\r\n\tAbout 25 percent of all foods produced globally are lost due to microbial growth. L. monocytogenes is a microorganism ubiquitously present in the environment and affects animals and humans. L. monocytogenes can enter a factory and is able to survive in biofilms in the food processing environment. The use of adequate sanitation procedures is a prerequisite in risk prevention. Moreover, effective control measures for L. monocytogenes are very important to food operators.
\r\n\r\n\tThe safety and shelf life maximizing of food products to meet the demand of retailers and consumers is a challenge and a concern of food operators.
\r\n\r\n\tTo obtain food systems more sustainable, several developments are ongoing to ensure safe food products with an extended shelf life and a reduction of food loss and waste. The problem of antimicrobial resistance is also a great issue that must be taken into consideration.
\r\n\r\n\tThe implementation of natural antimicrobials, using food cultures, ferments, or bacteriophages, is one approach to control L. monocytogenes in food products that meet the consumer preference for clean label solutions.
\r\n\tThis book intends to provide the reader with a comprehensive overview of the current state-of-the-art about Listeria monocytogenes in terms of occurrence in humans, animals, and food-producing plants. Its control by more natural agents allows for more sustainable food systems and points future directions to transform challenges into opportunities.
The strength and breadth of nuclear cardiology lie in its great potential for future creative growth. This growth involves the development of new biologically derived radiopharmaceuticals, avdanced imaging techologies, and a broad/based set of research and clinical aplications involving diagnosis, functional categorization, prognosis, evaluation of therapeutic interventions, and the ability to deal with many of the major investigative issues in contemporary cardiology such as myocardial hibernation, stunning, and viability. The past decade has been caracteriyed by major advances in nuclear cardiology that have greatly enhanced the clinical utility of the various radionuclide techniques used for the assessment of regional myocardial perfusion and regional and global left ventricular function under resting and stress condotions. Despite the emergence of alternative noninvasive techniques for the diagnosis of coronary aretry disease (CAD) and the assessment of prognosis of viability, such as ergo- stress tests, stress echocardiography, the use and application of nuclear cardiology techniques have continued to increase. The establishment of the American Society of Nuclear Cardiology (ASNC) and its educational programs has led to a greater diffusion on nuclear cardiology technology in the community hospital setings and has promoted the emergence and dissemination of imaging and procedural guidelines for nuclear cardiology methods. The establishment of the Journal of Nuclear Cardiology, the official journal of ASNC, allowed a greater number of manuscript to be published in the field [1, 2, 3]
\nIn the few past decade, significant advances have been made in the ability to image the heart with radionuclide tracers under stress and resting conditions in patientse with suspected or known coronary aretry disease (CAD) for the detection of ischemia, determination of prognosis, assessment of myocardial viability, preoperative risk assessment for patients undergoing noncardiac surgery, mand evaluation of the efficacy of revasculariyation in patients undergoing coronary artery bypass surgery or an interventional procedure [1, 2, 3].
\nFor many years, planar imaging and SPECT with 201Tl (201 Talium) constituted the only scintigrafic techniques available for detecting CAD and assessing prognosis in patients undergoing stress perfusion imaging. The major limitation of 201Tl scintigraphy is the high false/positive rate observed in many laboratories, wich is attributed predominantly to image attenuation aretfact and variants of normal that are interpreted as defects consequent to a significant coronary artery stenoses. Although quantification of 201Tl images improves specificity, the false/positive rate remains problematic, particulary in the women and in obese patients. Breast attenuation artifact in women are sometimes difficult to distiguish from perfusion abnormalities secondary to inducible ischemia or myocardial scar.
\nIn recent years, new 99mTc (technetium) labeled perfusion agents have been introduced into clinical practice to enhance the specificity of Single Photon Emission Cumputed Tomography (SPECT) and to provide additional information regarding and global left ventricular systolic function via ECG gating of images [3, 4, 8]. It was immadiately apparent that the quality of images obtained with these 99mTc-labeled radionuclides was superior to that images obtained with 201Tl because of the more favorable psysical characteristic of 99mTc imaging with gamma camera. Perhaps most importantly, 99mTc imaging allows easy gated acqusition, permiting simulateous evaluation of regional systolic thickening, global left ventricular function (LVEF), and myocardial perfusion. One the most significant avdances in myocardial perfusion imaging in the past decade is the development of quantitative SPECT perfusion imaging. Radionuclide imaging is an intrinsically digital technique that is ideally suited for quantification. A number of validated software packages are commercially available for quantification of SPECT myocardial perfusion and function (Auto Quant; Emory Toolbox; 4D/MSPECT; and Wackers Liu CQ), and are carried by the major vendors of nuclear medicine imaging equipment. The basic principles of SPECTR quantification are similar for each of these software packages. Each commercially available package also includes software for computation of LVEF and left ventricular volumes from ECG-gated SPECT images [7, 9, 10, 11].
\nCAD is still the single greatest cause of death of men and women in the world, despite a declining total death rate. Using USA data over 459.000 deaths were due to CAD -1 of every deaths. There are aproximatelly 2.2 million hospital discharges with CAD as the diagnosis annually.
\nThe reduction of the morbidity and mortality due to CAD is thus primary importance to physicians and patients. Stress myocardial perfusion imaging (MPI) has emerged as an important noninvasive means of evaluating patients with suspected CAD, with over than 10 millions studies performed in USA annually [1, 2, 16, 17, 18].
\n\n
The first step in evaluating patients for CAD involves the assessment of the presence of traditional risk factors. Modifiable risks include hypercholesterolemia, hypertension, diabetes mellitus, obesity, tobacco use, and physical inactivity. Nonmodifiable risk factor includes a family history of CAD in first-degree relatives under the age of 60, advanced age, and gender? Once risk factors associated with CAD are evaluated, a patient\'s risk for having CAD should be assessed. This is often performed by taking symptoms such as a chest pain, age, and gender into account. Symptoms suggestive of CAD, in addition to other risk factors, drive decisions for further testing [2, 12, 17, 18].
\nA cornerstone of the diagnosis of CAD has been exercise tolerance testing (ETT). The ETT is the safe and easily performed, usually in an office setting. But generally, ETT electrocardiography (ECG) has a sensitivity of 50 to 70%, and a specificity of 60 to 80%.
\nThus, the major limitation of the ETT is its diagnostic accuracy for the detection of significant CAD. In patients able to exercise, the diagnostic accuracy of stress myocardial perfusion imaging (MPI) is significantly higher than the ETT alone and provides greater risk stratification for predicting the future cardiac events.
