mechanical thrombectomy, FlowTriever",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/82376.pdf",chapterXML:"https://mts.intechopen.com/source/xml/82376.xml",downloadPdfUrl:"/chapter/pdf-download/82376",previewPdfUrl:"/chapter/pdf-preview/82376",totalDownloads:1,totalViews:0,totalCrossrefCites:0,dateSubmitted:"August 31st 2021",dateReviewed:"January 10th 2022",datePrePublished:"June 26th 2022",datePublished:null,dateFinished:"June 24th 2022",readingETA:"0",abstract:"Acute pulmonary embolism (PE) is a restrictive pulmonary vascular compromise with devastating complications depending on size and location. Massive and sub-massive classifications reflect hemodynamic compromise and cardiac dysfunction due to right ventricular strain, respectively. In addition to cardiac dysfunction, pulmonary ischemia and infarction play a key clinical factor. Mainstay management is with anticoagulation to prevent further clot propagation. Recent technological advances have revolutionized treatment modalities. Mechanical thrombectomy, catheter-based clot retrieval, is an effective way to eliminate emboli, restore cardiopulmonary function, and prevent ischemic injury. One such device, the FlowTriever System, has emerged as a way interventionalists can proceed with embolectomy and provide high level, life-saving care for acutely decompensated patients.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/82376",risUrl:"/chapter/ris/82376",signatures:"Adam Raskin, Anil Verma and Kofi Ansah",book:{id:"10712",type:"book",title:"Thrombectomy - Recent Advances in Ischaemic Damage Treatment",subtitle:null,fullTitle:"Thrombectomy - Recent Advances in Ischaemic Damage Treatment",slug:null,publishedDate:null,bookSignature:"Dr. Nieves Saiz-Sapena, Dr. Fernando Aparici-Robles and Prof. Georgios Tsoulfas",coverURL:"https://cdn.intechopen.com/books/images_new/10712.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-83969-786-9",printIsbn:"978-1-83969-785-2",pdfIsbn:"978-1-83969-787-6",isAvailableForWebshopOrdering:!0,editors:[{id:"204651",title:"Dr.",name:"Nieves",middleName:null,surname:"Saiz-Sapena",slug:"nieves-saiz-sapena",fullName:"Nieves Saiz-Sapena"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Pathophysiology of acute pulmonary embolism",level:"1"},{id:"sec_3",title:"3. Clinical manifestations",level:"1"},{id:"sec_4",title:"4. Diagnosis",level:"1"},{id:"sec_5",title:"5. Management of acute pulmonary embolism",level:"1"},{id:"sec_5_2",title:"5.1 Anticoagulation",level:"2"},{id:"sec_6_2",title:"5.2 Thrombolytic therapy",level:"2"},{id:"sec_7_2",title:"5.3 Mechanical thrombectomy",level:"2"},{id:"sec_8_2",title:"5.4 Technical aspects of mechanical thrombectomy",level:"2"},{id:"sec_9_2",title:"5.5 Mechanical thrombectomy case reports",level:"2"}],chapterReferences:[{id:"B1",body:'Papadakis MA, McPhee SJ, Rabow MW. Current Medical Diagnosis & Treatment 2020: Pulmonary Disorders. 59th ed. New York: McGraw-Hill Education; 2019. pp. 308-315'},{id:"B2",body:'Goldhaber SZ, Elliott CG. Acute pulmonary embolism: Part I: Epidemiology, pathophysiology, and diagnosis. Circulation. 2003;108(22):2726-2729'},{id:"B3",body:'Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: Increasing the models utility with the SimpliRED D-dimer. Thrombosis and Haemostasis. 2000;83(03):416-420'},{id:"B4",body:'Goldman L, Schafer AI. Goldman-Cecil Medicine: Pulmonary Embolism. 25th ed. Amsterdam: Elsevier; 2015. pp. 620-626'},{id:"B5",body:'Huisman MV, Klok FA. Diagnostic management of acute deep vein thrombosis and pulmonary embolism. Journal of Thrombosis and Haemostasis. 2013;11(3):412-422'},{id:"B6",body:'Anderson DR, Kahn SR, Rodger MA, Kovacs MJ, Morris T, Hirsch A, et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: A randomized controlled trial. Journal of the American Medical Association. 2007;298(23):2743-2753'},{id:"B7",body:'Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: A meta-analysis. Journal of the American Medical Association. 2014;311(23):2414-2421'},{id:"B8",body:'Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. The New England Journal of Medicine. 2014;370:1402-1411'},{id:"B9",body:'Piazza G, Hohlfelder B, Jaff MR, Ouriel K, Engelhardt TC, Sterling KM, et al. A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: The SEATTLE II study. Cardiovascular Interventions. 