Quality assessment specifications for the tasks of “call for tender”.
\r\n\t?
",isbn:"978-1-83880-725-2",printIsbn:"978-1-83880-724-5",pdfIsbn:"978-1-83880-726-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"eca24028d89912b5efea56e179dff089",bookSignature:"Dr. Julianna Cseri",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10192.jpg",keywords:"Neurogenic Origin, Disuse, Histological Changes, Metabolic Relations, Metabolic Changes, Molecular Background, Genetics, Signaling Pathways, Satellite Cells, Regenerative Capacity, Physical Training, Physiotherapy",numberOfDownloads:424,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 4th 2020",dateEndSecondStepPublish:"May 25th 2020",dateEndThirdStepPublish:"July 24th 2020",dateEndFourthStepPublish:"October 12th 2020",dateEndFifthStepPublish:"December 11th 2020",remainingDaysToSecondStep:"8 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Julianna Cseri, M.D., Ph.D., is currently a retired College Professor previously working at the University of Debrecen, Hungary. She is a physiologist working in the field of the skeletal muscle physiology. She has awarded general medicine diploma in 1973 in the University Medical School of Debrecen and started the scientific work at the same Department.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"135579",title:"Dr.",name:"Julianna",middleName:null,surname:"Cseri",slug:"julianna-cseri",fullName:"Julianna Cseri",profilePictureURL:"https://mts.intechopen.com/storage/users/135579/images/system/135579.jpg",biography:"Julianna Cseri, M.D., Ph.D., is currently a retired College Professor previously working at the Department of Physiotherapy, Faculty of Public Health, University of Debrecen, Debrecen, Hungary. She is a physiologist working in the field of the skeletal muscle physiology. She has awarded general medicine diploma in 1973 in the University Medical School of Debrecen and started the scientific work at the Department of Physiology, University Medical School of Debrecen (later Faculty of Medicine University of Debrecen), focusing on the electrophysiological characteristics of the skeletal muscle fibres. She achieved scientific qualification from the muscle electrophysiology. Her interest later was turned to the proliferation and differentiation of the skeletal muscle fibres in cell culture condition and the role of intracellular calcium homeostasis in the myogenesis and the muscle function. This work is closely related to the muscle degeneration and regeneration in vivo which has theoretical and practical significance in the field of physiotherapy.",institutionString:"University of Debrecen",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Debrecen",institutionURL:null,country:{name:"Hungary"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:[{id:"73008",title:"Sarcopenia in Older Adults",slug:"sarcopenia-in-older-adults",totalDownloads:76,totalCrossrefCites:0,authors:[null]},{id:"73653",title:"Effects of Physiotherapy Interventions on the Function of the Locomotor System in Elder Age: View of Theory and Practice",slug:"effects-of-physiotherapy-interventions-on-the-function-of-the-locomotor-system-in-elder-age-view-of-",totalDownloads:69,totalCrossrefCites:0,authors:[null]},{id:"73060",title:"Skeletal Muscle Stem Cell Niche from Birth to Old Age",slug:"skeletal-muscle-stem-cell-niche-from-birth-to-old-age",totalDownloads:69,totalCrossrefCites:0,authors:[null]},{id:"73963",title:"Total Antioxidant from Herbal Medicine as a Possible Tool for the Multifunctional Prevention of Muscular Atrophy",slug:"total-antioxidant-from-herbal-medicine-as-a-possible-tool-for-the-multifunctional-prevention-of-musc",totalDownloads:67,totalCrossrefCites:0,authors:[null]},{id:"73052",title:"Management of Sarcopenic Obesity for Older Adults with Lower-Extremity Osteoarthritis",slug:"management-of-sarcopenic-obesity-for-older-adults-with-lower-extremity-osteoarthritis",totalDownloads:81,totalCrossrefCites:0,authors:[null]},{id:"73448",title:"Nutritional Approaches for Attenuating Muscle Atrophy",slug:"nutritional-approaches-for-attenuating-muscle-atrophy",totalDownloads:62,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"184402",firstName:"Romina",lastName:"Rovan",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/184402/images/4747_n.jpg",email:"romina.r@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"2586",title:"Skeletal Muscle",subtitle:"From Myogenesis to Clinical Relations",isOpenForSubmission:!1,hash:"39cac55a7eca71b41c2a28933c1e2d4d",slug:"skeletal-muscle-from-myogenesis-to-clinical-relations",bookSignature:"Julianna Cseri",coverURL:"https://cdn.intechopen.com/books/images_new/2586.jpg",editedByType:"Edited by",editors:[{id:"135579",title:"Dr.",name:"Julianna",surname:"Cseri",slug:"julianna-cseri",fullName:"Julianna Cseri"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6550",title:"Cohort Studies in Health Sciences",subtitle:null,isOpenForSubmission:!1,hash:"01df5aba4fff1a84b37a2fdafa809660",slug:"cohort-studies-in-health-sciences",bookSignature:"R. Mauricio Barría",coverURL:"https://cdn.intechopen.com/books/images_new/6550.jpg",editedByType:"Edited by",editors:[{id:"88861",title:"Dr.",name:"René Mauricio",surname:"Barría",slug:"rene-mauricio-barria",fullName:"René Mauricio Barría"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"11552",title:"A Model for Process Oriented Risk Managenent",doi:"10.5772/intechopen.83880",slug:"a-model-for-process-oriented-risk-managenent",body:'\n\t\tEvery enterprise can be affected by risks with potential impact on their single organizational parts or on their organizations as a whole. The awareness of consequences deriving from threats, omissions or adverse events drives enterprises to support risk management programs whose aim is to reduce undesirable consequences.
\n\t\t\tThe need to identify, assess, and manage risks has motivated organizations to develop integrated frameworks to improve enterprise risk management. ERM is a framework designed by the Committee of Sponsoring Organizations of Treadway Commission (COSO, 2004) that helps business to assess and enhance their internal control systems. COSO defines ERM as “… a process, effected by an entity’s board of directors, management and other personnel, applied in strategy setting and across the enterprise, designed to identify potential events that may affect the entity, and manage risk to be within its risk appetite, to provide reasonable assurance regard in the achievement of entity objectives”.
\n\t\t\tThe literature about risk proposes various techniques to identify and classify risks in different fields of knowledge or descriptions of various innovative approaches for managing risks. For example, in (Alberts&Dorofee, 2009) two approaches for managing risks are compared: tactical risk management and systemic risk management. Tactical risk is traditional, bottom-up analysis defined as a measure of the likelihood that an individual potential event will lead to a loss coupled with the magnitude of loss. This approach has the limit that does not readily scale to distributed environments. In contrast to the bottom-up analyses employed in tactical risk management, systemic risk management approach starts at the top with the identification of a program’s key objectives. Once the key objectives are known, the next step is to identify a set of critical factors, called drivers that influence whether or not the key objectives will be achieved.
\n\t\t\tIn order to minimize the impact of risks Enterprise Risk management frameworks typically includes four major areas corresponding to the achievement of enterprise objectives:
\n\t\t\tStrategic: high-level goals, aligned with and supporting its mission
Operations: effective and efficient use of its resource
Reporting: reliability of reporting
Compliance: compliance with applicable laws and regulations
Many organizations are reluctant to support risk management programs, probably because of the high cost of human resources necessary for acquisition, manipulation and analysis of risk data. However, the management of operational risks is being given increasing attention as a fundamental part of monitoring, controlling and decision support systems because of the opportunity that Workflow Management Systems (WfMS) provides in terms of automatic collection of business process execution data.
\n\t\t\tThe problem of process measurement is considered to be important in several fields such as banking risks, insurance and industry; it can be an effective instrument to single out risks in different fields in order to avoid disastrous consequences. In fact, the Basel Committee encourages industry to develop methodologies and techniques to collect data for managing, measuring and monitoring operational risks; the Committee has also adopted a common industry definition of operational risk, namely:” the risk of direct or indirect loss resulting from inadequate or failed internal processes, people and systems or from external events”. (Basel Committee, 2001).
\n\t\t\tThe perspective on business process models is adopted by (Zur Muehlen et al., 2005). Through the application of value-focused process engineering principles to risk management models, the authors propose a framework that enables risk-oriented process management to incorporate a multi-disciplinary view of risk. This approach is useful especially in Business Process Reengineering scenarios, where a decision about the best process to reengineer must be taken on the basis of risk criteria.
\n\t\t\tThe importance of acquiring quantitative risk data is suggested by the UK’s Financial Service Authority (FSA, 2002):
\n\t\t\t“Due to both data limitations and lack of high-powered analysis tools, a number of operational risks cannot be measured accurately in a quantitative manner at the present time. However, we would encourage firms to collect data on their operational risks and to use measurement tools where this is possible and appropriate”.
\n\t\t\tThe lack of models and systems in the field of real time management of operational risks encourage new research activity. In this chapter we propose a model that integrates WfMS and Risk Management System (RMS) functionalities in order to represent operational risk management. The process oriented approach to continuous risk management, based on a top level model for the representation of qualitative and quantitative risks, is able to reduce effort and cost necessary to implement a risk management program. The capability to continuously measure executable process instances provided by a Workflow Management System (WfMS) is assumed as a major premise for the design of a workflow based risk management system. We will show how the typical WfMS capabilities, in terms of process enactment and performance evaluation, can be represented within an augmented model that integrates WfMS capabilities and continuous risk management aiming at the monitoring and control of operational risks. The benefits deriving from this approach are manifold: a) the cost reduction for the risk management systems due to the automatic process execution data recoding provided by the WfMS; b) the definition and management of qualitative and quantitative risks within the unifying framework of process management; c) the definition of a proactive policy for the treatment of operational risks.
\n\t\tThis section introduces the rationale and the building blocks of a model that can be exploited for the design and implementation of a process oriented risk management system. When the management decides to follow a risk management program, one of the hurdle hindering the success of such initiative is that many roles, e.g. business administration or IT, perceive different views of risks (Stankosky, 2005). This separation is mainly due to different goals pursued by different roles (Neef et al., 1998), (Nonaka, 2005). On the one hand, management roles adopt, more or less consciously, a system thinking approach (Weinberg, 2001) to the understanding of organizational structures, processes, policies, events, etc. This approach allows, once business processes have been designed and implemented, to monitor them at a high abstraction level relieving the manager from the details and the mechanics necessary to process execution. Watching at ‘the big picture’ and transcending organizational boundaries, the manager focuses himself on business goals and on risks that could threat their achievement. On the other hand, operational roles have a completely different view of risks. For example, IT personnel are usually concerned about how data and information can be stored/retrieved and how to provide access to ICT services over the organization’s ‘digital nervous system’. In this case, the perception of risks mainly concerns the availability and performances of communication/database systems, application programs, access policies, etc.
\n\t\t\tAs pointed out by Leymann and Roller (Leymann & Roller, 2000), workflow technology helps to bridge the gap between these different views of business processes because: a) management roles typically look at the process models and at their execution instances eventually asking for execution data to evaluate the process performance, b) operational roles implement process activities and perform them with the support of a workflow management system.
\n\t\t\tTop level model for process oriented risk management.
The model shown in figure 1 represents an integrated system aiming at the management of operational risks in a context where processes are enacted with the support of a workflow management system.
\n\t\t\tThe process management subsystem comprises the usual tools for process definition, process instance creation and execution as well as maintenance services. One of the most appealing features of workflow management systems is the measurement capability offered by this class of products. Both research and industrial applications are mature enough and provide measurement tools concerning workflow measurable entities (zur Muehlen M., 2004), (Oracle, 2002). Several kinds of duration measures about activities/processes, waiting queues, produced deliverable and human resource efforts are frequently evaluated and can provide quantitative knowledge about business processes. However, current workflow products do not take into account risk management. Indeed, the workflow log collects automatically raw execution data that can be used for process monitoring and performance evaluation. These log data are invaluable to lay out a process oriented risk management system.
\n\t\t\tThe premise behind the process oriented risk management system is similar to other widely accepted approaches to assessment and measurement: there exists information need that, when satisfied, increases the decision capability.
\n\t\t\tA widely accepted approach to project measurements in the field of software engineering is GQM (Goal-Question-Metrics) (Basili et al., 1994), (Mendoça & Basili, 2000). The GQM model is structured as a three level hierarchy: 1. conceptual level (GOAL); 2. operational level (QUESTION) and quantitative level (METRIC). The goal states a viewpoint for an object of measurement (e.g. products, processes, resources) that can be refined into several questions, in their turn refined into several metrics that, when evaluated, provide quantitative information about the viewpoint to be measured. The GQM approach is based upon the assumption that an organization must first specify the goals for itself and its projects in order to measure in a powerful way. Subsequently the organization must trace the goals and the relative operational data and finally provide a framework for interpreting the data according to the stated goals.
\n\t\t\tAnother well-known method for software measurement is PSM (Practical software and systems measurement) (McGarry et al., 2001). PSM describes how to define and implement a measurement program to support the information needs of the software and system acquire and supplier organization. It describes an approach to management based on integrating the concepts of a Measurement Information Model and a Measurement Process Model. A Measurement Information Model defines the relationship between the information needs of the manager and the objective data to be collected, commonly called measures. The Measurement Process Model describes a set of related measurement activities that are generally applicable in all circumstances, regardless of the specific information needs of any particular situation and provides an application (McGarry et al, 2001).
\n\t\t\tFrom the point of view of the risk management system, there exists an information need about process instances that a WfMS can help to satisfy. The left side of the model shown in figure 1 describes how a risk management system can be integrated with a WfMS. At definition time, when the process model is established, risk data are stated and relied to the process model. Note that the risk statement can be relied to both process and activity. This choice reflects the different process perspectives that managers and operational staff have on processes. Managers look at the process level and think in terms of risks at this level in order to provide support for continuous monitoring of risks deriving from the execution of workflow instances.
\n\t\tThe “call for tender” case study that we will refer in the following sections, is an open procedure managed by a public agency in order to select the provider of goods and services on the basis of award criteria stated in the tender specifications. The procedure usually involves a number of different Organizational Units starting from the proposal phase, in which the procurement is planned, to the selection of a winner, and the subsequent public announcement. In figure 2 the BPMN model that represents the call for tender is shown. Assuming that the acquisition act has already been stated, the procedure begins when an Organizational Unit is charged to plan the procurement. This activity is devoted to the writing of procurement documents such as:
\n\t\t\tCall for tender process: the BPMN model.
\n\t\t\t\tContract Notice. It includes the name, address and contact point of the contracting authority, a short description of the contract or purchase(s), and its estimated value.
\n\t\t\t\n\t\t\t\tTender Specifications. Guidelines and general information related to the tender, time limit for receipt of tenders, offer evaluation rules, specific information related to the tender, and award criteria.
\n\t\t\t\n\t\t\t\tInvitation to Tender. This document includes the submission modalities and the procedure for the request of additional information.