\nDiagnostic accuracy of various tests of CAD
Because of limitation to performed exercise test (patients with medical illness, debilitation, musculoskeletal problems, and the older who can’t reach a predicted maximum heart rate) MPI with pharmacologic stress using vasodilators (dipyridamole, and adenosine) or dobutamine can be implemented in such patients. In this moment, it has been estimated that 48% to 50% of all stress MPI is performed with pharmacologic agent. Briefly, dipyridamole and adenosine are potent coronary vasodilators that markedly increase coronary blood flow. This increased flow is less pronounced in arteries that are stenotic (flow restricted) due to atherosclerosis. This causes heterogeneous myocardial perfusion, which can be observed using that follows coronary blood flow as an alternative to vasodilator stress. Dobutamine works by increasing myocardial oxygen demand (through increased heart rate, systolic blood pressure, and myocardial contractility) [5, 6, 7, 8, 9]. As in exercise MPI scintigraphic images obtained at rest compared to those obtained during peak pharmacologic stress to distinguish myocardial ischemia from scar tissue (infarct area).
\nThe diagnostic accuracy of Tc-99m imaging with pharmacologic stress test for angiographically significant CAD has been evaluated in numerous study.
\nDiagnostic accuracy of stress myocardial perfusion imaging.
One of the most powerfull uses of MPI is the evaluation of the risk for future events in patients with suspected or known CAD. Over the years, MPI has evolved as an essential tool in the evaluation and assessment of patient prior to coronary revascularization. It has a dual role. Prior to coronary angiography, MPI is extremly useful in documeting ischemia and determining the functional impact of single or multiple lesions indentified subsequently. After coronary anatomy is known, and despite some limitations in the setting of multivessel disease, MPI remains the test of choise for indentifying the lesion responsible for the ischemic symptoms, or so colled culprit lesion. That is extremly useful for futher management decisions with respect to percutaneous interventions. In compare, the absence of reversible ischemia in patients with known CAD is an excellent prognostic marker and predicts a low annual event rate.
\nThe current definition of culprit lesion that is zone of ischemia under the coronary stenoses is not quite wright, because that is not definy two pathophysiologic aspects of ischemia; severity and extent. The primary objective of those study was to determinate and localizes culprit lesion by newly introduce parameters SRS (
In the past two decades, a great body of literature has established the use of nuclear imaging for risk stratification in patients with known or suspected coronary artery disease (CAD). Risk stratification is of crucial importance for the practice of contemporary medicine. Extending the paradigm of noninvasive cardiac testing beyond the detection of disease is especially important, may risk assessment permits patients who are identified as being at a high risk for subsequent cardiac events should receive aggressive management, possibly including cardiac catheterization for potential revascularization procedures that may improve their outcome. CAD is disease with a wide spectrum of severity and extent with outcome, such as nonfatal myocardial infarction (MI) or cardiac death being related to the severity of disease. Clinical trials have shown that patients with severe CAD as left main coronary artery disease, especially those with left ventricular dysfunction, can benefit from coronary artery bypass graft surgery (CABG) with significant reduction in their mortality rate. Whereas patients with single-vessel or with two-vessel disease (without proximal left anterior descending artery involvement) would have improved symptoms of angina following CABG and percutaneous transluminal coronary angioplasty with or without stent implantation, without any effect on their mortality rate.
\nCoronary angiography, considered the “gold standard” for the diagnosis of CAD, often does not provide information about the physiologic significance of atherosclerotic lesions, especially in borderline lesions. More importantly, it does not provide a clear marker of risk of adverse events, especially in patients with moderate disease severity. Andreas Gruentzig said; “
The presence of normal scintigraphic MPI study at a high level of stress (≥ 85 % of maximum predicted heart rate) or proper pharmacologic stress carries a very benign prognosis, with mortality rate less than 0.5% per year. This finding has been reproduced in many studies. Iskander and Iskandiran, pooling the results of SPECT imaging from more than 12000 patients in 14 studies, demonstrated that the events rate (death/MI) for patients with normal MPI finding is 0.6%, whereas abnormal study carries 7.4% per year event rate, a 12-fold increase [2, 3, 14, 18]..
\nThe current definition of culprit lesion; that is zone of ischemia under the coronary stenoses (what degree? That is not definition. Some autors ofer degree of stenoses ≤ 70 %, some ≤ 75%, even < 80-85% ) is not quite wright, because that is not definy two pathophysiologic aspects of ischemia; severity and extent. Iskander and Iskadrian have also shown that defects reversibility is an important predictor of type of cardiac events, whereas reversible perfusion defects are associated with nonfatal MI. This is very important finding, since a reversible defect on MPI imaging is the only available diagnostic tool that can independently predict the risk of nonfatal MI. Therefore, stress perfusion studies should be reported documenting defect severity (mild, moderate, severe), size (small, moderate, large) and reversibility to provide essential risk stratification.[2, 3, 16].
\nThe size and severity of the perfusion abnormality provide powerful prognostic information and has been shown to directly relate to outcome. MPI perfusion imaging and determination of culprit lesion is more predicitble of cardiac events than coronary angiography. As MPI imaging may identify those patients at high risk for subsequent cardiac events, perfusion imaging may be used to help guide further testing and revascularization procedures, and this obviously has important cost-effectiveness ramifications.
\nThe primary objective of this study was to determinate and localizes culprit lesion by newly introduce parameters SRS (
The rapid rates of technical advances and improved operator expertise have enabled this technique to gain more widespread application. Despite the large number of PTCA-s performed yearly, preprocedure documentation of myocardial ischemia is uncommon, occurring in only 29% of patients.
\nMyocardial perfusion imaging provides information on the extent and location of myocardial ischemia. The assessment of jeopardized myocardium may be performed and provides a measure of the relative value of PTCA in terms of the amount of jeopardized myocardium. The location of the stenosis may dictate the area at risk: extent and severity of perfusion defects were significantly smaller in patients with proximal compared with distal coronary artery occlusions.
\nBefore revascularization is performed, myocardial perfusion imaging may assist in management decisions by demonstrating the presence of myocardial ischemia, viability and delineating the severity and extent of coronary artery disease. The significance of equivocal lesions may be determined and culprit vessel may be successfully defined by SPECT imaging before angioplasty [2, 3, 10, 18].
\nThe coronary angiography provides information on the anatomical state of the coronary tree and, specifically, on the large epicardial arteries, while perfusion SPECT facilitates the evaluation of the grade of ischemia that a particular stenosis produces. MPI SPECT is of considerable use in the procedural indications of partial revascularization in patients with chronic coronary artery disease (CAD). In these cases the purpose is to detect the coronary stenosis that provokes the ischemia and is termed the "culprit lesion".
\nThe aim of the study Baskot at all. [2] was to determine and localize culprit lesion by MPI in cases of angiographically detected coronary narrowing ≥ 75% of at least one coronary artery.
