General formula and characteristic parameters of phyllosilicates 2:1.
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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\r\n\r\n\tThe future options of small bowel endoscopy shall be covered in the final chapter. The book will be written by experts in the field and prove to be a valuable resource to all the training and practicing gastroenterologists, physicians and surgeons who are looking for a composite overview of endoscopy in small bowel diseases.
",isbn:"978-1-83968-780-8",printIsbn:"978-1-83968-779-2",pdfIsbn:"978-1-83968-781-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"a7c515b4add9ecf0a5de381a72d145e5",bookSignature:"Dr. Mahesh Goenka, Dr. Usha Goenka and Dr. Gajanan Rodge",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10309.jpg",keywords:"Capsule Endoscopy, Enteroscopy, CT Enterography, MR Enterography, Ulcerative Colitis, Crohn's Disease, Malena, Hematochezia, Celiac Disease, Malabsorption, Motorised Spiral Enteroscopy, Device-assisted Enteroscopy",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 11th 2020",dateEndSecondStepPublish:"October 9th 2020",dateEndThirdStepPublish:"December 8th 2020",dateEndFourthStepPublish:"February 26th 2021",dateEndFifthStepPublish:"April 27th 2021",remainingDaysToSecondStep:"3 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"A world-renowned gastroenterologist and a perfect blend of an extraordinary clinician, enthusiastic academician, and a skillful endoscopist. He has performed more than >1,00,000 endoscopic procedures with expertise in advance therapeutic endoscopy such as Spyglass Cholangioscopy, Cellvizio & POEM. Dr. Goenka is appointed as a member of the International Committee of American Society of Gastrointestinal Endoscopy. He has written 135 publications in various medical journals and 55 books.",coeditorOneBiosketch:"Dr. Usha Goenka is a senior interventional radiologist and specializes in vascular & nonvascular interventional radiology. She has completed her post-graduation M.D. in Radiology from the prestigious Postgraduate Institute of Medical Education and Research (PGIMER), India. She has more than 35 publications in various national and international journals.",coeditorTwoBiosketch:"Dr. Gajanan Rodge is a young gastroenterologist and has a special interest in the field of endoscopy. He also has experience as a clinical associate in the Gastroenterology department at Lilavati Hospital. He has recently been awarded the Poster of Distinction Award at the APDW 2019.",coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"292494",title:"Dr.",name:"Mahesh",middleName:null,surname:"Goenka",slug:"mahesh-goenka",fullName:"Mahesh Goenka",profilePictureURL:"https://mts.intechopen.com/storage/users/292494/images/system/292494.jpg",biography:"PRESENT DESIGNATION :\n\nDirector, Institute of Gastrosciences and Liver, Apollo Gleneagles Hospital, Kolkata.\n\nPROFESSIONAL SOCIETY\t\t\t \n\nPresident, Asio-Pacific Digestive Week (2019)\nGovernor (Indian region), American College of Gastroenterology (2017-2020)\nPresident, Society of Gastrointestinal Endoscopy of India (2016-17) \nMember, International Committee, American Society of GI Endoscopy (ASGE)- 2013-16\n\n \nQUALIFICATION\n\nMNAMS\t: Gastroenterology 1995 (awarded by National Academy of \n\t\t Medical Sciences, New Delhi)\n\nD.M\t\t: Gastroenterology\n\t\t June 1989, Postgraduate Institute of Medical Education and \n\t\t Research (PGIMER) Chandigarh, India.\n\nM.D\t\t: Medicine \n\t\t June 1987, Postgraduate Institute of Medical Education and \n\t\t Research (PGIMER) Chandigarh, India.\n\nM.B.B.S\t: June 1981, Calcutta Medical College, Calcutta, India.\n\nF.A.C.G \t: Fellow, American College of Gastroenterology, 1996.\n\nF.A.S.G.E : Fellow, American Society of Gastrointestinal Endoscopy, 2007\n\nA.G.A.F\t: Fellow of the American Gastroenterological Association, 2016\n\nF.R.C.P\t: Fellowship of Royal College of Physicians, Glasgow 2017\n\n\nEXPERIENCE:\n\n8/96 onwards: Organised the Dept. at Apollo Gleneagles Hospital, AMRI & \n \t Eko Endoscopy Centre, Kolkata\n\n1/96 - 3/96: Fellow - Department of Endoscopic surgery, - Hamburg University, \n Germany. \n\n4/91 - 7/96: Assistant Professor (Gastroenterology) Postgraduate Institute of\n Medical Education and Research (PGIMER) Chandigarh, India.\n\n1/90 - 4/91: Pool Officer, Dept. of Gastroenterology, Postgraduate Institute of\n Medical Education and Research (PGIMER) Chandigarh, India. \n\n7/87 - 12/89: Senior Residency in Gastroenterology, (PGIMER) Chandigarh, India\n\n7/84 - 6/87: Residency in Medicine, (PGIMER) Chandigarh, India.