\n\t\t\tThe procurement documents are first sent to the Registry Office that proceeds to a formal registration of the call for tender. Then, the Information Services OU publishes the call for tender announcement enabling the interested enterprises to download the procurement documents. The Registry Office awaits the incoming request to participate until the time limit for receipt of tenders is reached. Afterward, the Board of Examiners is involved in the sub-process of “tender evaluation” that produces the ranking to be published by the Information Services.
\n\t\tA risk assessment methodology normally comprises a combination of qualitative and quantitative techniques. Management often uses qualitative assessment techniques where risks do not lend themselves to quantification or when sufficient reliable data required for quantitative assessments are not available. Quantitative techniques typically bring more precision and are used in more complex and sophisticated activities to supplement qualitative techniques. (COSO a,b).
\n\t\t\tStarting from these premises, we build on the top level model for process oriented risk management shown in figure 1 to determine quantitative and qualitative measures inspired by the GQM approach applied to the domain of business processes and in compliance with the 3 layer PSM measurement model.
\n\t\t\tFirst, let us discuss the method that faces with the quantitative approach. Since the adoption of a Workflow Management System is assumed as an automated support to the execution of business processes, we review some fundamental workflow concepts necessary to understand the measurement framework taken as reference in the following.
\n\t\t\tRelationship between process model, model instances and actors.
According to the main terms and concepts of the Workflow Reference Model (P. Lawrence Ed, “WfMC Workflow Handbook”, J. Wiley & Sons 1997), a WfMS is “a pro-active system for managing a series of tasks defined in one or more procedures. The system ensures that the tasks are passed among the appropriate participants in the correct sequence and completed within set times”. As shown in the UML diagram of figure 3. a WfMS allows the definition, the computerized representation and the execution of business processes wherein each process can be seen as a network of tasks. A single process model can generate different processes instances where each process instance can generate a network of task instances; each instance provide context for the work done by an actor on one or more work item instances. Considering the call for tender discussed in the previous section and following the GQM approach that defines in a top down fashion Goals, related Questions and Metrics, in the scenario of WfMS supported business processes we could be interested to obtain general goals stated in terms of efficiency, effectiveness and control costs. These goals are then refined into process oriented queries that, in their turn, are related to metric in order to provide a precise evaluation about the degree of goals achievement.
\n\t\t\t\n\t\t\t\tGoals:\n\t\t\t
\n\t\t\tG1) efficiency: the comparison of what is actually produced or performed with what can be achieved with the same consumption of resources (money, time, etc)
G2) effectiveness: the degree to which objectives are achieved and the extent to which targeted problems are resolved.
G3) control cost: the application of investigative procedures to detect variance of actual costs from budgeted costs, diagnostic procedures to ascertain the causes of variance and corrective procedures to effect realignment between actual and budgeted costs.
\n\t\t\t\tQuestions:\n\t\t\t
\n\t\t\tsome typical questions addressed by an analyst during the process evaluation are:
\n\t\t\tQ1. What is the duration of a given task instance of “tender evaluation”? (G1)
Q2. What is the global throughput (process stared and completed) over the past years? (G1)
Q3. How many work items has a given employee completed? (G1)
Q4. How many procurements have been done with respect to the procurement plan? (G2)
Q5. What is the exception rate in the WfMS after the deployment of processes? (G2)
Q6. What is the average cost of “call for tender”? (G3)
Q7. How much is the difference between the planned costs and the real costs of a process instance? (G3)
To obtain precise answers to the queries such as those above, we need to develop a measurement framework by means of which numbers can be assigned to the various entities represented within the WfMS. The following examples are representative of a three levels measurement framework: primitive, fundamental and derived measures whose complete definition can be found in (Aiello, 2002). It will be used as a fundamental model for a risk management system based on workflow execution data.
\n\t\t\tTwo primitive operators for measuring work and time are:
\n\t\t\tthe cardinality of a set, and
\n\t\t\tthe length of the time interval between the occurrence times of two events ei and ej. Let I be the set of process, task and work item instances and i a generic instance, i∈I. We assume that each instance, at a given time, can be in one among the states:
\n\t\t\t\t
filter(I, p)=I’ with I’⊆I
\n\t\t\tThe following example refers to the case study introduced in section 3. According to the predicate \n\t\t\t\t
A frequently used fundamental measure evaluates the workload in the scope provided applying a suitable filter to the set of all workflow instances. Queries of this kind require the capability to isolate within the WfMS the set of objects with the desired properties and then to evaluate its cardinality. By the combination of the operators # and
the example below shows how the measure
The need of a derived measure (the third level of measured framework) becomes evident if we consider the evaluation of contribution that resources, especially human resources, make to the progress of a process. Given a process P, the contribution of the generic actor to P is considered. The evaluation can be done from the point of view of time overhead, work overhead or cost and is expressed in percentage.
\n\t\t\tIn order to define some kind of contribution measures, it is necessary to introduce the auxiliary function
where map is a function that denotes the usual operator for the application of a function to a set of values
\n\t\t\tCare must be taken to specify the set
Let tactor_k be the working time spent by the generic actor on P. In general, to actor_k can be assigned more than one work item even in the context of a single process P. Given a process P, the actor time contribution
\n
Let ck the hourly cost of
Qualitative analysis is usually pursued relating likelihood and consequences of risks; a widely used model for this kind of analysis is the priority-setting matrix (Cooper et al. 2008), also known as risk matrix where cells, representing fuzzy risk exposure values, are grouped in a given number of risk classes. In the matrix shown in figure 4, the risk exposure classes are represented by: L means low, negligible risk, M indicates a moderate risk, H a risk with high impact and probably high loss, and E represents the class of intolerable, extreme risk with very likely loss. Obviously, when the impact or likelihood grows, or both, the risk consequently grows; therefore a risk can modify its position from a lower category to an upper category. For each category of risk exposure, different actions have to be taken: values E and H involve a necessary attention in priority management and a registration in the Mitigation plan; a value M requires to be careful during the whole process management; a value L falls within ordinary management.
\n\t\t\tA risk matrix.
The qualitative analysis is very useful either when a preliminary risk assessment is necessary or when a human judgement is the only viable approach to risk analysis. However, since a risk state (likelihood and/or consequence) might change continuously, the data collection about it is a time consuming activity often perceived as an unjustified cost. Another problem is the timing; if data are not collected according to a real time modality, they are of little or any value as the actions anticipated by the contingency plan could be no more effective. These considerations inhibit the implementation of risk management systems. The top level model for process oriented risk management suggests how, at definition time, the organization of questionnaires and checklists can be arranged. For example, within the scope of “call for tender”, if we are interested in the following goals:
\n\t\t\tG4. Transparency:\n\t\t\t
\n\t\t\tLack of hidden agendas and conditions, accompanied by the availability of full information required for collaboration, cooperation, and collective decision making.
\n\t\t\tMinimum degree of disclosure to which agreements, dealings, practices, and transactions are open to all for verification,
\n\t\t\tG5. Impartiality\n\t\t\t
\n\t\t\tImpartiality is a principle holding that decisions should be based on objective criteria rather than on the basis of bias, prejudice, or preferring the benefit to one person over another for improper reasons,
\n\t\t\tG6.Correctness\n\t\t\t
\n\t\t\tConformity to laws
\n\t\t\tthen, the related questions and checklists can be:
\n\t\t\tcall for tender: quality assessment | \n\t\t\t\t\t|||
goal | \n\t\t\t\t\t\tquestion | \n\t\t\t\t\t\tchecklist | \n\t\t\t\t\t\tTask | \n\t\t\t\t\t
G4 | \n\t\t\t\t\t\tQ8. Are the full information available and published on the web site? | \n\t\t\t\t\t\t[yes, no] | \n\t\t\t\t\t\tcall for tender announcement | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Q9. Are the evaluation criteria for call for tenders complete and non ambiguous? | \n\t\t\t\t\t\t[poor, sufficient, good, very good] | \n\t\t\t\t\t\tplan procurement | \n\t\t\t\t\t
G5 | \n\t\t\t\t\t\tQ10. Are all tenders evaluated with the same criteria? | \n\t\t\t\t\t\t[yes, no] | \n\t\t\t\t\t\ttender evaluation | \n\t\t\t\t\t
G6 | \n\t\t\t\t\t\tQ11. Is the announcement compliant with the current laws? | \n\t\t\t\t\t\t[compliant, not compliant] | \n\t\t\t\t\t\tplan procurement | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Q12. Has the call been registered at the registry office? | \n\t\t\t\t\t\t[yes, no] | \n\t\t\t\t\t\tprocurement registration | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Q13. Does the winner provide the right solution? | \n\t\t\t\t\t\t[poor, sufficient, good, very good] | \n\t\t\t\t\t\ttender evaluation | \n\t\t\t\t\t
Quality assessment specifications for the tasks of “call for tender”.
where we associate to each task a set of goals together with the corresponding set of questions (at least one question for each goal, according to the GQM approach) and a checklist that suggests the judgment to be expressed.. Generally, the question is aimed at assessing a quality criterion and is evaluated against a list of fuzzy values such as {compliant, not compliant} or {poor, sufficient, good, very good}. Human judgments collected as soon as possible can feed the risk matrix. In other words, we can define task quality criteria whose satisfaction provides a contribution in the direction of quality goals for the task and in general for the whole process. When given criteria are not satisfied, the risk relied to the task increases and the task monitoring rules react raising the risk status and invoking the appropriate risk treatment. We will return to this point in the next section.
\n\t\t\tA WfMS usually provides a suitable definition and execution environment that allows with little implementation effort the set up of a subsystem devoted to the collection of qualitative process execution data. Indeed, applications for the exposition of questionnaires and checklist can be easily designed and implemented because the WfMS usually allows the launch of a complementary software application both at scheduling time and at completion time of a task instance.
\n\t\t\tQualitative data collection through questionnaires and checklists.
This scenario is represented in figure 5; after the execution of tasks A and B, the WfMS decides that the next task to schedule is D putting the task in the work list of a role charged to execute it. As soon as an actor with those roles completes the task D, the workflow engine will launch the software application that allows the interaction with a questionnaire. The answers are collected and then stored in the workflow execution log feeding the part of the risk management system that has the responsibility for the monitoring and control of qualitative risks.
\n\t\tTo show how the top level model for process oriented risk management allows continuous operational risk management with respect to tasks and processes, let us consider the phases of a generic risk management methodology that encapsulates the concepts discussed so far:
\n\t\t\t\n\t\t\t\t\t\tDefine the context: goals, processes, stakeholders, evaluation criteria
\n\t\t\t\t\t\tIdentify the risks: what events can have an impact on tasks and processes?
\n\t\t\t\t\t\tAnalyze the risks: state the likelihoods, consequences, measures, thresholds, prioritization
\n\t\t\t\t\t\tWrite the contingency plan: define the approach – avoidance, minimization, transfer- about risk or a set of a related risks
\n\t\t\t\t\t\tMonitoring: collect qualitative and quantitative execution data, acquire risk status and record it, evaluate risk indicators
\n\t\t\t\t\t\tControl: decide for the best reaction when the risk probability increases or when unwanted events happen
\n\t\t\t\t\t\tCommunication: is a cross activity in the sense that data or information handled by a certain task/process can be communicated to the involved stakeholders.
To be useful a sound risk management system must be reactive; in other words, it must provide real time responses to unwished events that might happen in an unpredictable way. To specify the behaviour of a risk management system charged to manage events with a possible negative impact on the correct execution of tasks and processes, we shall use a rule based logic language called RSF (Degl’Innocenti et al., 1990); (Nota &Pacini, 1992). With this language a reactive system can be defined in terms of event-condition-transition rules able to specify systems requirements subjected to temporal constraints. As shown in figure 6, at risk definition time the risk manager has the possibility to access the process model database in order to link behavioral rules to tasks and processes that state how to react when the risk exceeds a given threshold.
\n\t\t\tAt process execution time, critical task or process attributes are evaluated against the measurement framework and/or the risk matrix discussed in the previous sections. Then, if the current risk state is acceptable the process enactment proceeds regularly, otherwise the dangerous situation is immediately notified at the appropriate responsibility role, e.g. the task executor, the process owner or the risk manager.
\n\t\t\tAt each time, the risk management system records a state concerning various kinds of data about risks. When an unwished event with a negative impact on an activity is recognized, the system reacts adjusting the state and eventually taking some risk treatment action.
\n\t\t\tAt risk definition time, as shown in figure 6, the risk manager defines a questionnaire containing, for example, two questions q10 and q11 (cfr. the case study “call for tender”) and establishes four risk assessment values for the activity D. At execution time, when D completes its execution, the workflow engine presents the questionnaire to the user, collect the answers and sends them to the RMS in order to associate the appropriate risk status for D depending on the collected responses. The rule for the treatment of qualitative risks linked to D states that: if the risk assumes the value E, then send an alert to the actor who executed D and activate an escalation procedure. The escalation signals a “process risk” to the process owner (the role responsible for the process instance that provide execution context for D) and an “organizational risk” to the appropriate business manager.
\n\t\t\tIn section 4 we outlined a three level measurement framework for performance evaluation when business process are supported by a WfMS that, during the execution of workflows, stores raw execution data in log files using them to feed the measurement framework.
\n\t\t\tBy the coupling of a WfMS with a RMS we can obtain an additional value in terms of capability to manage operational risks through quantitative techniques. Consider again the opportunity that a risk manager has at definition time to define the reactive behavior of a RMS. The rule b) in figure 6 shows how a reactive behavior can be relied to a task D. The rule states that when the workflow engine creates an instance of D assigning it to the worklist of an actor, a check has to be done. If the instance of D is created at a time greater than 50 time units after the instance creation of its father, (the process P to which D belongs) then two messages highlighting a schedule risk for the task D are produced, one to the actor that is executing the task and the other to the process owner.
\n\t\t\tThe measurement framework can bring more than a reactive behavior. The need to assess the risk relied to the missing process completion is one of the characteristic that we could require to a system that integrates a WfMS with a RMS. Such proactive behavior lays on the availability of execution data automatically collected by the WfMS and on the risk analysis data represented within the RMS.
\n\t\t\tRelations between process management and risk management.
Let P be a process and ip an instance in the execution of P. The WfMS can assess the residual duration of ip by considering the difference between the average duration of already completed instances of P and the current duration of ip. Remembering that
\n
Depending on the value returned by the application of residual_duration, the RMS has three possible alternative interpretations of the expected residual duration of P. When the value is equal to 0 we have an indication that from now on delay will be accumulated; if the value is less than 0, the process is late, otherwise, the residual duration represents an assessment of the time needed to complete the process. The measure
Apart from the workflow measurement framework used in this paper, the risk manager can take advantage of other existing set of risk indicators. It is sufficient to plan at risk definition time both: a) the link between expected value of measures and tasks b) the rules for the risk treatment.