\nIn the study four hundred and thirty-seven [437] patients were studied. In all of them angiographically detected significant coronary narrowing (≥ 75% luminal stenosis) before PCI. All the patients were submitted to MPI 99mTc-MIBI, with pharmacologic dipyridamole stress protocol with concomitant low level bicycle exercise 50 W (DipyEX). We measured relative uptake 99mTc-MIBI for each myocardial segment using short-axis tomogram study. A 5-point scoring system was used to assess the difference between uptake degree in stress and rest studies for the same segment, and we created two indices: Sum reversible score (SRS), Index of sum reversibility score (ISRS). In the results a total 1311 vascular territories (7429 segments) were analyzed before elective percutaneous coronary intervention (ePCI). Overall sensitivity, specificity and accuracy using SRS were 89.7%, 86, 7%, and 88, 2%, with a positive predictive value of 92, 7%. Overall sensitivity, specificity and accuracy using ISRS were 92.8%, 89.1%, and 92.3%, and the positive predictive value was 93.7%. Conclusion this work that is DipyEX MPI with two indices created SRS and ISRS significantly improves sensitivity, specificity and accuracy in the determination and localization of culprit lesion in patients undergoing elective PCI. In this work author defined culprit lesion using two physiological aspects; severity of ischemia and extension zone of ischemia. With quantification of these two parameters of culprit lesion, the author determined patients who underwent ePCI with stent implantation, and who had the best therapy effects with PCI therapy.
\n\n
Figure showed culprit lesion in the inferolateral segments in the AdenoEx (up line slices) MPI study
Nearly after elective PCI intervention we performed MPI with normal finding of perfusion
\n
Patient male 61 year old. St post IM with revascularization 1996 triple ACB (LIMA – LAD; venous graft on the D1 and
In April 2010 performed SPECT MPI, finding sugested invasive intervention.
Coronarography finding ;LM 90%, LAD occluded, LIMA graft wide open. Venous graft on the D1 occluded.
ACx stenoses 90%, OM with tubular stenosis 50 -70%
RCA dominant, occluded ostial, venous graft occluded okludiran.
Performed PCI with stent implantation (Tsunami gold 3.5 x 15) on LM and ACX
After four month MPI control when we founded in stent stenosis.
Culprit lesion
Coronarography finding
In the same act PCI with stent implantation
Final effect PCI
Control MPI after four month after PCI
We finding zone of reversible ischemia in the same area, suggest restenosis
\nControl Coronarography - fidning in stent stenonis
Re PCI with stent implantation
Final effect
Conversely, patients with high-risk scans may benefit from an early invasive strategy with a view toward revascularization depending on coronary anatomical finding. A substantial number of patients undergoing SPECT perfusion imaging will have mild ischemia without a multi-vessel disease scan pattern. If patients with mild ischemia have good exercise tolerance, they should be considered as candidates for intense medical therapy with follow-up exercise SPECT imaging possibly at 1 year. Unpublished data from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluations (COURAGE) trial seem to indicate that many ischemic defects may markedly improve with aggressive lowering of abnormal lipids an the other pharmacological interventions. Hachamovitch and colleagues reported patients with the mildly abnormal scan had a 0.8% annual cardiac death rate compared with 0.9% for those who underwent revascularization. The death rate in medically treated patients who had moderately abnormal scans was 2.3% versus 1.1% for such patients undergoing revascularization. Finally, patients with a severely abnormal scan treated medically had an annual cardiac death rate of 4.6% versus 1.3% for such patients who were revascularized. In the second study, these investigators showed that medically treated patients who had greater than 20% of the total myocardium rendered ischemic had higher annual cardiac death rate (6.7%) compared with 2.0% for patients with this degree of extensive ischemia who underwent revascularization. For patients with 10% or less of the total myocardium rendered ischemic, there was no difference in outcome between medical therapy and revascularization.
\nExercise myocardial perfusion imaging is a valuable adjunct for separating high to low risk patients who present symptoms consistent with stable CAD, or in patients who have known disease and in whom further prognostication is warranted. Multiple high-risk nuclear imaging variables can be identified, and the greater the extent of exercise/induced ischemia, the greater the risk of cardiac events. Adjunctive variables, such as transient ischemic cavity dilatation and functional assessment with evaluation of regional wall thickening or wall motion and left ventricular ejection fraction greatly assist in the risk stratification process [1, 3, 16, 18].
\nNuclear cardiology is uniquely placed to address all the major determinants of prognosis in CAD can be assessed by measurements of stress-induced perfusion or function. These measurements include the amount of infarcted myocardium, the amount of jeopardized myocardium (supplied by vessels with hemodynamically significant stenosis), and the degree of jeopardy (tightness of the individual coronary stenosis). Recent evidence in large patient cohorts has revealed that factor estimating the extent of left ventricular dysfunction (left ventricular ejection fraction, extent of infarcted myocardium, transient ischemic dilatation of the left ventricle and increasing lung uptake) are excellent predictors of cardiac mortality. However, measurements of inducible ischemia are the best predictors of the development of acute coronary syndromes. Several reports have shown that nuclear testing yields incremental prognostic value over clinical information with respect to cardiac death, or the combination of cardiac death and nonfatal myocardial infarction as isolated endpoints. Now it is possible to tailor therapeutic decision making for an individual patient based upon combination of clinical factors and nuclear scan results. Patients with severe perfusion abnormalities on their stress image may have a five- to ten-fold higher likelihood of cardiac death versus patient with a normal myocardial perfusion SPECT. If the defects perfusion determined as a culprit lesion, invasive therapy (PCI) is an optimized outcome for that patient [2, 12, 13, 15].
\nThe explosion of PTCA and stent placement in patients with single or multi-vessel disease has created a necessity for early detection of restenosis. A number of clinical studies have documented the usefulness of stress MPI for identifying restenosis in patients after PCI. One point of controversy is the optimal time to performing SPECT imaging after coronary intervention. Although current consensus in to obtain an exercise MPI study 4 to 6 weeks post intervention, whenever indicated, the proper timing for use of MPI remains to be determined. Based on existing knowledge about the timing interval of subacute thrombosis (< 4 weeks) and in-stent restenosis (3-6 month), we purpose the algorithm as a guide for the management of patients with known CAD after PCI [2, 15, 16, 18].
\nRecommendation for the diagnostic treatment after PCI.
Asymptomatic patients may be considered for stress MPI 4 to 6 weeks post intervention in order to assess the functional results of PCI and established a new baseline. Subsets of patients that benefit from this approach include those at high risk post PCI (patients with decreased LV function, proximal left anterior descending artery disease, previous sudden death, diabetes mellitus, hazardous occupations, and suboptimal PCI results). Stress MPI is also recommended in patients who develop atypical symptoms after PCI and there is necessity to assess whether these symptoms represent ischemia. Patient with symptoms typical of ischemia < 6 months post intervention should proceed with coronary angiography as a first step, unless contraindicated. If angina occurs later (> 6 months post PCI), stress/pharmacologic MPI can be used to assess degree and area of ischemia, since progression of native coronary disease rather than in-stent restenosis is more likely.