2015;8(10):1382-1392'},{id:"B10",body:'Tu T, Toma C, Tapson VF, Adams C, Jaber WA, Silver M, et al. A prospective, single-arm, multicenter trial of catheter-directed mechanical thrombectomy for intermediate-risk acute pulmonary embolism: The FLARE study. JACC. Cardiovascular Interventions. 2019;12(9):859-869'},{id:"B11",body:'Wible BC, Buckley JR, Cho KH, Bunte MC, Saucier NA, Borsa JJ. Safety and efficacy of acute pulmonary embolism treated via large-bore aspiration mechanical thrombectomy using the Inari FlowTriever device. Journal of Vascular and Interventional Radiology. 2019;30(9):1370-1375'},{id:"B12",body:'Toma C, Khandhar S, Zalewski AM, D’Auria SJ, Tu TM, Jaber WA. Percutaneous thrombectomy in patients with massive and very high-risk submassive acute pulmonary embolism. Catheterization and Cardiovascular Interventions. 2020;96(7):1465-1470'},{id:"B13",body:'Buckley JR, Wible BC. In-hospital mortality and related outcomes for elevated risk acute pulmonary embolism treated with mechanical thrombectomy versus routine care. Journal of Intensive Care Medicine. 2021:08850666211036446'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Adam Raskin",address:null,affiliation:'
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Its first known use in rehabilitation published by Max North named as “Virtual Environments and Psychological Disorders” (1994). Virtual reality uses special programmed computers, visual devices and artificial environments for the clients’ rehabilitation. Throughout technological improvements, virtual reality devices changed from therapeutic gloves to augmented reality environments. Virtual reality was being used in different rehabilitation professions such as occupational therapy, physical therapy, psychology and so on. In spite of common virtual reality approach of different professions, each profession aims different outcomes in rehabilitation. Virtual reality in occupational therapy generally focuses on hand and upper extremity functioning, cognitive rehabilitation, mental disorders, etc. Positive effects of virtual reality were mentioned in different studies, which are higher motivation than non‐simulated environments, active participation of the participants, supporting motor learning, fun environment and risk‐free environment. Additionally, virtual reality was told to be used as assessment. 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Focusing on school periods, this section outlines the development of the basic components of EF—inhibition, working memory, and attention. Cognitive and neurophysiological evaluations show that despite the emergence of EF in the first few years of life, it continues to grow significantly in childhood and adolescence. The components vary slightly according to their developmental sequence. The chapter links findings to long-standing developmental issues (i.e. developmental sequences and processes) and suggests the necessary research to establish a developmental framework covering early childhood throughout adolescence.",book:{id:"6772",slug:"occupational-therapy-therapeutic-and-creative-use-of-activity",title:"Occupational Therapy",fullTitle:"Occupational Therapy - Therapeutic and Creative Use of Activity"},signatures:"Gokcen Akyurek",authors:[{id:"197265",title:"Dr.",name:"Gokcen",middleName:null,surname:"Akyurek",slug:"gokcen-akyurek",fullName:"Gokcen Akyurek"}]},{id:"55024",doi:"10.5772/intechopen.68463",title:"Occupational Therapy in Oncology and Palliative Care",slug:"occupational-therapy-in-oncology-and-palliative-care",totalDownloads:2664,totalCrossrefCites:1,totalDimensionsCites:4,abstract:"Cancer is a chronic disease that may occur in both children and adults. Occupational therapy focuses on the activity limitations and participation problems in their life. Oncology rehabilitation involves in helping an individual with cancer to regain maximum physical, psychological, cognitive, social, and vocational functioning with the limits up to disease and its treatments in an interdisciplinary team concept. These treatment options are associated with the risk of some side effects, including fatigue, pain, cognitive problems, decrease in bone density and muscle endurance, weight loss, and stress- or anxiety-related psychosocial