\n\t\t\tIn this way standard measures can be used and evaluated locally to put under control potential risks engraving on tasks. The following ones are two simple measures chosen among a set of widely accepted measures (Hillson, 2004) to evaluate the progress of a project from the cost perspective:
\n\t\t\tCV = BCWP-ACWP (cost variance)
\n\t\t\tCPI = BCWP / ACWP (cost performance index)
\n\t\t\twhere BCWP is the Budgeted Cost of Work Performed at a time t0 and ACWP stands for Actual Cost for Work Performed at tn. Again, the enterprise can receive real time support by the integrated system WfMS+RMS because at task execution time the task cost can feed, for example, the cost variance. This evaluation provides input for the risk treatment rules that define the best reaction to take when the value of cost variance falls below a given threshold.
\n\t\tEnterprise risk management is an emergent research field. Apart from application area such as banking, insurance and health where risk management has traditionally been considered a primary management discipline, more and more organizations are planning today the introduction of a risk management system. The model for process oriented risk management proposed here arises from the consideration that the degradation of process execution in terms of poor performances/effectiveness, high costs and low quality can cause great difficulties even undermining the survival of organizations. It can be taken as a reference model by process focused enterprises for the implementation of advanced risk management systems. As a matter of fact, from the coupling of a WfMS with a risk management system we obtain an integrated system capable of managing risks that could have an impact on the regular execution of workflows. Any deviation from the prescribed workflow behavior implies a missed deadline, an increased execution cost or even a danger or an illegal situation. The basic information needs concerning the workflow execution, from the point of view of risk management, can be satisfied by the workflow engine either automatically recording relevant events during the process execution (i.e. creation, completion of work items, task and processes) or collecting qualitative data before or after the examination of each scheduled activity.
\n\t\t\tBoth kinds of measures, qualitative and quantitative are effective tools that help the management to identify threats during the enactment of processes. At risk definition time, the risk manager looks at the definition of activities and processes assigning to them risk monitoring rules that can be automatically managed by the WfMS during the workflow execution.
\n\t\t\tEven if the implementation of the top level model shown in figure 1 for process focused risk management can contribute to reduce the cost of data collection and to the acquisition of precise data about workflow execution, the model brings its advantages especially in the area of operational risks. A risk manager must be aware of this limitation considering the decision support system provided by the process focused risk management as an important part of a wider RMS that can take advantage also of traditional techniques in order to handle the four risk management areas discussed in the introduction.
\n\t\tBronchiectasis was originally described by René Laënnec in 1819. This term comes from two Greek words; “Bronkhia” and “Ektasis” meaning “Airway widening”. As a medical term, bronchiectasis refers to chronic lung disease associated with irreversible dilatation of the bronchial tree. For many years, it was considered as an orphan disease; however, the detection of bronchiectasis has been increased in the recent years as a result of increased health awareness and modern advances in the imaging techniques [1, 2].
\nThe prevalence of bronchiectasis varies in relation to geographic location. The estimated prevalence of bronchiectasis in developed countries (USA, UK, Germany, Spain) is up to 566 cases per 100,000, with 40% increase in the past decade [3, 4]. The recent findings from the British lung foundation’s project showed that around 212,000 people are currently living with bronchiectasis in the UK, with predominence of female gender and over-70 age [5]. In USA, 252,362 patients were indentified with an average annual prevalence of 701 per 100,000 persons between 2006 and 2014, with mean age of 76 years, predominace of female gender (65%), and dual diagnosis of chronic obstructive pulmonary disease (COPD) in most of the patients (51%) [6]. In China, the overall prevalence of physician-diagnosed bronchiectasis in people aged 40 years or older is estimated at 1.2% and is trending upward with aging of the population [7]. In comparison to European estimates, the recently reported patients with bronchiectasis in India were younger (median age of 56 years), more likely to be men, and showed a high frequency of severe, cystic bronchiectasis. Tuberculosis and other severe infections were the most frequently reported underlying cause [8].
\nMost of the cases of bronchiectasis are idiopathic in etiology, however, it may be found in a variety of pulmonary diseases, genetic or acquired, such as cystic fibrosis (CF), Kartagener syndrome (triad of situs inversus, chronic sinusitis, and bronchiectasis), COPD, alpha 1-antitrypsin deficiency, bronchial asthma, or primary immunodeficiencies [9, 10]. In the absence of CF, particularly with post-infectious and allergic hypersensitivity causes, the disease is known as non-cystic fibrosis bronchiectasis (NCFB) [10].
\nThe pathogenesis of bronchiectasis is based on the “vicious cycle hypothesis” which begins by infectious or noninfectious insult to the lung, resulting in neutrophil inflammation (proteases) and impairment of the mucociliary clearance followed by microbial colonization or infection, bronchial obstruction, and exaggerated inflammatory response. The “vicious cycle” (Figure 1) refers to the occurrence of repeated infections with repeated impairment of the mucociliary apparatus subsequent to infection and inflammation [10, 11, 12].
\nVicious cycle of bronchiectasis.
The clinical diagnosis of bronchiectasis is challenging as it manifests early non-specific symptoms and signs. However, the presence of chronic cough with overproduction of sputum which may worse at the morning increases the index of suspicion for bronchiectasis especially in non-smokers [13, 14]. Other significant signs of bronchiectasis include: hemoptysis, chronic respiratory failure, pulmonary hypertension, and right-sided heart failure [13].
\nBronchiectasis can be classified anatomically (cylindrical, varicoid, or cystic), and radiologically (localized or diffuse) [14]. Chest radiographs show non-specific findings of bronchiectasis such as: atelectatic changes, and hyperinflation [13, 14]. High-resolution computed tomography (HRCT) of the chest is a useful imaging tool for diagnosis of bronchiectasis and detection of the underlying causes. On HRCT, bronchiectatic changes include dilated airways, thick-walled bronchi with failed tapering at the periphery of the lung,, ring opacity, tram-track sign, and finger-in-glove sign, and signet-ring sign when the dilated bronchi is larger than the companion pulmonary artery branch (Bronchial-to-arterial ratio > 1) [14].
\nA bundle of minimum etiological tests has been recommended by European Respiratory Society (ERS) for newly diagnosed patients with bronchiectasis including: differential blood count, immunoglobulins (IgA, IgM and IgG), and allergic bronchopulmonary aspergillosis (ABPA)-specific tests (total IgE, specific IgE to Aspergillus, IgG to Aspergillus and eosinophil count), in addition to sputum culture for monitoring of bacterial and non-tuberculous infections [15].
\nEtiology-specific investigations include: Sweat chloride assessment and cystic fibrosis transmembrane conductance regulator (CFTR) genetic analysis for cystic fibrosis, serum alpha1-antitrypsin level and phenotyping for Alpha-1-antitrypsin deficiency, measurement of nasal nitric oxide levels and ciliated epithelial biopsy for primary ciliary dyskinesia, Rheumatoid factor and anti-cyclic citrullinated peptide (CCP) for autoimmune/connective tissue diseases, and specific CT findings of congenital malformations including Williams-Campbell syndrome (bronchomalacia); Mounier-Kuhn syndrome (tracheobronchomegaly) and lung sequestration [16].
\nBronchoscopy is not a routine diagnostic tool for bronchiectasis in the era of HRCT, but there are several indications for diagnostic bronchoscopy in such cases including: exclusion of foreign body obstruction especially in children, exclusion of proximal obstruction in adults with localized disease, obtaining microbiological results in acute ill patients, sampling of lower respiratory tract secretions when serial sputum testing did not yield results, obtaining endobronchial biopsy of airway cilia, and localizing the site of bleeding in patients with bronchiectasis and hemoptysis [17].
\nThe age-adjusted mortality rate for both male and female patients with diagnosed bronchiectasis is more than twice the mortality in the general population [4]. The independent risk factors influencing long-term mortality (over 13 years) in patients with bronchiectasis include: age, St George’s Respiratory Questionnaire activity score, Pseudomonas aeruginosa infection, total lung capacity (TLC), residual volume/TLC, and the transfer factor coefficient [18]. Therefore, in order to reduce the suspected poor prognosis with bronchiectasis, the treatment should be directed to improve symptoms, enhance quality of life, reduce exacerbations, and limit progression of the bronchiectatic lesions [15, 19].
\nTreatment of bronchiectasis has been considered by ERS guidelines according to the vicious cycle hypothesis [15]. Thus, the options of treatment include: long-term inhaled or oral antibiotic therapy, eradication of new pathogenic microorganisms and antibiotic treatment of exacerbations for chronic bronchial infection, long-term anti-inflammatory therapies for inflammation, long-term mucoactive treatments and airway clearance techniques for impaired mucociliary clearance, and long-term bronchodilator therapy, surgery and pulmonary rehabilitation for structural lung disease.
\nOptimization of the medical management and proper selection of patients are crucial in the decesion making for surgery. Therefore, the current guidelines by ERS and British Thoracic Society (BTS) did not consider surgery until the symptoms are controlled by optimized medical treatment [15, 20]. The indications of surgery as recently mentioned by BTS guideline (Figure 2) include: persistent symptoms despite up to a year of comprehensive medical treatment, exacerbations that are either severe or frequent and interfere with social/professional life, recurrent refractory or massive hemoptysis, post obstruction bronchiectasis distal to tumors, localized severely damaged lobe/segment that may be a source of sepsis that left in situ may lead to extension of lung damage, and treatment of complications such as empyema or lung abscess [20].
\nCurrent indications for surgical treatment of bronchiectasis [15, 20].
Up to date, there are only 46 published studies in literature between 1960 and 2019, evaluating the surgical management of bronchiectasis [21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66]. The most common clinical manifestations in these studies were: productive cough in 17.4–100% [54, 57], fetid sputum in 15.1–80% [35, 57], and hemoptysis in 10–76.5% [44, 59], while the main and indications of surgery include: failure of medical therapy in 39.6–100% [43, 50], recurrent chest infection in 19.8–100% [23, 54], massive or recurrent hemoptysis in 3–44.3% [32, 43], lung abscess in 1.8–36.5% [32, 58], lung masses or tumors in 1.4–17.6% [42, 46], and empyema in 1.1–8.1% [30, 57]. The mean duration of symptoms before surgery ranged from 1.78–10.6 years [30, 66].
\nFailure of prudent medical treatment is the main indication of surgery in these studies, especially with frequent exacerbations and repeated hospitalizations [41]. Some authors considered failure of treatment if sputum production persists after 2 or 3 cycles of treatment [35]. The permanently damaged areas of bronchiectasis have poor antibiotic penetration leading to failure of antibiotic therapy, and acts as a microbiological reservoir with subsequent recurrence of infection [61]. Moreover, medical treatment for long periods with persistent symptoms has additional psychological and social effects [32].
\nTherefore, surgery after failed medical treatment should aim to improve clinical condition and health-related quality of life, in addition to resolution of terrible bronchiectasis-related complications. This aim can be achieved when the focal lesions are completely removed, however, patients with multisegmental lesions should have palliative limited resection after failure of medical treatment or in the presence of life-threatening hemoptysis [47].
\nRecurrence of pulmonary infection is an important indication of surgery, as it can result in increased cost and side effects of antibiotic therapy for acute infection, in addition to affection of the normal lung tissue with extension of lung destruction during each episode [32]. When bronchiectasis is associated with lung abscess, surgery should be delayed until adequate control with antibiotic therapy and avoiding of preoperative drainage is recommended, however, the immediate indications of surgery in the presence of lung abscess include increased abscess size, unceasing sepsis, and contralateral contamination [30].
\nRecurrent or massive hemoptysis of more than 600 mL of blood within 24 hours indicates surgery which is considered as emergency after failure of the conservative therapy for hemoptysis. Even after initial cessation of bleeding by balloon blockade of the bleeding bronchus or bronchial artery embolization, early surgical treatment is indicated to avoid life-threatening recurrence of hemoptysis [30].
\nIn children, the indications for surgery are the same as in adult patients. Growth retardation can be considered as an additional indication for surgery in children with satisfactory postoperative results [43]. It is crucial to exclude the underlying diseases such as Kartagener syndrome and cystic fibrosis which limit the surgical resection [36].
\nPreoperative evaluation should include physical examination, imaging studies, arterial blood gases, pulmonary function tests, bronchoscopy, and perfusion scans if indicated. Additional diagnostic work-up may be required for patients with cardiovascular diseases including echocardiography, stress testing, myocardial perfusion studies, and coronary angiography [48].
\nChest radiography represents non-specific features of bronchiectasis with low sensitivity and difficult appreciation. The suggestive findings in moderate to severe patients include: stranding, cystic lesions, volume loss with crowding of vessels, atelectasis, tram-track appearance, ring-like opacities, and tubular densities [28, 67]. Despite inadequate role of chest radiography in evaluation of bronchiectasis, abnormalities on chest radiography is significantly correlated with severity of the disease on HRCT [68].
\nThe images of HRCT have higher sensitivity for diagnosis and localization of bronchiectasis than radiography with very low false negative and false positive results [41, 69]. The indications of HRCT include: clinical suspicion despite normal chest radiography, clarification of abnormalities on chest radiography, and decision making for surgery [70]. The use of HRCT is not restricted by age of the patient, thus HRCT is not uncommon diagnostic tool in children with bronchiectasis [56].
\nIn addition to the great help of HRCT in diagnosis of different types of bronchiectasis (Figure 3), preoperative localization of the lesions by HRCT has specific importance in making the decision for complete anatomic resection or limited resection with preservation of the lung tissue [30].
\nImages of high resolution computed tomography show types of bronchiectasis: (A) cylindrical, (B) varicose, and (C) cystic.
Bronchoscopy should be performed in all patients to determine the underlying causes of bronchial obstruction including: foreign body aspiration, endobronchial epithelial tumors, and enlarged hilar lymph nodes with lobar collapse [30, 36]. Preoperative removal of the secretions and clearing of the airways is an important indication of bronchoscopy in adult and children patients [63], as it is associated with lower rate of postoperative complications [41].
\nPulmonary function tests (PFTs) are not routinely performed in cases of bronchiectasis when the lesions are localized, but PFTs should be performed in diffuse bronchiectasis and in cases of repeated operations [36]. Pulmonary function tests can be performed in adult patients or in children older than 6 years of age [59]; however, cooperation of the child may affect completeness of the pulmonary function tests [35].
\nThe patients with bronchiectasis may have obstructive ventilatory pattern related to mucus retention or immunological abnormalities. The surgical resection of pulmonary segments with little contribution to ventilatory process is expected to have no or minimal effect on postoperative pulmonary function [31]. The expected loss of pulmonary function after surgical resection of bronchiectasis can be calculated from the equation: expected loss of function = preoperative function * (number of functional segments in the lobe to be resected/total number of segments of both lungs) [53].
\nVentilation/perfusion (V/Q) scintigraphy provides information about hemodynamic features (vascular perfusion), gas exchange, and quantitative lung function, which has a particular help in cases with diffuse bronchiectasis as it can determine the most affected non-perfused areas to be surgically resected [36, 37]. The affected area is considered non-perfused when the perfusion is <10% of the expected [37]. Moreover, V/Q scintigraphy is indicated in patients with poor pulmonary function to provide more quantitative information about ventilation function [38].