\n\n
The combination clinical and exercise MPI variables provided greater prognostic information than the combination of clinical and angiographic data. Iskandrian et al showed that in medically treated patients with CAD, exercise SPECT imaging provided independent and incremental prognostic information even when catheterization data are available. The extent of perfusion abnormality was the single best predictor of prognosis. MPI added incremental prognostic information and risk-stratified patient even after clinical and exercise information were known. The incremental prognostic information about prognosis and need for coronary angiography provided by MPI has additionally been demonstrated for specific patients subsets: women, patient following coronary angioplasty or CABG, after MI, and with unstable angina. Hachamovitch et al demonstrated the use of MPI to yield incremental prognostic information toward the identification of cardiac death. Patient with a mildly abnormal scan after exercise stress are at low risk for cardiac death, but intermediate risk for nonfatal MI. A noninvasive strategy of optimizing medical therapy in this patient subgroup may result in significant cost saving when compared with invasive management strategy [1, 2, 3, 12, 18].
\nThe prognostic efficacy of MPI is well established. Subsequent data have demonstrated in various patient subsets that nuclear tests add significant and incremental predictive value to less expensive clinical and exercise testing data. Angiographic data obtained from more expensive cardiac catheterization procedures add little or no significant incremental prognostic value when added to the results of MPI.
\nThe introduction of new drugs and interventional devices to treat CAD, coupled with the arrival of manage care, has led to era of cost-containment within the practice of cardiology. Stress MPI is increasingly seen as a gatekeeper for more costly diagnosis and interventional procedures. Steingart et al evaluated 378 patients with a full range of pretest probabilities for CAD, and demonstrated that the results of MPI significantly reduced referring physicians’ likelihood of recommending cardiac catheterization, on average by 49%.
\nUnder managed care health systems that operate under cost-containment and capitation, MPI will continue to impact significantly on the decision to perform cardiac catheterization and to refer patients for coronary revascurization. Recommendations for invasive and interventional procedures are often coupled with an appropriate understanding of the prognostic value of MPI. Patients with the normal stress radionuclide study do not generally require referral for additional procedures, even when the likelihood of underlying CAD is high, as based on clinical and stress ECG data. The need for cardiac catheterization and coronary revascularization rates should be based on the degree of abnormality as detected by MPI. Thus, there is an increasing role of MPI to play an important gatekeeper function in the current era of managed care and emphasis on cost-containment [2, 3, 8, 12, 18].
\nStress MPI has became a central guide in decision making with regard to CAD patients. Stress MPI is commonly used either before consideration of coronary revascularization or after its performance, to optimize decision making for CAD patients. Stress MPI is also used after myocardial revascularization procedures, to evaluate therapeutic efficacy; following the stabilization of acute ischemic syndromes; to determine subsequent risk; and before the performance of elective non-cardiac surgery, to identify the high-risk subsets of CAD patients who will require coronary revascularization prior to elective surgery.
\nAfter all, MPI has became an important instrument in defining cardiac risk and in identifying patients who are most likely to benefit from additional invasive diagnostic testing and potential coronary revascularization. MPI demonstrated significant incremental prognostic
\nZivkovic Miodrag, Baskot Branislav
\nHeart failure (HF) is becoming the main clinical challenge in cardiology in the twenty - first century and is associated with high morbidity and mortality. Heart failure is the third most prevalent cardiovascular disease in the United States. An estimated 5 million people in the USA have heart failure, and the prevalence of the condition increase to 10 million by 2040, according to prediction. The prevalence of heart failure increase with age from less than 1% in the 20 – 30-year-old age group to over 20% in people age 80 years and older. The diagnostic and therapeutic costs involved are estimated to have exceeded $34 billion in only one year. Despite advances in therapies, the long-term prognosis from patients with heart failure remain poor; 80% of men and 70% of women greater than 65 years of age with heart failure die within 8 years [1, 2, 19, 20, 21].
\nThe underllying etiology of HF needs to be determined; most patients have CAD (approximately 70% - 80%). Nuclear imaging can help in the differentiation between patients with ischemic and non-ischemic HF. In patients with ischemic cardiomiopathy, the precise coronary anatomy is also needed to determinate if revascularization needs to be considered. At present, invasive angiography is performed to obtain the coronary anatomy, but multi-slice CT (MSCT) may also provide this information. The presence of ischemia and viability needs to be determined to decide further if revascularization is indicated.
\nNuclear imaging is considered the first choice technique for assessment of ischemia and viability; booth single-photon emission CT (SPECT), and positron emission tomography (PET) can provide this information.
\nNuclear imaging can provide some indirect evidence in the differentiation between ischemic and non-ischemic HF. With stress,-rest SPECT study, reversible defects indicate ischemia and fixed defects of perfusion indicates scar tissue; booth this findings are markers of coronary artery disease. Moreover, lot of studies with nuclear perfusion imaging demonstrated that patients with ischemic HF had extensive and diffuse perfusion defects, whereas tracer uptake (myocardial perfusion) was mostly homogeneous (ischemic) in patients with non-ischemic HF.
\nSimilarly, PET studies also demonstrated that patients with non-ischemic HF had more homogeneous tracer uptake, whereas patients with ischemic HF had areas of severely reduced uptake (reflecting scar formation). Accordingly, nuclear imaging can help in the differentiation between ischemic and non-ischemic cardiomyopathy, but for the diagnosis of underlying coronary artery disease, visualization of the coronary artery is needed. Invasive angiography is the technique of choice, but recently MSCT has been introduced for noninvasive angiography. With 64-slice MSCT and dual-source slice MSCT, we obtained more consistent image quality with improve visualization of the coronary artery tree. In the presence of a flow-limiting stenosis, resting myocardial is preserved, but once an increased myocardial oxygen demand occurs, a perfusion demand-supply mismatch follows, resulting in myocardial ischemia. Then, a sequence of events is initiated, which is referred to as the “ischemic cascade”. Perfusion abnormalities occur at an early stage, whereas diastolic and systolic left ventricular dysfunction occur later. Accordingly, such techniques as nuclear imaging that defect perfusion abnormalities should have a high sensitivity for detection of ischemia, because these abnormalities occur early in the cascade [19, 20, 21].
\nIn the heart failure patients, the combination between the coronary anatomy and the presence of ischemia in the territories of the stenotic vessels determines the need for revascularization. In the absence of ischemia, the presence of viability needs to evaluation.