problems. Occupational therapy approaches are a holistic view in a client center and use training in activities of daily living, assistive technology, education of energy conservation techniques, and management of treatment-related problems, such as pain, fatigue, and nausea. In palliative and hospice care, occupational therapists support clients with cancer by minimizing the secondary symptoms related to cancer and its treatments. At the end of life, occupational therapy offers to identify the roles and activities that are meaningful and purposeful to the client with cancer and try to determine the barriers that limit their performance. Clients with cancer who have childhood cancer or adult cancer can face problems about body structure and functions, activity, and participation, which may limit their participation to their daily life.",book:{id:"5711",slug:"occupational-therapy-occupation-focused-holistic-practice-in-rehabilitation",title:"Occupational Therapy",fullTitle:"Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation"},signatures:"Sedef Şahin, Semin Akel and Meral Zarif",authors:[{id:"183079",title:"Ph.D.",name:"Sedef",middleName:null,surname:"Şahin",slug:"sedef-sahin",fullName:"Sedef Şahin"},{id:"183078",title:"Dr.",name:"Burcu Semin",middleName:null,surname:"Akel",slug:"burcu-semin-akel",fullName:"Burcu Semin Akel"},{id:"198859",title:"Dr.",name:"Meral",middleName:null,surname:"Zarif",slug:"meral-zarif",fullName:"Meral Zarif"}]},{id:"56049",doi:"10.5772/intechopen.69101",title:"Measurement of Participation: The Role Checklist Version 3: Satisfaction and Performance",slug:"measurement-of-participation-the-role-checklist-version-3-satisfaction-and-performance",totalDownloads:2801,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"Participation in society is an area of interest to both clinicians and population researchers. Measurement of participation is therefore important, yet differences in definition, in terms of both content and scope, have made general agreement on one instrument tool elusive. What is recognized is the need for a theoretically based tool that captures both the insider and the outsider perspective. The outsider perspective, inclusive of the generally held views of a society, supports the utility for aggregating population data, whereas the insider perspective provides the internally held views of an individual needed for client-centered treatment planning. The Role Checklist Version 3 modifies one of the most commonly used assessment tools in occupational therapy practice, has good preliminary psychometric properties, and is theoretically consistent with both the ICF and the Model of Human Occupation. The Model of Human Occupation is the most widely used theoretical model in occupational therapy. This chapter provides an overview of the theoretical development, empirical testing, and implications for use of this participation measure by occupational therapists along with implications for population researchers.",book:{id:"5711",slug:"occupational-therapy-occupation-focused-holistic-practice-in-rehabilitation",title:"Occupational Therapy",fullTitle:"Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation"},signatures:"Patricia J. Scott, Kelsey McKinney, Jeff Perron, Emily Ruff and Jessica\nSmiley",authors:[{id:"195495",title:"Dr.",name:"Patricia J",middleName:null,surname:"Scott",slug:"patricia-j-scott",fullName:"Patricia J Scott"},{id:"208801",title:"Dr.",name:"Kelsey G.",middleName:null,surname:"McKinney",slug:"kelsey-g.-mckinney",fullName:"Kelsey G. McKinney"},{id:"208802",title:"Mr.",name:"Jeffrey M.",middleName:null,surname:"Perron",slug:"jeffrey-m.-perron",fullName:"Jeffrey M. Perron"},{id:"208803",title:"Dr.",name:"Emily G.",middleName:null,surname:"Ruff",slug:"emily-g.-ruff",fullName:"Emily G. Ruff"},{id:"208804",title:"Dr.",name:"Jessica L.",middleName:null,surname:"Smiley",slug:"jessica-l.