\nSome authors tried to find the correlation between morphologic type of bronchiectasis and the hemodynamic perfusion features. The study by Ashour in 1996, determined a correlation of cylindric morphology with pulmonary perfusion, contrary to non-perfusion predominance in cystic type, thus the surgery for diffuse bronchiectasis can be reserved for non-perfused cystic lesions which are more damaged than cylindrical lesions [71]. Thereafter, Al-Kattan and colleagues reported a new hemodynamic classification of bronchiectasis in patients with diffuse or bilateral disease, combining the perfusion and morphologic features to provide a reasonable extent of surgery and to obtain maximum postoperative clinical improvement [37].
\nThe preoperative preparation of patients with bronchiectasis should aim to provide the best possible status. Therefore, the preoperative preparation should be performed by a multidisciplinary team consists of infectious disease specialists, pulmonologists, and thoracic surgeons [72].
\nThe patients should have appropriate preoperative preparation until the sputum volume reduced to 20-50 mL per day [54, 63], or the antibiotic therapy is modified according to new culture sensitivity results of the sputum [63]. As the gram-negative bacterial infection has a significant risk for perioperative complications, surgery should be performed after negative proof of Gram-negative bacillus on sputum culture analysis [58].
\nIn patients with a history of tuberculosis, surgery should be reserved for patients with inactive disease. Some surgeons postponed elective surgery 6 months if the sputum culture was positive for acid-fast bacilli and after the completion of antituberculosis treatment [41].
\nPreoperatively, patients should be hospitalized and prepared for at least 2 weeks before surgery [48]. The patients who are scheduled for surgery should have no active pulmonary infection at the time of surgery. Therefore, broadspectrum antibiotics should be given for 48 hours prior to surgery, or prophylactic antibiotics are given according to results of sputum culture and sensitivity tests [36, 54]. For prophylaxis, cephalosporin and aminoglycoside are preferred if the culture is negative and the patient has no contraindications or allergies [48].
\nThe patients should have intensive chest physiotherapy in the preoperative period, to obtain acceptable decrease of the daily volume of the sputum [54]. Patients should have chest physiotherapy including postural drainage for at least 2 weeks bfore surgery [57], or it should be continued until the daily sputum is ≤50 mL [50]. Preoperative postural drainage is essential to clean intra-tracheal secretions, decrease the sputum volume and sputum accumulation, and hence control of the infection and optimize the respiratory status [50, 58].
\nThe recommended airway clearance techniques are active breathing techniques or oscillating positive expiratory pressure (PEP). Review of HRCT findings is helpful to determine the appropriate postural drainage in relevance to the affected pulmonary segments. The gravity assisted positioning, where not contraindicated, is recommended to enhance the effectiveness of an airway clearance technique. Modified postural drainage without head down tilt should be considered when the postural drainage is not tolerated and when the symptoms of gastroesophageal reflux increased with the technique [17, 20].
\nNutritional support and pulmonary rehabilitation should be considered before surgical referral [20]. In patients on long-term steroid therapy, the doses may be increased by 5–10 mg/day, but surgery should be postponed in patients with uncontrolled respiratory symptoms [72].
\nThe anesthetic management during surgery for bronchiectasis should consider: (1) cleaning of the bronchus opposite to the side of surgery by aspiration before placement of endotracheal tube, and (2) avoiding contralateral contamination by: insertion of double-lumen endotracheal tube, use of Fogarty embolectomy catheter as a bronchus blocker, or advancing of the endotracheal tube to the main bronchus of the opposite side of resection [35, 37, 41, 54, 57].
\nPosterolateral thoracotomy is the standard approach for pulmonary resection in patients with bronchiectasis. Preservation of the integrity of chest wall muscles using muscle-sparing technique is essential to reduce postoperative pain and generate an effective cough [29]. When the decision is for bilateral lung resection, the second operation can be performed with an interval of 1–4 months [49, 53].
\nThe extent of lung resection is determined by extent of the disease and cardiopulmonary reserve, thus lobectomy is performed for lesions limited to one lobe, segmentectomy is performed for fairly limited disease or when the pulmonary function is impaired, while pneumonectomy is reserved for extensive disease affecting the whole lung [33, 50, 54]. In some instances, bilobectomy and lobectomy plus segmentectomy can be performed [40, 44, 48, 50, 52, 61]. Extrapleural dissection is preferred to avoid spillage of lung content into pleural space. After identification of the hilar structures and opening of the major fissure, arterial, venous, and bronchial branches are isolated and divided, respectively [39, 63].
\nCertain recommendations can be followed to prevent or reduce the incidences of postoperative air leak and bronchopleural fistula (BPF) after lung resection including: preservation of peribronchial tissues and avoidance of extensive lymph node dissection near to bronchi to minimize bronchial devascularization, division of the bronchus before mobilization of the resected part to avoid contamination of the healthy segments, division of the bronchial stump as short as possible which sutured by non-absorbable materials or closed with a mechanical stapler then buttressed by tissue glue or a flap from pleura, pericardium, pericardial fat pad, muscle, or omentum [41, 73].
\nTo reduce the extension of contamination during surgery, extrapleural intrapericardial pneumonectomy is recommended when there is pleural sepsis or complete fusion of the pleura. Also, the evidence of pleural infection indicates pleural space irrigation with antibiotic [73]. Following placement of the chest drains, bronchoscopic evaluation of the bronchial sutures with removal of any secretions in the airway should be performed [63]. The resected specimens should be sent for histopathological examination [41].
\nThere is a little research work regarding use of VATS in the management of bronchiectasis. The reported VATS approaches for lobectomy in patients with bronchiectasis include three ports, two ports, or one port VATS [55, 62, 66]. Additionally, a two-port thoracoscopy with a utility mini-thoracotomy has been reported [45].
\nFor three ports completely VATS procedure, the ports are placed through the 7th or 8th intercostal space in the midaxillary line for a 10-mm 30° thoracoscope, the 4th or 5th intercostal space along the anterior axillary line (4–5 cm incision), and the 7th or 8th intercostal space in the auscultatory triangle (1.5 cm incision) [55]. For two ports VATS lobectomy, a 2 cm camera port through the 7th or 8th intercostal space in the anterior axillary line and a 3–5 cm utility incision through the 4th or 5th intercostal space in the anterior or mid axillary line [62]. Ocakcioglu et al. described uniportal VATS lobectomy through a utility incision of 3–5 cm from the 5th intercostal space in the anterior position without use of rib retractor. A 10 mm 30° thoracoscope is placed in the anterior part of the incision, while dissecting and holding clamps are placed through the dorsal part [66].
\nDuring 3 ports VATS, the incisions change depending on the type of lung resection, whether it is an upper or lower lobectomy [62]. The presence of intrathoracic adhesions is a challenging problem during VATS which can be released by blunt or sharp dissection, or it may result in conversion of the VATS procedure to open procedure [55, 64]. As in open thoracotomy, the pulmonary artery is firstly identified and divided before the division of the veins to avoid congestion of the lobe, with separate dissection of the major pulmonary veins and the bronchus [64]. The dissection of vascular and airway structures is performed by an endoscopic linear cutter [55]. At the end of VATS procedure, the thorax is closed after retrieval of the resected specimens and meticulous control of air leak and hemorrhage [66].
\nBronchoscopy can be performed in the operating room for bronchial hygiene, immediately after surgery [56]. The early postoperative care should include: pain control including epidural analgesia, chest physiotherapy, antibiotic therapy according to results of culture and sensitivity [37, 56].
\nGenerally, the duration of postoperative systematic antibiotic therapy is 5 days, but it can be longer according to the inflammatory condition. Early ambulation and active cough, and 3–4 times percussive chest physiotherapy are essential for proper expectoration and lung re-expansion. The standard criteria for removal of chest tube are: stable vital signs, small amount of drainage (<100 mL/day) with clear color, lung re-expansion on chest X-ray, and absence of air leak [63].
\nAfter discharge, patients should have specific or wide-spectrum antibiotic therapy for 1 week. Chest physiotherapy can be reinitiated at home and continued for 2 weeks after discharge [33].
\nTo date, few studies have evaluated postoperative outcomes after lung resection for bronchiectasis (Table 1). There is no perioperative mortality (early, operative, in-hospital, postoperative, or 30-days) after surgical resection of bronchiectasis in most of the published studies. The reported rates of perioperative mortality ranged from 0.41% [23] to 8.3% [25]. The causes of early mortality in literature include: respiratory failure [2, 27, 28, 41, 49, 57], intraoperative bleeding [24, 28, 46], postoperative pneumonia [25, 37], empyema [25, 32], pulmonary edema [27, 46], cardiac-related causes including myocardial infarction or arrhythmia [27, 35, 47, 49, 58], speptic shock [27, 56], gastrointestinal bleeding due to sepsis and stress ulcer [39], uncontrolled hemoptysis [27], pulmonary embolism [22, 32, 48, 58], cardiac arrest in patients with Kartagener syndrome [36], disseminated intravascular coagulation [44], nephropathy [22], downstream consequences of bronchial stump fistula [48, 60], multiple organ failure [48, 60], and causes unrelated to disease or technique such as cerebral edema in a child due to previously undiagnosed aquaeductus stenosis and hydrocephalus [24]. The disease-related consequences which indirectly attribute to early death include: severe disease requiring pneumonectomy or completion [28, 58], massive bleeding during the operation because of dense adhesions due to chronic and recurrent infections [44, 46], and Kartagener syndrome [36].
\nAuthor | \nYear | \nNumber | \nMorbidity (%) | \nEarly mortality (%) | \nLate mortality (%) | \nAsymptomatic (%) | \n
---|---|---|---|---|---|---|
Hewlett and Ziperman | \n1960 | \n107 | \n20.6 | \n0 | \n1.9 | \n36.4 | \n
Streete and Salyer | \n1960 | \n240 | \n22.1 | \n0.8 | \n2.1 | \n22.3 | \n
Sanderson et al. | \n1974 | \n242 | \n33.5 | \n0.4 | \n2.9 | \n62.5 | \n
George et al. | \n1979 | \n99 | \n88.9 | \n3 | \n4 | \n39.6 | \n
Annest et al. | \n1982 | \n24 | \n12.5 | \n8.3 | \n8.3 | \n45.8 | \n
Wilson and Decker | \n1982 | \n84 | \n10.7 | \n0 | \n1.2 | \n73.8 | \n
Dogan et al. | \n1989 | \n487 | \n10.7 | \n3.1 | \n0.4 | \n73.3 | \n
Agasthian et al. | \n1996 | \n134 | \n24.6 | \n2.2 | \n0 | \n59.2 | \n
Ashour et al. | \n1999 | \n85 | \n12.9 | \n0 | \n0 | \n74.1 | \n
Fujimoto et al. | \n2001 | \n90 | \n22.2 | \n0 | \n0 | \n45.6 | \n
Prieto et al. | \n2001 | \n119 | \n12.6 | \n0 | \n0 | \n67.6 | \n
Kutlay et al. | \n2002 | \n166 | \n10.8 | \n1.8 | \n0 | \n75 | \n
Balkanli et al. | \n2003 | \n238 | \n8.8 | \n0 | \n0 | \n82.5 | \n
Mazieres et al. | \n2003 | \n16 | \n18.8 | \n0 | \n0 | \n31.3 | \n
Haciibrahimoglu et a | \n2004 | \n35 | \n17.1 | \n2.9 | \n0 | \n64.7 | \n
Otgun et al. | \n2004 | \n54 | \n7.4 | \n5.6 | \n0 | \n45.1 | \n
Al-Kattan et al. | \n2005 | \n66 | \n18.2 | \n1.5 | \n0 | \n73.8 | \n
Schneiter et al. | \n2005 | \n48 | \n18.8 | \n0 | \n0 | \n62.5 | \n
Aghajanzadeh et al. | \n2006 | \n29 | \n37.9 | \n3.4 | \n0 | \n67.9 | \n
Yuncu et al. | \n2006 | \n81 | \n18.5 | \n0 | \n0 | \n81.7 | \n
Eren et al. | \n2007 | \n143 | \n23.1 | \n1.4 | \n0 | \n75.9 | \n
Guerra et al. | \n2007 | \n51 | \n15.7 | \n0 | \n0 | \n77.8 | \n
Sirmali et al | \n2007 | \n176 | \n13.1 | \n0 | \n0 | \n73.3 | \n
Stephen et al. | \n2007 | \n149 | \n14.8 | \n0.7 | \n0.7 | \n54.3 | \n
Giovannetti et al. | \n2008 | \n45 | \n11.1 | \n0 | \n0 | \n71.1 | \n
Bagheri et al. | \n2010 | \n277 | \n15.9 | \n0.7 | \n0 | \n68.6 | \n
Gursoy et al. | \n2010 | \n92 | \n16.3 | \n1.1 | \n0 | \n84 | \n
Zhang et al. | \n2010 | \n790 | \n16.2 | \n1.1 | \n0 | \n67.7 | \n
Caylak et al. | \n2011 | \n339 | \n12.7 | \n0.6 | \n0 | \n71 | \n
Cobanoglu et al. | \n2011 | \n62 | \n19.4 | \n0 | \n0 | \n45 | \n
Gorur et al. | \n2011 | \n122 | \n13.1 | \n0 | \n0 | \n77.3 | \n
Sehitogullari et al. | \n2011 | \n129 | \n22.5 | \n0 | \n0.8 | \n60.2 | \n
Hiramatsu et al. | \n2012 | \n31 | \n19.4 | \n0 | \n0 | \n74.2 | \n
Al-Refaie et al. | \n2013 | \n138 | \n13 | \n0 | \n0 | \n84.2 | \n
Zhou et al. | \n2013 | \n56 | \n23.2 | \n0 | \n0 | \n58.9 | \n
Andrade et al. | \n2014 | \n109 | \n36.7 | \n0.9 | \n0.9 | \nNR | \n
Balci et al. | \n2014 | \n86 | \n16.3 | \n1.2 | \n0 | \n82.6 | \n
Jin et al. | \n2014 | \n260 | \n11.5 | \n0.8 | \n1.9 | \n78 | \n
Sahin et al. | \n2014 | \n60 | \n20 | \n0 | \n3.3 | \n74.1 | \n
Vallilo et al. | \n2014 | \n53 | \n24.5 | \n3.8 | \n0 | \n34.1 | \n
Coutinho et al. | \n2016 | \n69 | \n14.5 | \n0 | \n0 | \n73.3 | \n
Baysungur et al. | \n2017 | \n41 | \n9.8 | \n0 | \n0 | \nNR | \n
Dai et al. | \n2017 | \n37 | \n21.6 | \n0 | \n0 | \n62.2 | \n
Hao et al. | \n2019 | \n99 | \n17.2 | \n0 | \n0 | \n26 | \n
Nega et al. | \n2019 | \n22 | \n22.7 | \n4.5 | \n0 | \n89.5 | \n
Ocakcioglu et al. | \n2019 | \n14 | \n14.3 | \n0 | \n0 | \n85.7 | \n
The rates of late or long-term mortality ranged from 0.41% [27] to 8.3% [25]. The reported causes of late mortality after surgical management of bronchiectasis included: respiratory failure [24, 52], progressive respiratory disease [25], sepsis [59], coronary artery thrombosis [22], cor pulmonale or pulmonary heart disease [22, 58], myocardial failure [22], glomerulonephritis [22], kidney failure [58], post-pneumonectomy pneumonia in the remaining lung [56], massive bleeding from the Malecot catheter used for drainage ofresidual space infection [44], suicide [22], and other causes of late deaths not attributable to bronchiectasis [21, 23, 26].