\nAnother nuclear study performed in the evaluating of therapy effects in HF, is radionuclide angiography (RNV). That is the most reproducible, accurate, and simple method for noninvasively assessing left ventricular ejection fraction (LVEF). RNV are now most often used for serial assessment of LVEF in patients who undergo chemotherapy, assessment of global regional wall motion in patients with recent or old myocardial infarction, and in patients with congestive heart failure. In the patients with heart failure, evaluation of left ventricular systolic function is essential to plan management and determine prognosis. At the present time most RNV are acquired by multiple – view planar image technique. In this moment SPECT RNV is not routinely performed in most nuclear cardiology laboratories. The greatest attraction of SPECT RNV is the ability to evaluate cardiac chambers and regional wall motion without overlap of other structures. LVEF may be calculated based on count changes from either a conventional planar image (
\n\n
HBO is medical procedure of breathing the 100% oxygen under pressures higher than atmospheric pressure is and it carries out into hyperbaric chambers. Contemporary, HBO changes the rheological blood characteristic, recovers the function of blood vessels endothelium and it has good antiaggregation effects. The oxygen’s pharmacokinetic and neo-angiogenesis effects and its effect on oxygen-dependent reactions inside the mitochondria’s and homeopathy effect on the other organs are the reasons to use HBO in the treatment of HF. Nuclear imaging by SPECT imaging in the evaluation between ischemic and non-ischemic HF we performed, and followed with quantification per segments before and after therapy in the evaluation positive therapeutic effect. We also performed RNV like gold standard in the evaluation global and regional LVEF before and after the therapy. In the pilot study with 18 patients, we had recovery perfusion in all patients with non-ischemic HF. Before therapy we finding with RNV average measured LVEF was 23.4%. After treatment LVEF measured average 34, 3%. The results was increase by 10, 9% (from 5% to 20% measured individually).
\nConclusion of this pilot study was that diagnostic information finding by nuclear cardiology (perfusion and function) suggested significantly positive therapy effects HBO and Erythropoietin in the therapy of heart failure ischemic and non-ischemic origin.
\n\n
SPECT with DipyEX (dipyridamole = concomitant low level exercise 50W) performed and evaluated before and after HBO + EPO therapy
Radonuclide ventriculography for evaluating global ejection fraction Performed before and after HBO = EPO therapy
\n
SPECT scan performed before HBO = EPO therapy
\nRadionuclide venticulography performed before and after HBO = EPO therapy when we seen the greatest increase of LVEF with improve wall motion and regional kinetics
\nThe field of cardiovascular imaging is changing. In one hand, myocardial perfusion imaging is a well/established clinical technique for the diagnostic and prognostic workup of coronary artery disease. It has been the mainstay of nuclear cardiology for decades. On the other hand, several alternative imaging methodologies for noninvasive functional assessment of ischemic heart disease have emerged, and noninvasive coronary angiography is becoming a clinical reality. Nuclear imaging technology has progressed significantly toward higher sensitivity and resolution, and novel, highly specific radiotracers have been introduced. These developments are indicator of steady evolution of nuclear cardiology beyond the assessment of myocardial perfusion and toward characterization of biologic events on the tissue level. It is hoped that radiotracers techniques, with their unique translational potential and their superior detection sensitivity, will take a leading role in personalized cardiovascular medicine, in which therapeutic and/or preventive strategies are based on individual disease biology. The value of more specific imaging targets, which are increasingly entering clinical practice. This includes imaging of heart failure, absolute quantification of myocardial blood flow, imaging of myocardial metabolism, and imaging of the cardiac autonomic nervous system.
\nThe goal of this chapter is to provide the reader with a comprehensive overview of the most recent development in nuclear cardiology, in the era of interventional cardiology. It is hoped that the reader, after going through this article, will share the enthusiasm of the author for this discipline, which holds the potential to be a key component in the new paradigm of early detection coronary artery disease for indication for interventional cardiology, as well as assessment new therapeutic effect (HBO + EPO) of heart failure.
\nColorectal cancer is the third most common cancer and the fourth leading cause of cancer-related deaths worldwide [1]. Especially, rectal cancer accounts for 30–40% of colorectal cancer, and the treatment strategy is different and more complicated compared to colon cancer because of its anatomical features. Although the treatment outcome of rectal cancer has greatly improved with the development of multimodality treatment including neoadjuvant radiotherapy, cytotoxic chemotherapy, and target agents, surgery remains the mainstay of therapy. Since the concept of total mesorectal excision (TME) was first described by Richard Heald in 1979, this procedure became the gold standard technique for rectal cancer surgery until now [2]. The fundamental principle of TME is en bloc resection of the rectum with its surrounding fatty tissue complex which contains the blood vessels and lymphatics down to the pelvic floor. To achieve complete TME and sphincter preserving surgery in low-lying rectal cancer, knowledge for regarding the pelvic fascia (mesorectal, parietal) and autonomic nerves, a thorough understanding of the pelvic floor anatomy is essential.
The rectum is the most distal part of the large intestine that exists from the sacral promontory level to the anorectal ring. The anterior and lateral portion of the upper one-third of the rectum is covered with peritoneum, and the middle one-third of the rectum is covered with peritoneum on its anterior portion. The lower one-third cannot be observed in the intraperitoneal space because it is located in the extraperitoneal space. The taenia coli disappears in the rectum, forming one longitudinal muscle layer surrounding the rectum. The length of the rectum is approximately 12-15 cm and has three curvatures, which is related to Houston’s valves. The upper and lower part are convex to the right, and the middle portion is convex to the left. The middle valve is the most prominent and is located approximately equal to the level of peritoneal reflection [3].
The rectum is surrounded by a fatty tissue complex called the mesorectum, which corresponds to the mesentery of the rectum. Mesorectum contains abundant blood vessels, lymphatics, and lymph nodes, and it is enveloped by thin visceral pelvic fascia [4]. It is developed thickest in the posterolateral side and the anterior part is formed relatively thin. In addition, the volume of the mesorectum decreases as it approaches the pelvic floor, and disappears approximately 2 cm above the levator ani muscle (Figure 1). A number of studies have revealed that the mesorectum is an important structure for tumor spreading, and en bloc resection through sharp dissection of mesorectum is very important in improving treatment outcomes [2, 5, 6].
Anatomy of the rectum and mesorectum. (a) Structures around the rectum. The rectum is surrounded by mesorectum, and the rectum and mesorectum are enveloped by the fascia propria of the rectum. (b) Total mesorectal excision (TME). En bloc resection of mesorectum is important.
Dissecting the correct anatomical plane can lead to good oncological outcomes and preserve the autonomic nerves to prevent postoperative urinary, sexual, and defecatory dysfunction. If pelvic dissection is performed along the exact embryologic fascial plane, the operation can be done without bleeding. To perform precise total mesorectal excision, a thorough understanding of the fascia around the rectum and pelvic cavity is essential. Figure 2 shows the anatomical relationship of the fascia around the rectum.
Anatomy of fascia around the rectum. The fascia propria of the rectum covers the rectum and mesorectum. The presacral fascia covers the anterior surface of the sacrum. It combines with the fascia propria of the rectum at the S4 level (recto-sacral fascia = Waldeyer’s fascia). Denonvilliers’ fascia is a dense membrane between the rectum and seminal vesicles.
The rectum and mesorectum are enveloped by the fascia propria of the rectum, also called as mesorectal fascia. The mesorectal fascia corresponds to the visceral fascia of the rectum. Caudally, it ends at the internal sphincter and laterally ends at the internal iliac artery, and is connected to the parietal pelvic fascia [7]. A magnetic resonance image scan (MRI) can clearly show the boundaries of these mesorectum and mesorectal fascia (Figure 3). During total mesorectal excision, it is important to completely excise this mesorectal fascia without damage to obtain optimal oncologic outcome [6, 8, 9].