-smiley",fullName:"Jessica L. Smiley"}]},{id:"62493",doi:"10.5772/intechopen.79366",title:"Occupational Therapy in Forensic Settings",slug:"occupational-therapy-in-forensic-settings",totalDownloads:2516,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"It is necessary for a person to comply with the expectations of society and the rules of law to which these expectations are secured. Offenders turn back to the community after the penalty was executed by isolating from society and some occupations. An occupational imbalance is seen in the individuals, during this penalty period and afterward, because of limited occupational participation. As an occupational being, this affects their physical, mental and psychological well-being. Imprisonment is an important practice in criminal law to punish criminals. This may be necessary for the protection of society from criminals, but successful integration into a community after exiting the prison is the most important factor in preventing recidivism. Occupational therapy focuses on health and well-being by using meaningful and purposeful occupations. Occupation involves any activity that people perform or participate in, such as giving care to themselves or others, working, learning, playing games, and interacting with others. From this perspective, the role of occupational therapists in forensic settings is to determine the abilities of these individuals to congregate their deprived freedoms and use them to train them for an independent and autonomous life; to provide a professional orientation, career counseling, and self-esteem; to gain some habits for physical, spiritual and moral life and to reinforce.",book:{id:"6772",slug:"occupational-therapy-therapeutic-and-creative-use-of-activity",title:"Occupational Therapy",fullTitle:"Occupational Therapy - Therapeutic and Creative Use of Activity"},signatures:"Esma Ozkan, Sümeyye Belhan, Mahmut Yaran and Meral Zarif",authors:null}],mostDownloadedChaptersLast30Days:[{id:"55080",title:"Life Skills in Occupational Therapy",slug:"life-skills-in-occupational-therapy",totalDownloads:6023,totalCrossrefCites:3,totalDimensionsCites:0,abstract:"Occupational therapy is a health profession that uses the purposeful activities to achieve multiple and complex rehabilitation aims. The main goals of the occupational therapy are to support the reintegration of individuals in daily living skills as well as to increase their independence and autonomy. Interventions of occupational therapists have primarily focused on self-care, productivity, and leisure time activities. Since the life skills includes a wide range of abilities that enable a person to perform personal care and more complicated tasks such as traveling, shopping, community participation etc., occupational therapists provide life skills training programs to meet the needs of the clients. This chapter aims to contribute to the current understanding and practices of life skills from an occupational therapy perspective. The chapter starts with a brief discussion of the importance of life skills in occupational therapy. After this introduction, the first part takes a look at the definition of life skills and identifies core components of life skills. The second part describes assessment and interventions of life skills. The third one gives an overview about school life skills programs for children and adolescents. Finally, the last part explains some life skills programs in people with disadvantages.",book:{id:"5711",slug:"occupational-therapy-occupation-focused-holistic-practice-in-rehabilitation",title:"Occupational Therapy",fullTitle:"Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation"},signatures:"Hatice Abaoğlu, Özge Buket Cesim, Sinem Kars and Zeynep Çelik",authors:[{id:"197551",title:"Dr.",name:"Hatice",middleName:null,surname:"Abaoğlu",slug:"hatice-abaoglu",fullName:"Hatice Abaoğlu"},{id:"205199",title:"Dr.",name:"Sinem",middleName:null,surname:"Kars",slug:"sinem-kars",fullName:"Sinem Kars"},{id:"205200",title:"Dr.",name:"Zeynep",middleName:null,surname:"Celik",slug:"zeynep-celik",fullName:"Zeynep Celik"},{id:"205203",title:"Ms.",name:"Özge Buket",middleName:null,surname:"Cesim",slug:"ozge-buket-cesim",fullName:"Özge Buket Cesim"}]},{id:"62493",title:"Occupational Therapy in Forensic Settings",slug:"occupational-therapy-in-forensic-settings",totalDownloads:2516,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"It is necessary for a person to comply with the expectations of society and the rules of law to which these expectations are secured. Offenders turn back to the community after the penalty was executed by isolating from society and some occupations. An occupational