\nThe reported rates of morbidity ranged from 7% [7] to 38% [39]. The most common complication is atelectasis or sputum retention requiring bronchoscopic intervention, followed by persistent air leak (Table 2). Most of the reported complications were minor, transient, and treatable.
\nComplications | \nMinimum rate [Reference] | \nMaximum rate [Reference] | \n
---|---|---|
Atelectasis or sputum retention | \n0.9% [21] | \n33.3% [24] | \n
Prolonged air leak | \n0.7% [54] | \n26.4% [23] | \n
Pneumonia | \n1.2% [57] | \n12.5% [34] | \n
Bronchopleural fistula | \n0.4% [48] | \n9.1% [65] | \n
Residual air space or expansion defect | \n2.2% [45] | \n9% [51] | \n
Empyema | \n0.6% [32] | \n8.1% [44] | \n
Wound infection | \n1.3% [44] | \n7.4% [27] | \n
Bleeding | \n1.1% [30] | \n8.3% [25] | \n
Cardiac arrhythmias | \n0.4% [58] | \n5.4% [63] | \n
Pulmonary embolism | \n0.4% [58] | \n3.8% [60] | \n
Respiratory insufficiency | \n0.8% [52] | \n3.5% [57] | \n
Pulmonary edema | \n0.8% [52] | \n2.2% [28] | \n
Pleural effusion | \n0.6% [32] | \n0.7% [54] | \n
Reported rates of complications after surgical treatment of bronchiectasis.
In comparison to the published studies in the 3rd and 4th decades of 20th century, the relatively low incidences of complication in the after while studies can reflect effective antibiotic therapy, improved anesthetic techniques, adequate blood transfusion, and detailed postoperative care [21, 22]. Other factors include: surgeon’s experience, preoperative awareness of the undesirable consequences of retained secretions, preoperative teaching of breathing exercises, scheduling tracheal suction or bronchoscopy in the early postoperative period [21], good intraoperative hemostasis and careful dissection [37], low number of pneumonectomies, accurate patient selection, and careful perioperative management [45].
\nTreatment of postoperative complications after surgery for bronchiectasis depends on its type and severity. The treatment options for complications include: physiotherapy, tube thoracotomy, bronchoscopic treatment for atelectasis, negative suction applied to the chest tubes for prolonged air leak, surgical reintervention for closure of bronchopleural fistula, medical treatment or decortication for pleural empyema, pharmacological control of supraventricular arrhythmias, reexploration for postoperative bleeding, and mechanical ventilation for respiratory insufficiency [39, 41, 60].
\nCobanoglu et al. did not report any significant statistical difference between tubular and saccular morphologic types of bronchiectasis regarding postoperative complication rates; however, the most severe postoperative complication, bronchopleural fistula, developed in 2 (3.22%) cases with saccular bronchiectasis [50]. Zhou et al. did not find statistically significant difference in the rates of postoperative complications between thoracotomy and VATS procedure. Minor postoperative complications were reported after thoracotomy or completely VATS lobectomy, which included pneumonia, prolonged air leak (>7 days), and atelectasis [55]. Moreover, Hao et al. did not observe major postoperative complications such as bronchopleural fistula or respiratory insufficiency was observed in VATS and thoracotomy groups. The most common complication was persistent air leak for >7 days in 8.1% of VATS group and 6% of thoracotomy group [64].
\nThe clinical results after surgical resection of bronchiectasis are frequently classified into three categories. The first category (asymptomatic; excellent response) includes patients who are completely free of any symptoms suggestive of bronchiectasis, and considered themselves cured. The second category (clinical improvement; good response) includes those considered improved who have had some relief of the symptoms but still had some chronic pulmonary complaints. The third category (no improvement; poor response) includes patients with no-change, no-reduction in preoperative symptoms, or who are worse off since surgical resection. [22, 31, 32, 35, 44, 46, 47, 50]. Some authors referred to the excellent response as well outcome [36] or perfect response [41].
\nSanderson et al. expanded the classification of the clinical symptomatic outcome to five categories as: excellent (no symptoms at all), good (full physical capacity, occasional cough and sputum), fair-improved (tendency to cough and sputum with susceptibility to respiratory infection, hemoptysis or dyspnea), poor (residual symptoms), and worse (steady deterioration) [23]. Other authors reduced the classification of the clinical condition in two categories only by dividing the patients into an improved group (“excellent” or “good” outcomes) and an unimproved group (“no change” or “worse” outcomes) [52].
\nIn literature, through a range of follow-up between 9 months and 14 years, the proportion of asymptomatic patients or excellent improvement after surgery ranged from 22.3% [22] to 89.5% [65], while the proportion of clinical improvement with reduction of preoperative symptoms ranged from 9.6% [64] to 80.7% [56], and no improvement, worseness or relapse was reported in 1.6% [58] to 42.3% [22].
\nPatients with bronchiectasis report worse quality of life (QOL) than do persons in the general population [74, 75]. Recurrent bronchiectasis exacerbations are related to deterioration of lung function, progression of the disease, impairment of quality of life, and increased rate of mortality [76]. Postoperative QOL and the functional consequences of lung resection (pulmonary function and exercise capacity) are poorly addressed.
\nVallilo et al. reported a significant improvement of the QOL in patients with symptomatic bronchiectasis which was particularly relevant in the functional and physical QOL domains. Resection of the lung area which had not contributed to ventilatory response during exercise before surgery might enable the patients to maintain the exercise performance after lung resection without impairment to the response of the ventilatory system during maximal testing [60].
\nThe proper surgical treatment should aim to complete resection of the bronchiectatic lesions. Thus, intraoperatively detected lesions should be resected as appropriate whether determined on preoperative imaging studies or not [32]. Complete resection is defined as an anatomic resection of all affected segments preoperatively identified by high-resolution computed tomography or bronchography [48, 54, 57]. However, some authors considered pulmonary resection complete if the patient was believed to be free of bronchiectasis after thoracotomy [31, 35].
\nCompleteness of surgical resection is affected by localization of the disease and pulmonary function (Figure 4). In patients with unilateral localized bronchiectasis, the most important prognostic factor for good surgical outcomes is complete resection of all diseased segments. In bilateral localized bronchiectasis, complete surgical resection should be attempted if lung function permits, including combinations of lobectomy with segmentectomy or wedge resections on the same siting or staged [24, 39, 73]; however, limited resection of the most predominant lesion is preferred for selected patients with bilateral diffuse bronchiectasis [34, 63]. The reported completeness of resection in patients with localized bronchiectasis ranged from 55.4% [23] to 94.2% [54].
\nSimplified algorithm for complete surgical resection according to extent of bronchiectasis.
Sanderson et al. found a preponderance of excellent results after complete resection in comparison with incomplete resection (36% versus 10%, P < 0.005) [23]. Agasthian et al. found that complete resection resulted in a significant increase in proportion of asymptomatic patients than incomplete resection (65.2% versus 21.4%, p < 0.05) [28]. In the study by Kutlay et al., the excellent to good results of complete resection were significantly better than those of incomplete resection (98.5 versus 76.5%, P < 0.05) [32]. Similarly, other authors reported significantly better clinical results with complete resection than incomplete resection [35, 36, 44, 46, 50, 52].
\nThere is no single independent perioperative variable that can predict occurrence of adverse events after lung resection with scant available data. In the study by Fujimoto et al., the logistic analyses extracted the type of bronchiectasis (cylindrical or others), the history of sinusitis, and the type of resection (complete or incomplete) for discrimination between patients with excellent or improved clinical outcome and patients with no clinical change [30]. Hiramatsu et al. reported immuno compromised status, Pseudomonas aeruginosa infection, and extent of residual bronchiectasis, as independent and significant factors of postoperative shorter relapse-free interval [53].
\nEren et al. fond that the lack of preoperative bronchoscopic examination, a FEV1 of <60% of the predicted value, a history of tuberculosis, and incomplete resection were independent predictors of postoperative complications [41]. Bagheri et al. statistically evaluated several variables including: sex, age, localization of disease, and complete or incomplete resection using multivariate logistic regression. Complete resection was found to have a significantly better surgical outcome compared to incomplete resection [46]. In the study by Zhang et al., the logistic regression analysis showed that tuberculous bronchiectasis, type of bronchiectasis (saccular versus others), and type of resection (incomplete or complete) were three independent factors associated with poor surgical outcome [48]. The multivariable analyses by Jin et al., showed that age, sputum volume, gram-negative bacillus infection, and bronchial stump coverage were the four independent factors related with poor surgical outcome [58].
\nAccording to the reported results by Sahin et al., the prognostic variables in pediatric patients were: FEV1 less than 60% of the predicted value, hemoptysis, and duration of symptoms [59]. Interestingly, Gorur et al. stated that multi-segmental resectable bronchiectasis should not be considered an occult risk factor for morbidity after lung resection. Moreover, the number of resected segments, hemoptysis, and absence of preoperative fiberoptic bronchoscopy were not associated with postoperative complications. Impaired pulmonary function was significantly associated with residual air space; however it did not predict the risk of persistent air leak, atelectasis or empyema [51].
\nCompletion pneumonectomy is historically recognized as a high-risk procedure especially when done for a benign disease [77]. To reduce the high-risk of completion pneumonectomy when indicated, precautions such as optimal exposure, intrapericardial isolation of blood vessels, and bronchial reinforcement are recommended [78]. In the study by Agasthian et al., all died patients after lung resection had completion pneumonectomy. The causes of death were respiratory failure and intraoperative bleeding [28]. However, Fujimoto et al. reported acceptable mortality and morbidity after completion pneumonectomy without mortality and only one patient had postoperative bronchopleural fistula that could be managed conservatively [30].
\nPatients with non-localized (multi-segmental or bilateral) bronchiectasis are generally regarded as an exclusion of surgery [39]. However, considering the limited and palliative effect of medical treatment and the risk of transplantation or radical operation, recent studies offered a limited operation to some of these patients [34, 63]. Moreover, some surgeons favored surgery in non-localized bronchiectasis to prevent extension of the disease to the unaffected lung [38].
\nGeorge et al. suggested that bilateral bronchiectasis need not be a contraindication to operation. In properly selected patients, lasting symptomatic improvement can be provided by resection [24]. Mazieres et al. reported favorable outcome after a limited lung resection in properly selected symptomatic patients with severe multisegmental bilateral bronchiectasis, particularly those with cystic lesions and functionless territories [34].
\nSchneiter et al. found the same patients’ satisfaction at 6 months after surgery for patients who had resectable non-localized or localized bronchiectasis, with non-significant differences in the rates of recurrent infection and hemoptysis [38]. Aghajanzadeh et al. reported the benefits of surgery in 87 bilateral non-localized bronchiectases, and concluded that staged bilateral resection for bronchiectases can be performed at any age with acceptable morbidity and mortality [39]. Additionally, Dai et al. reported the safety of lobectomy for the predominant lesions in non-localized bronchiectasis, with significant relief of symptoms, good rates of satisfaction, no operative mortality, and minimal postoperative complications [63].
\nThe prevalence of bronchiectasis in children ranges from 0.2 to 735 cases per 100,000 [79]. Cystic fibrosis is the most common cause of bronchiectasis in developed countries while in developing countries non-CF etiologies particularly post-infectious causes are more common [80]. Surgical treatment of bronchiectasis in children is considered for cases with resectable disease after failure of the proper medical treatment. Moreover, surgery can be considered in children with diffuse disease who have expected benefit after excision of the most predominant lesions [36, 79].
\nIn literature, the studies that evaluate surgical treatment of bronchiectasis in children are scanty. However, these studies confirmed the safety of surgery for childhood bronchiectasis with low rates of mortality and morbidity. Complete resection can be considered when possible, as most of the children can benefit from surgery especially if the total excision is accomplished [26, 35, 36, 43, 56, 59].
\nThe reported surgical outcomes in children with bronchiectasis highlight: acceptable mortality and morbidity [35, 36, 43, 56, 59], significant impact of surgery on improvement of symptoms and quality of life [43, 56], good results after segmentectomy when the pulmonary segment is entirely free of disease [26], increase the chance of cure after complete resection which results in significantly better outcome than incomplete resection [35, 43], preference of pneumonectomy instead of leaving residual disease when bronchiectasis is unilateral [36], and significant impact of duration of symptoms and timely intervention on the management and prognosis [59].
\nBronchiectasis is a significant chronic lung disease associated with vicious cycle of inflammation, infection, mucus accumulation, and structural tissue damage. Current guidelines recommend surgical treatment of bronchiectasis in patients with localized disease when symptoms are not controlled by optimized medical treatment. Other indications in literature include recurrent refractory or massive hemoptysis, bronchiectasis distal to tumors, and treatment of subsequent complications.
\nHRCT is the gold standard imaging tool of bronchiectasis, as has a great help in preoperative localization of the lesions which affects the decision making for surgery. Preoperative bronchoscopy is important to diagnose the underlying causes of bronchial obstruction and to clear the airways by removal of secretions. Preoperative PFTs can be performed to determine the segments with little ventilatory contribution and minimal effects on postoperative pulmonary function after surgical resection. Perfusion scans can be used to determine the most affected non-perfused areas to be resected, particularly when the pulmonary function is affected. According to hemodynamic analysis of perfusion scans in diffuse bronchiectasis, surgery can be reserved for non-perfused cystic lesions which are more damaged than cylindrical lesions.
\nPreoperative preparation for lung resection should include sputum culture analysis to modify antibiotic therapy with culture sensitivity results. It is crucial to eradicate active pulmonary infection and provide prophylactic antibiotic therapy with cephalosporin and aminoglycoside before surgery. Preoperative airway clearance techniques including active breathing, oscillating PEP, and postural drainage, are recommended to control infection and optimize the respiratory status. Other important preoperative considerations include nutritional support and pulmonary rehabilitation.