Magnetic resonance image scan. Magnetic resonance image scan (MRI) can clearly show the boundaries of these mesorectum and mesorectal fascia. (a) T2 weighted image on MRI. Axial view. The rectum and mesorectum are enveloped by the fascia propria of the rectum (mesorectal fascia). (b) T2 weighted image on MRI. Coronal view. Mesorectum, mesorectal fascia, and puborectalis muscle.
The presacral fascia, also called as parietal pelvic fascia, covers the anterior surface of the sacrum and encloses the sacral vessels and nerves. It combines with the mesorectal fascia at the S4 level and became part of the anococcygeal ligament at the level of anorectal junction. The presacral venous plexus is formed by the two lateral sacral veins, the middle sacral vein, and the communicating veins, and it runs underneath the presacral fascia. If the dissection plane is too deep to damage the presacral fascia during the posterior dissection, life-threatening massive bleeding can occur and it often is difficult to control. Therefore, dissection should be done along with the space between the mesorectal fascia and the presacral fascia until the recto-sacral fascia is encountered [10, 11].
Recto-sacral fascia, also known as Waldeyer’s fascia, is a dense connective tissue linking the presacral fascia to the mesorectal fascia at the S4 level. As the posterior dissection proceeds down along the plane between the mesorectal fascia and the presacral fascia, a dense, tough recto-sacral fascia is identified. To enter the retro-rectal space and reach the pelvic floor, this fascia must be incised and dissected further caudally. This fascia has a different thickness from individuals, it is not visible when it is too thin. Because the presacral artery and venous plexus and autonomic nerves pass behind this fascia, it is important to perform sharp division to avoid excessive bleeding due to presacral vein injury (Figure 4) [8, 12].
Recto-sacral fascia (Waldeyer’s fascia). Recto-sacral fascia (Waldeyer’s fascia) is a dense connective tissue linking the presacral fascia to the mesorectal fascia at the S4 level. It is important to perform sharp dissection [
During the anterior dissection of the rectum, a thin, dense connective tissue layer known as the Denonvilliers’ fascia presents between the seminal vesicles and rectum [13]. The rectum can be separated from the seminal vesicles and prostate by opening this membrane at the level of anterior peritoneal reflection. After incising the fascia and entering the embryologic plane between the rectum and the seminal vesicles, the dissection should be performed below the Denonvilliers’ fascia [14]. It is because there were neurovascular bundles running from the pelvic plexus to the ventral side of the Denonvilliers’ fascia, especially in the directions of 10 and 2 o’clock, and these neurovascular bundles were related to urogenital function (Figure 5) [15]. However, if the deeply infiltrative tumor is located on the anterior wall of the rectum, the dissection should be performed in front of the Denonvilliers’ fascia for curative resection. In females, there is a thin membranous structure that separates the rectum and vagina, which is called the rectovaginal septum. Although Denonvilliers reported that the Denonvilliers’ fascia was not present in females, many researchers considered that the rectovaginal septum was consistent with the Denonvilliers’ fascia in males (Figure 6) [16, 17, 18, 19]. During the anterior dissection of the rectum in female, care must be taken not to perforate the vagina since this septum is very thin.
Denonvilliers’ fascia. During anterior dissection of the rectum. The dense connective tissue between rectum and seminal vesicles can be seen. The dissection should be performed below the Denonvilliers’ fascia.
Rectovaginal septum. In female, the rectovaginal septum was consistent with the denonvilliers’ fascia in male.
The rectum enters the pelvic floor and becomes the anus. The anal canal is defined as from the dentate line to the anal verge by anatomists, but most surgeons consider the anal canal from the anorectal ring to the anal verge [20]. The anorectal ring is where the rectum enters the pelvic floor and is angled by the puborectalis muscle. This ring can be palpated by a meticulous digital rectal exam. The dentate line, which divides the upper two-thirds and lower third of the anal canal, is an anatomically important landmark of the anal canal, and there are 6–14 longitudinal folds on the dentate line known as columns of Morgagni (Figure 7). The upper and lower part of the anal canal differs in venous and lymphatic drainage, innervation, and the epithelial surface based on the dentate line. Above the dentate line, the blood drains into the portal venous system, and lymphatics drains to the superior rectal and iliac lymphatic chains. Below the dentate line, the blood drains into the caval system, and lymphatics drain into the inguinal lymph nodes.
Anal canal and anal sphincter complex. (a) The dentate line divides the upper two thirds and lower third of the anal canal, and there are longitudinal folds known as columns of Morgagni. The external sphincter consists of three separate parts: Subcutaneous, superficial, and deep part [
There are two sphincter muscles surrounding the anus, the internal sphincter and the external sphincter. The internal sphincter is connected from the inner circular smooth muscle of the rectum and descends to 1–1.5 cm below the dentate line. Its length is about 2.5–4 cm and the mean thickness is about 0.5 cm. It is an involuntary smooth muscle and plays an important role in the maintenance of fecal incontinence because it contributes a majority of the resting pressure of the anal canal. The outer longitudinal muscle of the rectum conjoins the fibers from the puborectalis muscle and is located between the external and internal sphincter. The external sphincter muscle is a striated muscle surrounding the internal sphincter in the shape of a cylinder, and it extends slightly below the internal sphincter. The external sphincter consists of three separate parts: subcutaneous, superficial, and deep part. The subcutaneous external sphincter attaches to the perianal skin encircling the anus. The external anal sphincter is innervated by the rectal branch of the pudendal nerve and is under voluntary control [20, 22, 23]. The intersphincteric groove between the internal and external sphincter is an important landmark in surgery for patients with distal rectal cancer such as intersphincteric resection (ISR) [24].
The pelvic floor is a structure that forms the bottom of the pelvis, and plays an important role in supporting the pelvic organs. In the past, pelvic floor muscles could not be visualized clearly, however, the development of magnetic resonance imaging assessments and improvements in minimally invasive surgery techniques such as laparoscopy and robotic surgery can clearly show the anatomy of this region It is mainly composed of the levator ani muscle complex: pubococcygeus, iliococcygeus, and puborectalis muscle. The levator ani muscle received direct innervation from sacral nerve roots (S3-S5) and play an important role in cooperative action through coordinated contraction and relaxation during defecation [25]. The pubococcygeus is located in the most anterior portion of the levator ani muscles, and from both pubic bone to the coccyx. The iliococcygeus is the posterior part of the levator ani muscle and extends from the ischial spine to the anococcygeal raphe and coccyx. The puborectalis muscle, which is located below the pubococcygeus, forms a U-shaped ring around the rectum and makes an anorectal angle to prevent fecal incontinence. The coccygeus muscle, which is also a part of the pelvic floor, is located posterior portion of the levator ani muscle and reinforces the posterior pelvic floor (Figure 8) [20]. The pelvic floor has two hiatuses: the urogenital hiatus and the rectal hiatus. The rectal hiatus is located in the posterior of the pelvic floor through which the anal canal passes. The perineal body, a pyramidal fibromuscular mass, is located between the urogenital hiatus and the anal canal, strengthens the pelvic floor [26]. During distal rectal cancer surgery for sphincter preservation such as ISR, the intersphincteric space between the puborectalis muscle and the rectal wall should be identified, and the dissection continues down to the deep part of the anal canal through the intersphincteric space (Figure 9) [24]. On the other hand, during an abdominoperineal resection, the levator ani muscles must be cut [27].