imbalance is seen in the individuals, during this penalty period and afterward, because of limited occupational participation. As an occupational being, this affects their physical, mental and psychological well-being. Imprisonment is an important practice in criminal law to punish criminals. This may be necessary for the protection of society from criminals, but successful integration into a community after exiting the prison is the most important factor in preventing recidivism. Occupational therapy focuses on health and well-being by using meaningful and purposeful occupations. Occupation involves any activity that people perform or participate in, such as giving care to themselves or others, working, learning, playing games, and interacting with others. From this perspective, the role of occupational therapists in forensic settings is to determine the abilities of these individuals to congregate their deprived freedoms and use them to train them for an independent and autonomous life; to provide a professional orientation, career counseling, and self-esteem; to gain some habits for physical, spiritual and moral life and to reinforce.",book:{id:"6772",slug:"occupational-therapy-therapeutic-and-creative-use-of-activity",title:"Occupational Therapy",fullTitle:"Occupational Therapy - Therapeutic and Creative Use of Activity"},signatures:"Esma Ozkan, Sümeyye Belhan, Mahmut Yaran and Meral Zarif",authors:null},{id:"62210",title:"Occupational Therapy’s Role in the Treatment of Children with Autism Spectrum Disorders",slug:"occupational-therapy-s-role-in-the-treatment-of-children-with-autism-spectrum-disorders",totalDownloads:2725,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Occupational therapists (OT) offer a wide range of therapies for individuals with ASD on the basis of specific deficits and difficulties. This chapter explores the role that OT plays, and the expertise, in relation to the interdisciplinary team. In addition, it discusses and presents empirical support for several therapeutic approaches commonly used by OTs working with individuals with ASD.",book:{id:"6772",slug:"occupational-therapy-therapeutic-and-creative-use-of-activity",title:"Occupational Therapy",fullTitle:"Occupational Therapy - Therapeutic and Creative Use of Activity"},signatures:"Bryan M. Gee, Amy Nwora and Theodore W. Peterson",authors:null},{id:"55049",title:"Community Participation in People with Disabilities",slug:"community-participation-in-people-with-disabilities",totalDownloads:2405,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Despite the fact that participation is an important building and a valuable target, the conceptualization, identification and measurement methods vary widely. This chapter tried to gain an insider’s perspective from the obstacles that summarize what meaning participation means, how to characterize it, and what prevents and supports participation. Participation is seen as a right and a responsibility attributed to and attributed to both the person and the community. Participation does not take place in a vacuum; the environment dynamically influences participation. The effects of this conceptual framework are discussed for change at the level of evaluation, research and systems to support the participation of the people with disability.",book:{id:"5711",slug:"occupational-therapy-occupation-focused-holistic-practice-in-rehabilitation",title:"Occupational Therapy",fullTitle:"Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation"},signatures:"Gokcen Akyurek and Gonca Bumin",authors:[{id:"32431",title:"Prof.",name:"Gonca",middleName:null,surname:"Bumin",slug:"gonca-bumin",fullName:"Gonca Bumin"},{id:"197265",title:"Dr.",name:"Gokcen",middleName:null,surname:"Akyurek",slug:"gokcen-akyurek",fullName:"Gokcen Akyurek"}]},{id:"56049",title:"Measurement of Participation: The Role Checklist Version 3: Satisfaction and Performance",slug:"measurement-of-participation-the-role-checklist-version-3-satisfaction-and-performance",totalDownloads:2801,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"Participation in society is an area of interest to both clinicians and population researchers. Measurement of participation is therefore important, yet differences in definition, in terms of both content and scope, have