\nPosterolateral thoracotomy is the standard approach for the surgical resection of bronchiectasis. The extent of resection depends on extent of the disease and cardiopulmonary reserve. Preservation of peribronchial tissues, short bronchial stump, and buttressing techniques are recommended to reduce postoperative air leak and BPF. The safety and feasibility of VATS in the treatment of bronchiectasis was shown in scant studies with low morbidity and mortality. The proper care after surgery should include bronchoscopic removal of secretions, pain control, chest physiotherapy, and appropriate antibiotic therapy.
\nIn literature, the mortality rates after lung resection range from 0.41% to 8.3%. The most common causes of early mortality are respiratory failure, intraoperative bleeding, postoperative pneumonia, empyema, pulmonary edema, and cardiac-related causes; while the most common causes of late mortality are respiratory failure, progressive respiratory disease, sepsis, coronary artery thrombosis, and cor pulmonale. The morbidity rates range from 7–38%. Atelctasis or sputum retention is the most common postoperative complication, followed by persistent air leak, pneumonia, and BPF. Most of the reported complications are minor, transient, and treatable. During follow-up periods between 9 months and 14 years, the proportion of asymptomatic patients (excellent improvement) after surgery ranges from 22.3% to 89.5%. Postoperative QOL is poorly addressed, but it can be improved after resection of functionless pulmonary segments.
\nComplete resection of the affected parenchyma results in better clinical outcome than incomplete resection; however, completeness of resection is affected by localization of the disease and pulmonary function. A large number of predictors of surgical outcomes were investigated in literature, including: type of resection, type of bronchiectasis, immuno compromised status, Pseudomonas aeruginosa infection, extent of residual bronchiectasis, lack of preoperative bronchoscopic examination, FEV1 < 60% of the predicted value, tuberculosis, hemoptysis, duration of symptoms, age, sputum volume, gram-negative bacillus infection, bronchial stump coverage, and impaired pulmonary function.
\nRecent studies reported acceptable outcomes after a limited lung resection for the most predominant lesion in properly selected patients with non-localized bronchiectasis. Surgery can be safely performed in children with bronchiectasis, particularly when the disease is resectable disease after failure of the proper medical treatment. Acceptable postoperative rates of mortality and morbidity and a significant symptomatic improvement were reported in children.
\nABPA | allergic bronchopulmonary aspergillosis |
BPF | bronchopleural fistula |
BTS | British Thoracic Society |
CCP | cyclic citrullinated peptide |
CF | cystic fibrosis |
CFTR | cystic fibrosis transmembrane conductance regulator |
COPD | chronic obstructive pulmonary disease |
ERS | European Respiratory Society |
FEV1 | forced expiratory volume in 1 second |
HRCT | high resolution computed tomography |
NCFB | non-cystic fibrosis bronchiectasis |
PEP | positive expiratory pressure |
PFTs | pulmonary function tests |
QOL | quality of life |
TLC | total lung capacity |
VATS | video-assisted thoracoscopic surgery |
IntechOpen is the first native scientific publisher of Open Access books, with more than 116,000 authors worldwide, ranging from globally-renowned Nobel Prize winners to up-and-coming researchers at the cutting edge of scientific discovery. Established in Europe with the new headquarters based in London, and with plans for international growth, IntechOpen is the leading publisher of Open Access scientific books. The values of our business are based on the same ones that any scientist applies to their research -- we have created a culture of respect, collegiality and collaboration within an atmosphere that’s relaxed, friendly and progressive.
",metaTitle:"Social Media Community Manager and Marketing Assistant",metaDescription:"We are looking to add further talent to our team in The Shard office in London with a full-time Marketing and Communications Specialist position. The candidate will bring with them a creative and enthusiastic mindset, high level problem-solving skills, the latest marketing and social media platforms skills and strong involvement in community-best practices to engage with researchers and scholars online. The ideal candidate will be a dynamic, forward thinking, approachable team player, able to communicate with all in the global, growing company, with an ability to understand and build a rapport within the research community.",metaKeywords:null,canonicalURL:null,contentRaw:'[{"type":"htmlEditorComponent","content":"We are looking to add further talent to our team in The Shard office in London with a full-time Social Media Community Manager and Marketing Assistant position. The candidate will bring with them a creative and enthusiastic mindset, high level problem-solving skills, the latest marketing and social media platforms skills and strong involvement in community-best practices to engage with researchers and scholars online. The ideal candidate wll be a dynamic, forward thinking, approachable team player, able to communicate with all in the global, growing company, with an ability to understand and build a rapport within the research community.
\\n\\nThe Social Media Community Manager and Marketing Assistant will report to the Senior Marketing Manager. They will work alongside the Marketing and Corporate Communications team, supporting the preparation of all marketing programs, assisting in the development of scientific marketing and communication deliverables, and creating content for social media outlets, as well as managing international social communities.
\\n\\nResponsibilities:
\\n\\nEssential Skills:
\\n\\nDesired Skills:
\\n\\nWhat makes IntechOpen a great place to work?
\\n\\nIntechOpen is a global, dynamic and fast-growing company offering excellent opportunities to develop. We are a young and vibrant company where great people do great work. We offer a creative, dedicated, committed, passionate, and above all, fun environment where you can work, travel, meet world-renowned researchers and grow your career and experience.
\\n\\nTo apply, please email a copy of your CV and covering letter to hogan@intechopen.com stating your salary expectations.
\\n\\nNote: This full-time position will have an immediate start. In your cover letter, please indicate when you might be available for a block of two hours. As part of the interview process, all candidates that make it to the second phase will participate in a writing exercise.
\\n\\n*IntechOpen is an Equal Opportunities Employer consistent with its obligations under the law and does not discriminate against any employee or applicant on the basis of disability, gender, age, colour, national origin, race, religion, sexual orientation, war veteran status, or any classification protected by state, or local law.
\\n"}]'},components:[{type:"htmlEditorComponent",content:'We are looking to add further talent to our team in The Shard office in London with a full-time Social Media Community Manager and Marketing Assistant position. The candidate will bring with them a creative and enthusiastic mindset, high level problem-solving skills, the latest marketing and social media platforms skills and strong involvement in community-best practices to engage with researchers and scholars online. The ideal candidate wll be a dynamic, forward thinking, approachable team player, able to communicate with all in the global, growing company, with an ability to understand and build a rapport within the research community.
\n\nThe Social Media Community Manager and Marketing Assistant will report to the Senior Marketing Manager. They will work alongside the Marketing and Corporate Communications team, supporting the preparation of all marketing programs, assisting in the development of scientific marketing and communication deliverables, and creating content for social media outlets, as well as managing international social communities.
\n\nResponsibilities:
\n\nEssential Skills:
\n\nDesired Skills:
\n\nWhat makes IntechOpen a great place to work?
\n\nIntechOpen is a global, dynamic and fast-growing company offering excellent opportunities to develop. We are a young and vibrant company where great people do great work. We offer a creative, dedicated, committed, passionate, and above all, fun environment where you can work, travel, meet world-renowned researchers and grow your career and experience.
\n\nTo apply, please email a copy of your CV and covering letter to hogan@intechopen.com stating your salary expectations.
\n\nNote: This full-time position will have an immediate start. In your cover letter, please indicate when you might be available for a block of two hours. As part of the interview process, all candidates that make it to the second phase will participate in a writing exercise.
\n\n*IntechOpen is an Equal Opportunities Employer consistent with its obligations under the law and does not discriminate against any employee or applicant on the basis of disability, gender, age, colour, national origin, race, religion, sexual orientation, war veteran status, or any classification protected by state, or local law.
\n'}]},successStories:{items:[]},authorsAndEditors:{filterParams:{sort:"featured,name"},profiles:[{id:"58592",title:"Dr.",name:"Arun",middleName:null,surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/58592/images/1664_n.jpg",biography:"Arun K. Shanker is serving as a Principal Scientist (Plant Physiology) with the Indian Council of Agricultural Research (ICAR) at the Central Research Institute for Dryland Agriculture in Hyderabad, India. He is working with the ICAR as a full time researcher since 1993 and has since earned his Advanced degree in Crop Physiology while in service. He has been awarded the prestigious Member of the Royal Society of Chemistry (MRSC), by the Royal Society of Chemistry, London in 2015. Presently he is working on systems biology approach to study the mechanism of abiotic stress tolerance in crops. His main focus now is to unravel the mechanism of drought and heat stress response in plants to tackle climate change related threats in agriculture.",institutionString:null,institution:{name:"Indian Council of Agricultural Research",country:{name:"India"}}},{id:"4782",title:"Prof.",name:"Bishnu",middleName:"P",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4782/images/system/4782.jpg",biography:"Bishnu P. Pal is Professor of Physics at Mahindra École\nCentrale Hyderabad India since July 1st 2014 after retirement\nas Professor of Physics from IIT Delhi; Ph.D.’1975 from IIT\nDelhi; Fellow of OSA and SPIE; Senior Member IEEE;\nHonorary Foreign Member Royal Norwegian Society for\nScience and Arts; Member OSA Board of Directors (2009-\n11); Distinguished Lecturer IEEE Photonics Society (2005-\n07).",institutionString:null,institution:{name:"Indian Institute of Technology Delhi",country:{name:"India"}}},{id:"69653",title:"Dr.",name:"Chusak",middleName:null,surname:"Limsakul",slug:"chusak-limsakul",fullName:"Chusak Limsakul",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Prince of Songkla University",country:{name:"Thailand"}}},{id:"75563",title:"Dr.",name:"Farzana Khan",middleName:null,surname:"Perveen",slug:"farzana-khan-perveen",fullName:"Farzana Khan Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/75563/images/system/75563.png",biography:"Dr Farzana Khan Perveen (FLS; Gold-Medallist) obtained her BSc (Hons) and MSc (Zoology: Entomology) from the University of Karachi, MAS (Monbush-Scholar; Agriculture: Agronomy) and from the Nagoya University, Japan, and PhD (Research and Course-works from the Nagoya University; Toxicology) degree from the University of Karachi. She is Founder/Chairperson of the Department of Zoology (DOZ) and Ex-Controller of Examinations at Shaheed Benazir Bhutto University (SBBU) and Ex-Founder/ Ex-Chairperson of DOZ, Hazara University and Kohat University of Science & Technology. \nShe is the author of 150 high impact research papers, 135 abstracts, 4 authored books and 8 chapters. She is the editor of 5 books and she supervised BS(4), MSc(50), MPhil(40), and Ph.D. (1) students. She has organized and participated in numerous international and national conferences and received multiple awards and fellowships. She is a member of research societies, editorial boards of Journals, and World-Commission on Protected Areas, International Union for Conservation of Nature. Her fields of interest are Entomology, Toxicology, Forensic Entomology, and Zoology.",institutionString:"Shaheed Benazir Bhutto University",institution:{name:"Shaheed Benazir Bhutto University",country:{name:"Pakistan"}}},{id:"23804",title:"Dr.",name:"Hamzah",middleName:null,surname:"Arof",slug:"hamzah-arof",fullName:"Hamzah Arof",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/23804/images/5492_n.jpg",biography:"Hamzah Arof received his BSc from Michigan State University, and PhD from the University of Wales. Both degrees were in electrical engineering. His current research interests include signal processing and photonics. Currently he is affiliated with the Department of Electrical Engineering, University of Malaya, Malaysia.",institutionString:null,institution:{name:"University of Malaya",country:{name:"Malaysia"}}},{id:"41989",title:"Prof.",name:"He",middleName:null,surname:"Tian",slug:"he-tian",fullName:"He Tian",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"East China University of Science and Technology",country:{name:"China"}}},{id:"33351",title:null,name:"Hendra",middleName:null,surname:"Hermawan",slug:"hendra-hermawan",fullName:"Hendra Hermawan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/33351/images/168_n.jpg",biography:null,institutionString:null,institution:{name:"Institut Teknologi Bandung",country:{name:"Indonesia"}}},{id:"11981",title:"Prof.",name:"Hiroshi",middleName:null,surname:"Ishiguro",slug:"hiroshi-ishiguro",fullName:"Hiroshi Ishiguro",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Osaka