\n\nINTERNATIONAL RECOGNITION\n\n1.\tAppointed as Clinical Professor of Medicine Gastroenterology at Medical College of Wisconsin USA for 2019 to 2024.\n2.\tElected as Governor (Indian region). American College of Gastroenterology for 3yrs. (2017-2020)- Initiated and Organised Best of American College of Gastroenterology, Kolkata, Bangalore and New Delhi on 17, 18, 19th Jan 2020.\n3.\tAdjunct Professor of Medicine at University of Wisconsin School, USA\n4.\tAppointed as member of International Committee of American Society of Gastrointestinal Endoscopy (2014-18)\n5.\tAppointed as Adjunct Associate Professor in Dept. of Medicine at University of Queensland, Australia for 3 yrs. (2011-2014)\n6.\tInvited as Faculty for Asio-Pasific Digestive Week (APDW) held at Kobe, Japan in Nov 2016. and HongKong 2017, Korea 2018\n7.\tInvited as a Guest Speaker to the 12th World congress at Paris organized by International agency for Research of Cancer and World Health Organization (WHO) at UNESCO Headquarters in August 2013. Delivered two lectures. \n8.\tInvited to visit Department of Gastroenterology at Zhongshan Hospital, Fudan University at Sanghai, China in July 2013.\n9.\tInvited faculty for Asia Pacific Digestive week (APDW) 2011 held at Singapore from 1st to 4th Oct 2011.\n10.\tVisiting Professorship awarded by University of Alabama at Birmingham, USA. Invited to the Basil I Hirschowitz Endoscopy Center of Excellence & delivered talks on ERCP and Small Bowel Endoscopy on 4th Oct’2010\n11.\tMember of Asia Pacific Panel Recommendations for Optimal Management of Hepatitis B “APPROACH group”(Headed by Prof M Omata of Japan) to draw guide line on treatment of Hepatitis B- sole member respesenting India. (Work published subsequently in Hepatology International)\n12.\tDelivered a guest lecture on “Small bowel Endoscopy” at Dubai in April’2010 during Annual meeting of Middle- East Chapter of Indian Society of Gastroenterology\n13.\tAdvisory Editorial Board member of Journal of Bioscience & Medicine, official Journal of International Association for Biological and Biomedical Science.\n14.\tReviewer for Malaysian Journal of Medical sciences & Journal of Gastroenterology & Hepatology, Gastrointestinal Endoscopy, World Journal of Gastroenterology, World J of GI Endoscopy.\n15.\tInvited in 2013 by World Journal of Gastroenterology and World Journal of Hepatology to write state of Art Review Articles on Capsule Endoscopy and Hilar Cholangiocarcinoma respectively. \n16.\tGuest faculty at Digestive Diseases week, Annual meeting of American Gastroenterology Association during 2014 and 2015. Delivered guest lectures at Chicago and Washington respectively\n\n\nNATIONAL RECOGNITION\n\n1.\tPresident of Society of Gastrointestinal Endoscopy of India (SGEI 2016-17), a scientific national body of GI endoscopists (about 1500 members)\n2.\tAppointed Fellow of West Bengal Academy of Science & Technology (2011)\n3.\tAwarded Adjunt Professorship by Apollo Hospitals Education and Research Foundation July 2012\n4.\tReviewer for Tropical Gastroenterology, Indian J of Gastroenterology\n5.\tEditor of Apollo Medicine Journal\n6.\tMember of National Task Force by Indian Association for study of liver on Hepatocellure carcinoma, Hepatitis C, & by Indian society of Gastroenterology on GI Bleed and Inflammatory Bowel Disease \n7.\tEditor-In-Chief, Journal of Digestive Endoscopy, official journal of Society of Gastrointestinal Endoscopy of India (2015 onwards)\n\nAWARDS AND SCHOLARSHIPS\n\n1.\tApollo Distinguished Academician award 2019 by Apollo Hospitals, Chennai.\n\n2.\tAcademic achievement award 2016 by Apollo Hospital Group in 2016.\n\n3.\tJ. Mitra Award 2005-06 given by Indian Society of Gastroenterology in the year 2006 for contribution to G. I. Endoscopy.\n\n4.\tSISCO PENTAX ORATION for 2002 awarded by Society of G. I. Endoscopy for contribution in the field of G. I. Endoscopy.\n\n5.\tResearch fellowship awarded by Indian Association for Study of the Liver (1993) for research contribution in the field of hepatology.\n\n6.\tAwarded Academic achievements awards by Apollo Hospital Educational and Research Foundation for original research publication in 2011\n\n7.\tSilver Medal (first order) for securing 1st position in M.D. (Medicine) at PGIMER, Chandigarh.\n\n8.\tFirst in the first MBBS examination of Calcutta University (awarded Maharaja Gwalior Prize).\n\n9.\tHonours in Chemistry, Anatomy, Physiology, Ophthalmology and E.N.T. from the Calcutta University.\n\n10.\tCollege merit scholarship during the 2nd, 3rd, 4th and final years of MBBS from the Calcutta University.\n\n11.\tSilver Medal for the best student of 1st year class in MBBS.