made general agreement on one instrument tool elusive. What is recognized is the need for a theoretically based tool that captures both the insider and the outsider perspective. The outsider perspective, inclusive of the generally held views of a society, supports the utility for aggregating population data, whereas the insider perspective provides the internally held views of an individual needed for client-centered treatment planning. The Role Checklist Version 3 modifies one of the most commonly used assessment tools in occupational therapy practice, has good preliminary psychometric properties, and is theoretically consistent with both the ICF and the Model of Human Occupation. The Model of Human Occupation is the most widely used theoretical model in occupational therapy. This chapter provides an overview of the theoretical development, empirical testing, and implications for use of this participation measure by occupational therapists along with implications for population researchers.",book:{id:"5711",slug:"occupational-therapy-occupation-focused-holistic-practice-in-rehabilitation",title:"Occupational Therapy",fullTitle:"Occupational Therapy - Occupation Focused Holistic Practice in Rehabilitation"},signatures:"Patricia J. Scott, Kelsey McKinney, Jeff Perron, Emily Ruff and Jessica\nSmiley",authors:[{id:"195495",title:"Dr.",name:"Patricia J",middleName:null,surname:"Scott",slug:"patricia-j-scott",fullName:"Patricia J Scott"},{id:"208801",title:"Dr.",name:"Kelsey G.",middleName:null,surname:"McKinney",slug:"kelsey-g.-mckinney",fullName:"Kelsey G. McKinney"},{id:"208802",title:"Mr.",name:"Jeffrey M.",middleName:null,surname:"Perron",slug:"jeffrey-m.-perron",fullName:"Jeffrey M. Perron"},{id:"208803",title:"Dr.",name:"Emily G.",middleName:null,surname:"Ruff",slug:"emily-g.-ruff",fullName:"Emily G. Ruff"},{id:"208804",title:"Dr.",name:"Jessica L.",middleName:null,surname:"Smiley",slug:"jessica-l.-smiley",fullName:"Jessica L. 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In today's highly integrated world, AI promises to become a robust and powerful means for obtaining solutions to previously unsolvable problems. This Series is intended for researchers and students alike interested in this fascinating field and its many applications.",coverUrl:"https://cdn.intechopen.com/series/covers/14.jpg",latestPublicationDate:"June 11th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:9,editor:{id:"218714",title:"Prof.",name:"Andries",middleName:null,surname:"Engelbrecht",slug:"andries-engelbrecht",fullName:"Andries Engelbrecht",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNR8QAO/Profile_Picture_1622640468300",biography:"Andries Engelbrecht received the Masters and PhD degrees in Computer Science from the University of Stellenbosch, South Africa, in 1994 and 1999 respectively. He is currently appointed as the Voigt Chair in Data Science in the Department of Industrial Engineering, with a joint appointment as Professor in the Computer Science Division, Stellenbosch University. Prior to his appointment at Stellenbosch University, he has been at the University of Pretoria, Department of Computer Science (1998-2018), where he was appointed as South Africa Research Chair in Artifical Intelligence (2007-2018), the head of the Department of Computer Science (2008-2017), and Director of the Institute for Big Data and Data Science (2017-2018). 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He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. He won the “Catedra Telefonica” Awards in Modality of Knowledge Transfer, 2017, 2018, and 2019 editions, and awards in Modality of COVID Research in 2020.