University",country:{name:"Japan"}}},{id:"45747",title:"Dr.",name:"Hsin-I",middleName:null,surname:"Chang",slug:"hsin-i-chang",fullName:"Hsin-I Chang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"National Chiayi University",country:{name:"Taiwan"}}},{id:"61581",title:"Dr.",name:"Joy Rizki Pangestu",middleName:null,surname:"Djuansjah",slug:"joy-rizki-pangestu-djuansjah",fullName:"Joy Rizki Pangestu Djuansjah",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/61581/images/237_n.jpg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"94249",title:"Prof.",name:"Junji",middleName:null,surname:"Kido",slug:"junji-kido",fullName:"Junji Kido",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Yamagata University",country:{name:"Japan"}}},{id:"12009",title:"Dr.",name:"Ki Young",middleName:null,surname:"Kim",slug:"ki-young-kim",fullName:"Ki Young Kim",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/12009/images/system/12009.jpg",biography:"Http://m80.knu.ac.kr/~doors",institutionString:null,institution:{name:"National Cheng Kung University",country:{name:"Taiwan"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5699},{group:"region",caption:"Middle and South America",value:2,count:5172},{group:"region",caption:"Africa",value:3,count:1689},{group:"region",caption:"Asia",value:4,count:10244},{group:"region",caption:"Australia and Oceania",value:5,count:888},{group:"region",caption:"Europe",value:6,count:15650}],offset:12,limit:12,total:10244},chapterEmbeded:{data:{}},editorApplication:{success:null,errors:{}},ofsBooks:{filterParams:{sort:"dateEndThirdStepPublish",topicId:"24"},books:[{type:"book",id:"10287",title:"Smart Metering Technology",subtitle:null,isOpenForSubmission:!0,hash:"2029b52e42ce6444e122153824296a6f",slug:null,bookSignature:"Mrs. Inderpreet Kaur",coverURL:"https://cdn.intechopen.com/books/images_new/10287.jpg",editedByType:null,editors:[{id:"94572",title:"Mrs.",name:"Inderpreet",surname:"Kaur",slug:"inderpreet-kaur",fullName:"Inderpreet Kaur"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],filtersByTopic:[{group:"topic",caption:"Agricultural and Biological Sciences",value:5,count:9},{group:"topic",caption:"Biochemistry, Genetics and Molecular Biology",value:6,count:16},{group:"topic",caption:"Business, Management and Economics",value:7,count:2},{group:"topic",caption:"Chemistry",value:8,count:6},{group:"topic",caption:"Computer and Information Science",value:9,count:10},{group:"topic",caption:"Earth and Planetary Sciences",value:10,count:4},{group:"topic",caption:"Engineering",value:11,count:15},{group:"topic",caption:"Environmental Sciences",value:12,count:2},{group:"topic",caption:"Immunology and Microbiology",value:13,count:4},{group:"topic",caption:"Materials Science",value:14,count:4},{group:"topic",caption:"Mathematics",value:15,count:1},{group:"topic",caption:"Medicine",value:16,count:56},{group:"topic",caption:"Neuroscience",value:18,count:1},{group:"topic",caption:"Pharmacology, Toxicology and Pharmaceutical Science",value:19,count:6},{group:"topic",caption:"Physics",value:20,count:2},{group:"topic",caption:"Psychology",value:21,count:3},{group:"topic",caption:"Robotics",value:22,count:1},{group:"topic",caption:"Social Sciences",value:23,count:3},{group:"topic",caption:"Technology",value:24,count:1},{group:"topic",caption:"Veterinary Medicine and Science",value:25,count:2}],offset:12,limit:12,total:1},popularBooks:{featuredBooks:[{type:"book",id:"7802",title:"Modern Slavery and Human Trafficking",subtitle:null,isOpenForSubmission:!1,hash:"587a0b7fb765f31cc98de33c6c07c2e0",slug:"modern-slavery-and-human-trafficking",bookSignature:"Jane Reeves",coverURL:"https://cdn.intechopen.com/books/images_new/7802.jpg",editors:[{id:"211328",title:"Prof.",name:"Jane",middleName:null,surname:"Reeves",slug:"jane-reeves",fullName:"Jane Reeves"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8545",title:"Animal Reproduction in Veterinary Medicine",subtitle:null,isOpenForSubmission:!1,hash:"13aaddf5fdbbc78387e77a7da2388bf6",slug:"animal-reproduction-in-veterinary-medicine",bookSignature:"Faruk Aral, Rita Payan-Carreira and Miguel Quaresma",coverURL:"https://cdn.intechopen.com/books/images_new/8545.jpg",editors:[{id:"25600",title:"Prof.",name:"Faruk",middleName:null,surname:"Aral",slug:"faruk-aral",fullName:"Faruk Aral"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9961",title:"Data Mining",subtitle:"Methods, Applications and Systems",isOpenForSubmission:!1,hash:"ed79fb6364f2caf464079f94a0387146",slug:"data-mining-methods-applications-and-systems",bookSignature:"Derya Birant",coverURL:"https://cdn.intechopen.com/books/images_new/9961.jpg",editors:[{id:"15609",title:"Dr.",name:"Derya",middleName:null,surname:"Birant",slug:"derya-birant",fullName:"Derya Birant"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9157",title:"Neurodegenerative Diseases",subtitle:"Molecular Mechanisms and Current Therapeutic Approaches",isOpenForSubmission:!1,hash:"bc8be577966ef88735677d7e1e92ed28",slug:"neurodegenerative-diseases-molecular-mechanisms-and-current-therapeutic-approaches",bookSignature:"Nagehan Ersoy Tunalı",coverURL:"https://cdn.intechopen.com/books/images_new/9157.jpg",editors:[{id:"82778",title:"Ph.D.",name:"Nagehan",middleName:null,surname:"Ersoy Tunalı",slug:"nagehan-ersoy-tunali",fullName:"Nagehan Ersoy Tunalı"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8686",title:"Direct Torque Control Strategies of Electrical Machines",subtitle:null,isOpenForSubmission:!1,hash:"b6ad22b14db2b8450228545d3d4f6b1a",slug:"direct-torque-control-strategies-of-electrical-machines",bookSignature:"Fatma Ben Salem",coverURL:"https://cdn.intechopen.com/books/images_new/8686.jpg",editors:[{id:"295623",title:"Associate Prof.",name:"Fatma",middleName:null,surname:"Ben Salem",slug:"fatma-ben-salem",fullName:"Fatma Ben Salem"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7434",title:"Molecular Biotechnology",subtitle:null,isOpenForSubmission:!1,hash:"eceede809920e1ec7ecadd4691ede2ec",slug:"molecular-biotechnology",bookSignature:"Sergey Sedykh",coverURL:"https://cdn.intechopen.com/books/images_new/7434.jpg",editors:[{id:"178316",title:"Ph.D.",name:"Sergey",middleName:null,surname:"Sedykh",slug:"sergey-sedykh",fullName:"Sergey Sedykh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9839",title:"Outdoor Recreation",subtitle:"Physiological and Psychological Effects on Health",isOpenForSubmission:!1,hash:"5f5a0d64267e32567daffa5b0c6a6972",slug:"outdoor-recreation-physiological-and-psychological-effects-on-health",bookSignature:"Hilde G. Nielsen",coverURL:"https://cdn.intechopen.com/books/images_new/9839.jpg",editors:[{id:"158692",title:"Ph.D.",name:"Hilde G.",middleName:null,surname:"Nielsen",slug:"hilde-g.-nielsen",fullName:"Hilde G. Nielsen"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9208",title:"Welding",subtitle:"Modern Topics",isOpenForSubmission:!1,hash:"7d6be076ccf3a3f8bd2ca52d86d4506b",slug:"welding-modern-topics",bookSignature:"Sadek Crisóstomo Absi Alfaro, Wojciech Borek and Błażej Tomiczek",coverURL:"https://cdn.intechopen.com/books/images_new/9208.jpg",editors:[{id:"65292",title:"Prof.",name:"Sadek Crisostomo Absi",middleName:"C. Absi",surname:"Alfaro",slug:"sadek-crisostomo-absi-alfaro",fullName:"Sadek Crisostomo Absi Alfaro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9139",title:"Topics in Primary Care Medicine",subtitle:null,isOpenForSubmission:!1,hash:"ea774a4d4c1179da92a782e0ae9cde92",slug:"topics-in-primary-care-medicine",bookSignature:"Thomas F. Heston",coverURL:"https://cdn.intechopen.com/books/images_new/9139.jpg",editors:[{id:"217926",title:"Dr.",name:"Thomas F.",middleName:null,surname:"Heston",slug:"thomas-f.-heston",fullName:"Thomas F. Heston"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9343",title:"Trace Metals in the Environment",subtitle:"New Approaches and Recent Advances",isOpenForSubmission:!1,hash:"ae07e345bc2ce1ebbda9f70c5cd12141",slug:"trace-metals-in-the-environment-new-approaches-and-recent-advances",bookSignature:"Mario Alfonso Murillo-Tovar, Hugo Saldarriaga-Noreña and Agnieszka Saeid",coverURL:"https://cdn.intechopen.com/books/images_new/9343.jpg",editors:[{id:"255959",title:"Dr.",name:"Mario Alfonso",middleName:null,surname:"Murillo-Tovar",slug:"mario-alfonso-murillo-tovar",fullName:"Mario Alfonso Murillo-Tovar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8697",title:"Virtual Reality and Its Application in Education",subtitle:null,isOpenForSubmission:!1,hash:"ee01b5e387ba0062c6b0d1e9227bda05",slug:"virtual-reality-and-its-application-in-education",bookSignature:"Dragan Cvetković",coverURL:"https://cdn.intechopen.com/books/images_new/8697.jpg",editors:[{id:"101330",title:"Dr.",name:"Dragan",middleName:"Mladen",surname:"Cvetković",slug:"dragan-cvetkovic",fullName:"Dragan Cvetković"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7831",title:"Sustainability in Urban Planning and Design",subtitle:null,isOpenForSubmission:!1,hash:"c924420492c8c2c9751e178d025f4066",slug:"sustainability-in-urban-planning-and-design",bookSignature:"Amjad Almusaed, Asaad Almssad and Linh Truong - Hong",coverURL:"https://cdn.intechopen.com/books/images_new/7831.jpg",editors:[{id:"110471",title:"Dr.",name:"Amjad",middleName:"Zaki",surname:"Almusaed",slug:"amjad-almusaed",fullName:"Amjad Almusaed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:12,limit:12,total:5143},hotBookTopics:{hotBooks:[],offset:0,limit:12,total:null},publish:{},publishingProposal:{success:null,errors:{}},books:{featuredBooks:[{type:"book",id:"9208",title:"Welding",subtitle:"Modern Topics",isOpenForSubmission:!1,hash:"7d6be076ccf3a3f8bd2ca52d86d4506b",slug:"welding-modern-topics",bookSignature:"Sadek Crisóstomo Absi Alfaro, Wojciech Borek and Błażej Tomiczek",coverURL:"https://cdn.intechopen.com/books/images_new/9208.jpg",editors:[{id:"65292",title:"Prof.",name:"Sadek Crisostomo Absi",middleName:"C. Absi",surname:"Alfaro",slug:"sadek-crisostomo-absi-alfaro",fullName:"Sadek Crisostomo Absi Alfaro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9139",title:"Topics in Primary Care Medicine",subtitle:null,isOpenForSubmission:!1,hash:"ea774a4d4c1179da92a782e0ae9cde92",slug:"topics-in-primary-care-medicine",bookSignature:"Thomas F. Heston",coverURL:"https://cdn.intechopen.com/books/images_new/9139.jpg",editors:[{id:"217926",title:"Dr.",name:"Thomas F.",middleName:null,surname:"Heston",slug:"thomas-f.-heston",fullName:"Thomas F. Heston"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8697",title:"Virtual Reality and Its Application in Education",subtitle:null,isOpenForSubmission:!1,hash:"ee01b5e387ba0062c6b0d1e9227bda05",slug:"virtual-reality-and-its-application-in-education",bookSignature:"Dragan Cvetković",coverURL:"https://cdn.intechopen.com/books/images_new/8697.jpg",editors:[{id:"101330",title:"Dr.",name:"Dragan",middleName:"Mladen",surname:"Cvetković",slug:"dragan-cvetkovic",fullName:"Dragan Cvetković"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9343",title:"Trace Metals in the Environment",subtitle:"New Approaches and Recent Advances",isOpenForSubmission:!1,hash:"ae07e345bc2ce1ebbda9f70c5cd12141",slug:"trace-metals-in-the-environment-new-approaches-and-recent-advances",bookSignature:"Mario Alfonso Murillo-Tovar, Hugo Saldarriaga-Noreña and Agnieszka Saeid",coverURL:"https://cdn.intechopen.com/books/images_new/9343.jpg",editors:[{id:"255959",title:"Dr.",name:"Mario Alfonso",middleName:null,surname:"Murillo-Tovar",slug:"mario-alfonso-murillo-tovar",fullName:"Mario Alfonso Murillo-Tovar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9785",title:"Endometriosis",subtitle:null,isOpenForSubmission:!1,hash:"f457ca61f29cf7e8bc191732c50bb0ce",slug:"endometriosis",bookSignature:"Courtney Marsh",coverURL:"https://cdn.intechopen.com/books/images_new/9785.jpg",editors:[{id:"255491",title:"Dr.",name:"Courtney",middleName:null,surname:"Marsh",slug:"courtney-marsh",fullName:"Courtney Marsh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7831",title:"Sustainability in Urban Planning and Design",subtitle:null,isOpenForSubmission:!1,hash:"c924420492c8c2c9751e178d025f4066",slug:"sustainability-in-urban-planning-and-design",bookSignature:"Amjad Almusaed, Asaad Almssad and Linh Truong - Hong",coverURL:"https://cdn.intechopen.com/books/images_new/7831.jpg",editors:[{id:"110471",title:"Dr.",name:"Amjad",middleName:"Zaki",surname:"Almusaed",slug:"amjad-almusaed",fullName:"Amjad Almusaed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9376",title:"Contemporary Developments and Perspectives in International Health Security",subtitle:"Volume 1",isOpenForSubmission:!1,hash:"b9a00b84cd04aae458fb1d6c65795601",slug:"contemporary-developments-and-perspectives-in-international-health-security-volume-1",bookSignature:"Stanislaw P. Stawicki, Michael S. Firstenberg, Sagar C. Galwankar, Ricardo Izurieta and Thomas Papadimos",coverURL:"https://cdn.intechopen.com/books/images_new/9376.jpg",editors:[{id:"181694",title:"Dr.",name:"Stanislaw P.",middleName:null,surname:"Stawicki",slug:"stanislaw-p.