Anatomy of the pelvic floor. (a) Inferior view. The levator ani muscle consists of pubococcygeus, iliococcygeus, and puborectalis muscle [
Levator ani muscles and intersphincteric space. (a) Puborectalis and pubococcygeus muscle. (b) Intersphincteric space between rectum and puborectalis muscle.
The anococcygeal ligament is a fibrous membrane, which extends between the coccyx and the margin of the anal canal. In an anatomical study, the anococcygeal ligament was divided into two layers. The ventral layer of the ligament was loose and rich in small and fragile vessels and extended from the presacral fascia to the conjoint longitudinal muscle layer of the anal canal. The dorsal layer of the ligament was thin and dense and extended between the coccyx and external anal sphincter (Figure 10) [28]. To fully mobilize the rectum from the pelvic floor at the final stage of total mesorectal excision, the anococcygeal ligament must be divided. If the anococcygeal ligament cannot be seen in the final step, it can be visualized after the mesorectum is completely mobilized from the pelvic floor.
Anococcygeal ligament. (a) Anococcygeal ligament and pelvic floor. During posterior dissection of the rectum. (b) Anococcygeal ligament during cadeveric dissection. Lt. hemipelvis.
In case of very low-lying rectal cancer, several surgical options can be considered (Figure 11). If the tumor did not invade the anal sphincter complex, the ultra-low anterior resection with coloanal anastomosis could be considered. If the tumors are located close to the dentate line, the intersphincteric resection (ISR) could be considered. The ISR is the partial or complete resection of the internal anal sphincter along the intersphincteric plane. However, if the tumor invades the external sphincter complex, the abdominoperineal resection (APR) should be performed. For invasive low rectal cancer which invades the levator ani muscle, extralevator APR (ELAPE) should be considered to achieve adequate resection margin. The ELAPE is the cylindrical anorectal excision and removes more tissue around the tumor including levator ani muscle (Figure 12). This procedure has the advantage of reducing the risk of tumor perforation during operation and acquiring sufficient safety resection margin, but there is still controversy about the long-term oncologic outcome [29]. In addition, the postoperative complications can be increased due to the wide resection range.
Low-lying rectal cancer. (a) T2 weighted image on MRI. Coronal view. The low-lying rectal cancer invades internal anal sphincter. (b) T2 weighted image on MRI. Sagittal view.
Sugical plane for low-lying rectal cancer. (a) Low anterior resection (LAR). (b) Intersphincteric resection (ISR). (c) Abdominoperineal resection (APR). (d) Extralevator APR.
In terms of quality of life, the importance of not only oncological outcomes but also functional outcomes such as urinary function, sexual function, and defecatory function after rectal cancer surgery have been emphasized. Urinary dysfunction after rectal surgery occurs in approximately 27%, and it includes difficulty emptying the bladder and incontinence [30, 31]. Sexual dysfunction for males consists of erectile dysfunction, absence of ejaculation, or retrograde ejaculation. For females, it causes sexual dysfunction such as impaired ability to achieve orgasm, decreased vaginal secretion, or dyspareunia [15]. The major cause of postoperative urogenital dysfunction is autonomic nerve damage that occurs during surgery. As minimally invasive surgery such as laparoscopy and robotic approach develops, meticulous nerve preserving surgery became possible with good visualization of the pelvic autonomic nerves [32, 33, 34]. To preserve the postoperative urogenital function, a thorough understanding of the anatomy of the pelvic autonomic nerve is crucial.
The superior hypogastric plexus, which is a collection of sympathetic nerve bundles arising from T10-L3, forms a dense nerve plexus at the anterior area to the body of L5 and bifurcates into hypogastric nerves at the level of the sacral promontory (Figure 13). The superior hypogastric plexus runs around the inferior mesenteric artery. Therefore, this nerve can be damaged during dissection around the origin of the inferior mesenteric artery, and it results in retrograde ejaculation, urinary incontinence [35]. The hypogastric nerve crosses the left common iliac artery at the level of the first sacrum and descends to the pelvic cavity along the lateral pelvic wall.
Hypogastric nerves. The hypogastric nerves run from the superior hypogastric plexus and descend to the pelvic cavity and meet the pelvic splanchnic nerves.
The pelvic splanchnic nerves are considered to be parasympathetic nerves that arise from the second to fourth sacral spinal nerves. These nerves enter the pelvis through the sacral foramen, posterior to the parietal fascia that covers the piriformis muscle and crosses the retrorectal space, to enter the visceral compartment through the visceral fascia about 4 cm from the midline. Small branches of the pelvic splanchnic nerves run medially and enter the mesorectum (Figure 14). These nerves regulate the emptying of the urinary bladder and influence erectile functions and motility of the rectum. Therefore, damage to these nerves causes erectile dysfunction and decreased blood flow to the vagina and vulva, which can reduce vaginal lubrication.
Pelvic splanchnic nerves. The pelvic splanchnic nerves arise from the S2 to S4 spinal nerves. Small branches of the pelvic splanchnic nerves run medially and enter the mesorectum.
The pelvic splanchnic nerves meet the hypogastric nerves and form the inferior hypogastric plexus at the lateral pelvic wall. It lies outside the fascia propria in the superficial layer of the parietal fascia. The inferior hypogastric plexus can be observed as a mesh-like structure at the posterolateral pelvic wall close to the prostate and seminal vesicles. Because the inferior hypogastric plexus consists of both sympathetic and parasympathetic efferent fibers, any damage to this plexus may cause severe disturbances in urogenital and sexual function including erection and ejaculation. It extends forward to form neurovascular bundles running down the seminal vesicle at 2 o’clock and 10 o’clock direction (Figure 15). These neurovascular bundles run through the posterolateral border of the prostate and continue to the periprostatic plexus, which supplies to the prostate, seminal vesicles, corpi cavernosi, and the vas deferens [15, 36]. Injury to the neurovascular bundles during anterior dissection may cause urinary and sexual dysfunction. Meticulous dissection is required because nerve damage may occur when surgery is performed along the wrong plane or excessive traction is performed.
Inferior hypogastric (pelvic) plexus. The inferior hypogastric (pelvic) plexus is a network of sympathetic and parasympathetic fibers arising from the hypogastric nerves and the pelvic splanchnic nerves. It can be observed as a mesh-like structure at the posterolateral pelvic wall. It extends forward to form neurovascular bundles running down the seminal vesicle on both sides.