\n\nPublic References:\nResearcher ID http://www.researcherid.com/rid/N-5967-2014\nORCID https://orcid.org/0000-0002-4621-2768 \nScopus Author ID https://www.scopus.com/authid/detail.uri?authorId=6602376272\nScholar Google https://scholar.google.es/citations?user=G1ks9nIAAAAJ&hl=en \nResearchGate https://www.researchgate.net/profile/Carlos_Travieso",institutionString:null,institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"23",title:"Computational Neuroscience",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",isOpenForSubmission:!0,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null},{id:"24",title:"Computer Vision",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",isOpenForSubmission:!0,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. Papakostas has received a diploma in Electrical and Computer Engineering in 1999 and the M.Sc. and Ph.D. degrees in Electrical and Computer Engineering in 2002 and 2007, respectively, from the Democritus University of Thrace (DUTH), Greece. Dr. Papakostas serves as a Tenured Full Professor at the Department of Computer Science, International Hellenic University, Greece. Dr. Papakostas has 10 years of experience in large-scale systems design as a senior software engineer and technical manager, and 20 years of research experience in the field of Artificial Intelligence. Currently, he is the Head of the “Visual Computing” division of HUman-MAchines INteraction Laboratory (HUMAIN-Lab) and the Director of the MPhil program “Advanced Technologies in Informatics and Computers” hosted by the Department of Computer Science, International Hellenic University. He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. Dr Ventura also holds the positions of Affiliated Professor at Virginia Commonwealth University (Richmond, USA) and Distinguished Adjunct Professor at King Abdulaziz University (Jeddah, Saudi Arabia). Additionally, he is deputy director of the Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI) and heads the Knowledge Discovery and Intelligent Systems Research Laboratory. He has published more than ten books and over 300 articles in journals and scientific conferences. Currently, his work has received over 18,000 citations according to Google Scholar, including more than 2200 citations in 2020. In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. 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Kasenga",hash:"91cde4582ead884cb0f355a19b67cd56",volumeInSeries:4,fullTitle:"Malaria",editors:[{id:"86725",title:"Dr.",name:"Fyson",middleName:"Hanania",surname:"Kasenga",slug:"fyson-kasenga",fullName:"Fyson Kasenga",profilePictureURL:"https://mts.intechopen.com/storage/users/86725/images/system/86725.jpg",institutionString:"Malawi Adventist University",institution:{name:"Malawi Adventist University",institutionURL:null,country:{name:"Malawi"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7123",title:"Current Topics in Neglected Tropical Diseases",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7123.jpg",slug:"current-topics-in-neglected-tropical-diseases",publishedDate:"December 4th 2019",editedByType:"Edited by",bookSignature:"Alfonso J. Rodriguez-Morales",hash:"61c627da05b2ace83056d11357bdf361",volumeInSeries:3,fullTitle:"Current Topics in Neglected Tropical Diseases",editors:[{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7064",title:"Current Perspectives in Human Papillomavirus",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7064.jpg",slug:"current-perspectives-in-human-papillomavirus",publishedDate:"May 2nd 2019",editedByType:"Edited by",bookSignature:"Shailendra K. Saxena",hash:"d92a4085627bab25ddc7942fbf44cf05",volumeInSeries:2,fullTitle:"Current Perspectives in Human Papillomavirus",editors:[{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",institutionURL:null,country:{name:"India"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},subseriesFiltersForPublishedBooks:[{group:"subseries",caption:"Bacterial Infectious Diseases",value:3,count:2},{group:"subseries",caption:"Parasitic Infectious Diseases",value:5,count:4},{group:"subseries",caption:"Viral Infectious Diseases",value:6,count:7}],publicationYearFilters:[{group:"publicationYear",caption:"2022",value:2022,count:2},{group:"publicationYear",caption:"2021",value:2021,count:4},{group:"publicationYear",caption:"2020",value:2020,count:3},{group:"publicationYear",caption:"2019",value:2019,count:3},{group:"publicationYear",caption:"2018",value:2018,count:1}],authors:{paginationCount:301,paginationItems:[{id:"116250",title:"Dr.",name:"Nima",middleName:null,surname:"Rezaei",slug:"nima-rezaei",fullName:"Nima Rezaei",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/116250/images/system/116250.jpg",biography:"Professor Nima Rezaei obtained an MD from Tehran University of Medical Sciences, Iran. He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. 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