-stawicki",fullName:"Stanislaw P. Stawicki"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7769",title:"Medical Isotopes",subtitle:null,isOpenForSubmission:!1,hash:"f8d3c5a6c9a42398e56b4e82264753f7",slug:"medical-isotopes",bookSignature:"Syed Ali Raza Naqvi and Muhammad Babar Imrani",coverURL:"https://cdn.intechopen.com/books/images_new/7769.jpg",editors:[{id:"259190",title:"Dr.",name:"Syed Ali Raza",middleName:null,surname:"Naqvi",slug:"syed-ali-raza-naqvi",fullName:"Syed Ali Raza Naqvi"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9279",title:"Concepts, Applications and Emerging Opportunities in Industrial Engineering",subtitle:null,isOpenForSubmission:!1,hash:"9bfa87f9b627a5468b7c1e30b0eea07a",slug:"concepts-applications-and-emerging-opportunities-in-industrial-engineering",bookSignature:"Gary Moynihan",coverURL:"https://cdn.intechopen.com/books/images_new/9279.jpg",editors:[{id:"16974",title:"Dr.",name:"Gary",middleName:null,surname:"Moynihan",slug:"gary-moynihan",fullName:"Gary Moynihan"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7807",title:"A Closer Look at Organizational Culture in Action",subtitle:null,isOpenForSubmission:!1,hash:"05c608b9271cc2bc711f4b28748b247b",slug:"a-closer-look-at-organizational-culture-in-action",bookSignature:"Süleyman Davut Göker",coverURL:"https://cdn.intechopen.com/books/images_new/7807.jpg",editors:[{id:"190035",title:"Associate Prof.",name:"Süleyman Davut",middleName:null,surname:"Göker",slug:"suleyman-davut-goker",fullName:"Süleyman Davut Göker"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],latestBooks:[{type:"book",id:"7434",title:"Molecular Biotechnology",subtitle:null,isOpenForSubmission:!1,hash:"eceede809920e1ec7ecadd4691ede2ec",slug:"molecular-biotechnology",bookSignature:"Sergey Sedykh",coverURL:"https://cdn.intechopen.com/books/images_new/7434.jpg",editedByType:"Edited by",editors:[{id:"178316",title:"Ph.D.",name:"Sergey",middleName:null,surname:"Sedykh",slug:"sergey-sedykh",fullName:"Sergey Sedykh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8545",title:"Animal Reproduction in Veterinary Medicine",subtitle:null,isOpenForSubmission:!1,hash:"13aaddf5fdbbc78387e77a7da2388bf6",slug:"animal-reproduction-in-veterinary-medicine",bookSignature:"Faruk Aral, Rita Payan-Carreira and Miguel Quaresma",coverURL:"https://cdn.intechopen.com/books/images_new/8545.jpg",editedByType:"Edited by",editors:[{id:"25600",title:"Prof.",name:"Faruk",middleName:null,surname:"Aral",slug:"faruk-aral",fullName:"Faruk Aral"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9569",title:"Methods in Molecular Medicine",subtitle:null,isOpenForSubmission:!1,hash:"691d3f3c4ac25a8093414e9b270d2843",slug:"methods-in-molecular-medicine",bookSignature:"Yusuf Tutar",coverURL:"https://cdn.intechopen.com/books/images_new/9569.jpg",editedByType:"Edited by",editors:[{id:"158492",title:"Prof.",name:"Yusuf",middleName:null,surname:"Tutar",slug:"yusuf-tutar",fullName:"Yusuf Tutar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9839",title:"Outdoor Recreation",subtitle:"Physiological and Psychological Effects on Health",isOpenForSubmission:!1,hash:"5f5a0d64267e32567daffa5b0c6a6972",slug:"outdoor-recreation-physiological-and-psychological-effects-on-health",bookSignature:"Hilde G. Nielsen",coverURL:"https://cdn.intechopen.com/books/images_new/9839.jpg",editedByType:"Edited by",editors:[{id:"158692",title:"Ph.D.",name:"Hilde G.",middleName:null,surname:"Nielsen",slug:"hilde-g.-nielsen",fullName:"Hilde G. Nielsen"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7802",title:"Modern Slavery and Human Trafficking",subtitle:null,isOpenForSubmission:!1,hash:"587a0b7fb765f31cc98de33c6c07c2e0",slug:"modern-slavery-and-human-trafficking",bookSignature:"Jane Reeves",coverURL:"https://cdn.intechopen.com/books/images_new/7802.jpg",editedByType:"Edited by",editors:[{id:"211328",title:"Prof.",name:"Jane",middleName:null,surname:"Reeves",slug:"jane-reeves",fullName:"Jane Reeves"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8063",title:"Food Security in Africa",subtitle:null,isOpenForSubmission:!1,hash:"8cbf3d662b104d19db2efc9d59249efc",slug:"food-security-in-africa",bookSignature:"Barakat Mahmoud",coverURL:"https://cdn.intechopen.com/books/images_new/8063.jpg",editedByType:"Edited by",editors:[{id:"92016",title:"Dr.",name:"Barakat",middleName:null,surname:"Mahmoud",slug:"barakat-mahmoud",fullName:"Barakat Mahmoud"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10118",title:"Plant Stress Physiology",subtitle:null,isOpenForSubmission:!1,hash:"c68b09d2d2634fc719ae3b9a64a27839",slug:"plant-stress-physiology",bookSignature:"Akbar Hossain",coverURL:"https://cdn.intechopen.com/books/images_new/10118.jpg",editedByType:"Edited by",editors:[{id:"280755",title:"Dr.",name:"Akbar",middleName:null,surname:"Hossain",slug:"akbar-hossain",fullName:"Akbar Hossain"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9157",title:"Neurodegenerative Diseases",subtitle:"Molecular Mechanisms and Current Therapeutic Approaches",isOpenForSubmission:!1,hash:"bc8be577966ef88735677d7e1e92ed28",slug:"neurodegenerative-diseases-molecular-mechanisms-and-current-therapeutic-approaches",bookSignature:"Nagehan Ersoy Tunalı",coverURL:"https://cdn.intechopen.com/books/images_new/9157.jpg",editedByType:"Edited by",editors:[{id:"82778",title:"Ph.D.",name:"Nagehan",middleName:null,surname:"Ersoy Tunalı",slug:"nagehan-ersoy-tunali",fullName:"Nagehan Ersoy Tunalı"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9961",title:"Data Mining",subtitle:"Methods, Applications and Systems",isOpenForSubmission:!1,hash:"ed79fb6364f2caf464079f94a0387146",slug:"data-mining-methods-applications-and-systems",bookSignature:"Derya Birant",coverURL:"https://cdn.intechopen.com/books/images_new/9961.jpg",editedByType:"Edited by",editors:[{id:"15609",title:"Dr.",name:"Derya",middleName:null,surname:"Birant",slug:"derya-birant",fullName:"Derya Birant"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8686",title:"Direct Torque Control Strategies of Electrical Machines",subtitle:null,isOpenForSubmission:!1,hash:"b6ad22b14db2b8450228545d3d4f6b1a",slug:"direct-torque-control-strategies-of-electrical-machines",bookSignature:"Fatma Ben Salem",coverURL:"https://cdn.intechopen.com/books/images_new/8686.jpg",editedByType:"Edited by",editors:[{id:"295623",title:"Associate Prof.",name:"Fatma",middleName:null,surname:"Ben Salem",slug:"fatma-ben-salem",fullName:"Fatma Ben Salem"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"1007",title:"Prenatal Diagnosis",slug:"prenatal-diagnosis",parent:{title:"Diagnostics",slug:"diagnostics"},numberOfBooks:1,numberOfAuthorsAndEditors:22,numberOfWosCitations:3,numberOfCrossrefCitations:2,numberOfDimensionsCitations:6,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicSlug:"prenatal-diagnosis",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"775",title:"Prenatal Diagnosis",subtitle:"Morphology Scan and Invasive Methods",isOpenForSubmission:!1,hash:"8a319bf0e3730c8caea504b894f71057",slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",bookSignature:"Richard Kwong Wai Choy and Tak Yeung Leung",coverURL:"https://cdn.intechopen.com/books/images_new/775.jpg",editedByType:"Edited by",editors:[{id:"83826",title:"Dr.",name:"Richard",middleName:null,surname:"Choy",slug:"richard-choy",fullName:"Richard Choy"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:1,mostCitedChapters:[{id:"37632",doi:"10.5772/29702",title:"Invasive Prenatal Diagnosis",slug:"invasive-prenatal-diagnosis",totalDownloads:2564,totalCrossrefCites:1,totalDimensionsCites:2,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Sonja Pop-Trajković, Vladimir Antić and Vesna Kopitović",authors:[{id:"69225",title:"Dr.",name:"Sonja",middleName:null,surname:"Pop-Trajkovic",slug:"sonja-pop-trajkovic",fullName:"Sonja Pop-Trajkovic"}]},{id:"37627",doi:"10.5772/26960",title:"Real-Time Quantitative PCR for Detection Cell Free Fetal DNA",slug:"real-time-quantitative-pcr-for-detection-cell-free-fetal-dna",totalDownloads:3403,totalCrossrefCites:0,totalDimensionsCites:1,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Tuba Gunel, Hayri Ermis and Kilic Aydinli",authors:[{id:"68399",title:"Dr.",name:"Tuba",middleName:null,surname:"Gunel",slug:"tuba-gunel",fullName:"Tuba Gunel"},{id:"123657",title:"Prof.",name:"Hayri",middleName:null,surname:"Ermis",slug:"hayri-ermis",fullName:"Hayri Ermis"},{id:"123662",title:"Prof.",name:"Kılıc",middleName:null,surname:"Aydınlı",slug:"kilic-aydinli",fullName:"Kılıc Aydınlı"}]},{id:"37628",doi:"10.5772/30590",title:"Prenatal Evaluation of Fetuses Presenting with Short Femurs",slug:"prenatal-evaluation-of-fetuses-presenting-with-short-femurs",totalDownloads:45795,totalCrossrefCites:0,totalDimensionsCites:1,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Funda Gungor Ugurlucan, Hülya Kayserili and Atil Yuksel",authors:[{id:"83201",title:"Dr.",name:"Funda",middleName:null,surname:"Gungor Ugurlucan",slug:"funda-gungor-ugurlucan",fullName:"Funda Gungor Ugurlucan"},{id:"83223",title:"Prof.",name:"Atil",middleName:null,surname:"Yuksel",slug:"atil-yuksel",fullName:"Atil Yuksel"},{id:"146115",title:"Prof.",name:"Hulya",middleName:null,surname:"Kayserili",slug:"hulya-kayserili",fullName:"Hulya Kayserili"}]}],mostDownloadedChaptersLast30Days:[{id:"37630",title:"Fetal Therapy: Where Do We Stand",slug:"fetal-therapy",totalDownloads:2618,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Sebastian Illanes and Javier Caradeux",authors:[{id:"82625",title:"Dr.",name:"Sebastián",middleName:null,surname:"Illanes",slug:"sebastian-illanes",fullName:"Sebastián Illanes"},{id:"121286",title:"Dr.",name:"Javier",middleName:null,surname:"Caradeux",slug:"javier-caradeux",fullName:"Javier Caradeux"}]},{id:"37626",title:"Normal and Abnormal Fetal Face",slug:"normal-and-abnormal-fetal-face",totalDownloads:36769,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Israel Goldstein and Zeev Wiener",authors:[{id:"116911",title:"Dr.",name:"Israel",middleName:null,surname:"Goldstein",slug:"israel-goldstein",fullName:"Israel Goldstein"}]},{id:"37628",title:"Prenatal Evaluation of Fetuses Presenting with Short Femurs",slug:"prenatal-evaluation-of-fetuses-presenting-with-short-femurs",totalDownloads:45795,totalCrossrefCites:0,totalDimensionsCites:1,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Funda Gungor Ugurlucan, Hülya Kayserili and Atil Yuksel",authors:[{id:"83201",title:"Dr.",name:"Funda",middleName:null,surname:"Gungor Ugurlucan",slug:"funda-gungor-ugurlucan",fullName:"Funda Gungor Ugurlucan"},{id:"83223",title:"Prof.",name:"Atil",middleName:null,surname:"Yuksel",slug:"atil-yuksel",fullName:"Atil Yuksel"},{id:"146115",title:"Prof.",name:"Hulya",middleName:null,surname:"Kayserili",slug:"hulya-kayserili",fullName:"Hulya Kayserili"}]},{id:"37632",title:"Invasive Prenatal Diagnosis",slug:"invasive-prenatal-diagnosis",totalDownloads:2564,totalCrossrefCites:1,totalDimensionsCites:2,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Sonja Pop-Trajković, Vladimir Antić and Vesna Kopitović",authors:[{id:"69225",title:"Dr.",name:"Sonja",middleName:null,surname:"Pop-Trajkovic",slug:"sonja-pop-trajkovic",fullName:"Sonja Pop-Trajkovic"}]},{id:"37634",title:"Prenatal Diagnosis of Severe Perinatal (Lethal) Hypophosphatasia",slug:"prenatal-diagnosis-for-severe-perinatal-lethal-form-of-hypophosphatasia",totalDownloads:1866,totalCrossrefCites:0,totalDimensionsCites:1,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Atsushi Watanabe, Hideo Orimo, Toshiyuki Takeshita and Takashi Shimada",authors:[{id:"70999",title:"Dr.",name:"Atsushi",middleName:null,surname:"Watanabe",slug:"atsushi-watanabe",fullName:"Atsushi Watanabe"}]},{id:"37629",title:"The Experiences of Prenatal Diagnosis in China",slug:"the-experienes-of-prenatal-diagnosis-in-china",totalDownloads:1584,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Shangzhi Huang",authors:[{id:"70878",title:"Dr.",name:"Shangzhi",middleName:null,surname:"Huang",slug:"shangzhi-huang",fullName:"Shangzhi Huang"}]},{id:"37631",title:"Skeletal Dysplasias of the Human Fetus: Postmortem Diagnosis",slug:"skeletal-dysplasias-of-the-human-fetus-postmortem-diagnosis",totalDownloads:3249,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Anastasia Konstantinidou",authors:[{id:"71523",title:"Prof.",name:"Anastasia",middleName:null,surname:"Konstantinidou",slug:"anastasia-konstantinidou",fullName:"Anastasia Konstantinidou"}]},{id:"37633",title:"Understanding Prenatal Iodine Deficiency",slug:"understanding-prenatal-iodine-deficiency",totalDownloads:1723,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Inés Velasco, Federico Soriguer and P. Pere Berbel",authors:[{id:"67516",title:"Dr.",name:"Inés",middleName:null,surname:"Velasco",slug:"ines-velasco",fullName:"Inés Velasco"},{id:"131051",title:"Dr.",name:"Federico",middleName:null,surname:"Soriguer",slug:"federico-soriguer",fullName:"Federico Soriguer"},{id:"131052",title:"Prof.",name:"Pere",middleName:null,surname:"Berbel",slug:"pere-berbel",fullName:"Pere Berbel"}]},{id:"37625",title:"Current Issues Regarding Prenatal Diagnosis of Inborn Errors of Cholesterol Biosynthesis",slug:"current-issues-regarding-prenatal-diagnosis-of-inborn-errors-of-cholesterol-biosynthesis",totalDownloads:1370,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Maria Luís Cardoso, Mafalda Barbosa, Ana Maria Fortuna and Franklim Marques",authors:[{id:"70712",title:"Ph.D.",name:"Maria Luis",middleName:null,surname:"Cardoso",slug:"maria-luis-cardoso",fullName:"Maria Luis Cardoso"},{id:"78605",title:"Dr.",name:"Mafalda",middleName:null,surname:"Barbosa",slug:"mafalda-barbosa",fullName:"Mafalda Barbosa"},{id:"78608",title:"Dr",name:"Ana Maria",middleName:null,surname:"Fortuna",slug:"ana-maria-fortuna",fullName:"Ana Maria Fortuna"},{id:"78609",title:"Prof.",name:"Franklim",middleName:null,surname:"Marques",slug:"franklim-marques",fullName:"Franklim Marques"}]},{id:"37627",title:"Real-Time Quantitative PCR for Detection Cell Free Fetal DNA",slug:"real-time-quantitative-pcr-for-detection-cell-free-fetal-dna",totalDownloads:3403,totalCrossrefCites:0,totalDimensionsCites:1,book:{slug:"prenatal-diagnosis-morphology-scan-and-invasive-methods",title:"Prenatal Diagnosis",fullTitle:"Prenatal Diagnosis - Morphology Scan and Invasive Methods"},signatures:"Tuba Gunel, Hayri Ermis and Kilic Aydinli",authors:[{id:"68399",title:"Dr.",name:"Tuba",middleName:null,surname:"Gunel",slug:"tuba-gunel",fullName:"Tuba Gunel"},{id:"123657",title:"Prof.",name:"Hayri",middleName:null,surname:"Ermis",slug:"hayri-ermis",fullName:"Hayri Ermis"},{id:"123662",title:"Prof.",name:"Kılıc",middleName:null,surname:"Aydınlı",slug:"kilic-aydinli",fullName:"Kılıc Aydınlı"}]}],onlineFirstChaptersFilter:{topicSlug:"prenatal-diagnosis",limit:3,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[{type:"book",id:"10176",title:"Microgrids and Local Energy Systems",subtitle:null,isOpenForSubmission:!0,hash:"c32b4a5351a88f263074b0d0ca813a9c",slug:null,bookSignature:"Prof. Nick Jenkins",coverURL:"https://cdn.intechopen.com/books/images_new/10176.jpg",editedByType:null,editors:[{id:"55219",title:"Prof.",name:"Nick",middleName:null,surname:"Jenkins",slug:"nick-jenkins",fullName:"Nick Jenkins"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:8,limit:8,total:1},route:{name:"profile.detail",path:"/profiles/185252/lazar-ranin",hash:"",query:{},params:{id:"185252",slug:"lazar-ranin"},fullPath:"/profiles/185252/lazar-ranin",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var t;(t=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(t)}()