The rectum is surrounded by a fatty tissue complex called the mesorectum, which contains abundant blood vessels, lymphatics, and lymph nodes. The rectum and mesorectum are enveloped by the mesorectal fascia. During total mesorectal excision, it is important to completely excise this mesorectal fascia without damage. The mesorectal fascia conjoins with the recto-sacral fascia, which extends forward from the presacral fascia at the level of S4, and descends to the pelvic floor. To enter the retro-rectal space and reach the pelvic floor, this fascia must be incised and sharp dissection should be performed to prevent severe bleeding due to injury to the presacral plexus. During the anterior dissection of the rectum, it is important to recognize Denonvillers’ fascia located between the rectum and seminal vesicles, and dissection should be performed below the Denonvilliers’ fascia. The pelvic floor is a structure that forms the bottom of the pelvis and is mainly composed of the levator ani muscle complex: pubococcygeus, iliococcygeus, and puborectalis muscle. The levator ani muscle received direct innervation from sacral nerve roots (S3-S5) and play an important role in cooperative action during defecation. To reach the deep part of the anal canal, the dissection should be performed between the puborectalis muscle and the rectal wall. During the whole process of TME, surgeons should take care to identify and preserve the autonomic nerve in order to avoid postoperative urogenital dysfunction. Care should be taken not to damage the superior hypogastric nerve during IMA ligation, and not to damage the pelvic plexus during posterolateral pelvic dissection. In addition, during anterior dissection of the rectum, it is important to perform meticulous dissection so as not to injure small numerous neurovascular bundles running in the 2 o’clock and 10 o’clock directions of the seminal vesicle. Based on a sufficient understanding of pelvic anatomy, precise surgical techniques using advanced surgical tools will give favorable oncologic and functional outcomes for rectal cancer patients.
The authors declare no conflict of interest.
None.
IntechOpen - where academia and industry create content with global impact
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\\n\\nSara Uhac was appointed Managing Director of IntechOpen at the beginning of 2014. She directs and controls the company’s operations. Sara joined IntechOpen in 2010 as Head of Journal Publishing, a new strategically underdeveloped department at that time. After obtaining a Master's degree in Media Management, she completed her Ph.D. at the University of Lugano, Switzerland. She holds a BA in Financial Market Management from the Bocconi University in Milan, Italy, where she started her career in the American publishing house Condé Nast and further collaborated with the UK-based publishing company Time Out. Sara was awarded a professional degree in Publishing from Yale University (2012). She is a member of the professional branch association of "Publishers, Designers and Graphic Artists" at the Croatian Chamber of Commerce.
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\\n\\nDr Alex Lazinica
\\n\\nAlex Lazinica is co-founder and Board member of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his Ph.D. in Robotics at the Vienna University of Technology. There, he worked as a robotics researcher with the university's Intelligent Manufacturing Systems Group, as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and, most importantly, co-founded and built the International Journal of Advanced Robotic Systems, the world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career since it proved to be the pathway to the foundation of IntechOpen with its focus on addressing academic researchers’ needs. Alex personifies many of IntechOpen´s key values, including the commitment to developing mutual trust, openness, and a spirit of entrepreneurialism. Today, his focus is on defining the growth and development strategy for the company.
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\n\nBut, one thing we have in common is -- we are all scientists at heart!
\n\nSara Uhac, COO
\n\nSara Uhac was appointed Managing Director of IntechOpen at the beginning of 2014. She directs and controls the company’s operations. Sara joined IntechOpen in 2010 as Head of Journal Publishing, a new strategically underdeveloped department at that time. After obtaining a Master's degree in Media Management, she completed her Ph.D. at the University of Lugano, Switzerland. She holds a BA in Financial Market Management from the Bocconi University in Milan, Italy, where she started her career in the American publishing house Condé Nast and further collaborated with the UK-based publishing company Time Out. Sara was awarded a professional degree in Publishing from Yale University (2012). She is a member of the professional branch association of "Publishers, Designers and Graphic Artists" at the Croatian Chamber of Commerce.
\n\nAdrian Assad De Marco
\n\nAdrian Assad De Marco joined the company as a Director in 2017. With his extensive experience in management, acquired while working for regional and global leaders, he took over direction and control of all the company's publishing processes. Adrian holds a degree in Economy and Management from the University of Zagreb, School of Economics, Croatia. A former sportsman, he continually strives to develop his skills through professional courses and specializations such as NLP (Neuro-linguistic programming).
\n\nDr Alex Lazinica
\n\nAlex Lazinica is co-founder and Board member of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his Ph.D. in Robotics at the Vienna University of Technology. There, he worked as a robotics researcher with the university's Intelligent Manufacturing Systems Group, as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and, most importantly, co-founded and built the International Journal of Advanced Robotic Systems, the world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career since it proved to be the pathway to the foundation of IntechOpen with its focus on addressing academic researchers’ needs. Alex personifies many of IntechOpen´s key values, including the commitment to developing mutual trust, openness, and a spirit of entrepreneurialism. Today, his focus is on defining the growth and development strategy for the company.
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Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. He has contributed in stochastic estimation of control area especially, in the Multiple Target Tracking and Interactive Multiple Model (IMM) research, Ball & Beam Control Problem, Robotics, Levitation Control. He has contributed in developing Algorithms for Fingerprint Matching, Computer Vision and Face Recognition. He has been supervising Pattern Recognition, Formal Languages and Distributed Processing projects for several years. He has reviewed many books on Management, Computer Science. Currently, he is an active and permanent reviewer for many international conferences and symposia and the program committee member for many international conferences.\nIn teaching he has taught the core computer science subjects like, Digital Design, Real Time Embedded System Programming, Operating Systems, Software Engineering, Data Structures, Databases, Compiler Construction. 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In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"322007",title:"Dr.",name:"Maria Elizbeth",middleName:null,surname:"Alvarez-Sánchez",slug:"maria-elizbeth-alvarez-sanchez",fullName:"Maria Elizbeth Alvarez-Sánchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",country:{name:"Mexico"}}},{id:"337443",title:"Dr.",name:"Juan",middleName:null,surname:"A. Gonzalez-Sanchez",slug:"juan-a.-gonzalez-sanchez",fullName:"Juan A. Gonzalez-Sanchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico System",country:{name:"United States of America"}}},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}},{id:"338856",title:"Mrs.",name:"Nur Alvira",middleName:null,surname:"Pascawati",slug:"nur-alvira-pascawati",fullName:"Nur Alvira Pascawati",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universitas Respati Yogyakarta",country:{name:"Indonesia"}}}]}},subseries:{item:{id:"3",type:"subseries",title:"Bacterial Infectious Diseases",keywords:"Antibiotics, Biofilm, Antibiotic Resistance, Host-microbiota Relationship, Treatment, Diagnostic Tools",scope:"