\n\n12.\tGold medal for the best student in Anatomy in 2nd year MBBS.\n\n13.\tSilver Medal for the best student in Anatomy in 1st year MBBS.\n\n14.\tAnandlal Sanyal Prize in Mid – Wifery (1978 – 1979).\n\n15.\tSenior Prosector’s Prize in Anatomy (1975 – 1976).\n\n\nTEACHING EXPERIENCE\n\n1.\tPresently Heading the Dept. of Gastroenterology at Apollo Gleneagles Hospitals, Kolkata which imparts National Board Postgraduate Degree in Gastroenterology, called Diplomate in National Board (DNB)- actively involved in teaching of Postgraduate Students since last 7 yrs.\n\n2.\tFive & half years (1991-1996) as Assistant Professor (Gastroenterology) at Postgraduate Institute of Medical Education and Research (PGMER) Chandigarh, India. This institute imparts MD (Postgraduate) and DM (Super specialty) degrees\n\n3.\tOne and half year (1990-91) as Pool Officer, Dept. of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, India.\n\n4.\tTwo years (1987-1989) as Senior Residency in Gastroenterology, (PGIMER) Chandigarh, India (Teaching postgraduate, MD students)",institutionString:"Institute of Gastrosciences and Liver",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:null}],coeditorOne:{id:"292497",title:"Dr.",name:"Usha",middleName:null,surname:"Goenka",slug:"usha-goenka",fullName:"Usha Goenka",profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:"Dr. Usha Goenka is a senior interventional radiologist and specialises in vascular & nonvascular interventional radiology. She is currently working as the Director and Head, Department of clinical imaging and interventional radiology at Apollo Gleneagles Hospital, Kolkata. She has been a merit holder and university topper through her MBBS graduation. She has completed her post-graduation M.D. in Radiology from the prestigious Postgraduate Institute of Medical Education and Research (PGIMER), India. She has more than 35 publications in various national and international journals. She has a keen interest in teaching and has delivered more than 50 lectures in national and international conferences.",institutionString:"Apollo Gleneagles Hospital",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorTwo:{id:"292496",title:"Dr.",name:"Gajanan",middleName:null,surname:"Rodge",slug:"gajanan-rodge",fullName:"Gajanan Rodge",profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:"Apollo Gleneagles Hospital",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"9699",firstName:"Iva",lastName:"Lipović",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/9699/images/4740_n.png",email:"iva.l@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. 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Generally, the main principle to prevent corrosion is to eliminate one of the four main components causing the corrosion process (anodic reaction, cathodic reaction, electrolyte, and electrical connection between the cathode and the anode) [1]. Until about 1950, coatings were believed to act as a barrier, preventing water and oxygen to reach the metal. These two species are needed to drive the oxygen reduction reaction (cathodic reaction) that initiates the corrosion process. In 1952, Mayne found that the diffusion rate of water and oxygen in an unpigmented coating is too high. Consequently, he suggested that the amount of water and oxygen arriving at the metal/coating interface is greater than the one required for corrosion to precede [2–4]. His hypothesis was based on the fact that the barrier action could not explain the effectiveness of the coating, while the conductivity of the coating is the main factor controlling the corrosion protection degree offered by the coating [2, 5, 6]. Mayne also reported that when the coating is immersed in a solution, it will gain a certain charge, negative or positive, depending on the nature of the coating. In this case, the coating will allow the opposite charge species to pass through. He believed that the permeation of these species will be through the bulk of the matrix. Corti attributed that the permeation of such species is affected by the presence of pores or imperfections in the coating. Based on that, he concluded the permeation to be through the pores and voids in the coating [2, 3]. Funke has a different understanding to the way the coating works to protect the steel. He believed that the protection degree that the coating offers depends on the degree of adhesion. The permeation of water through the coating will result in a water accumulation between the substrate and the coating, leading to coating blistering or coating delamination as a result of generating hydroxyl ions as products of the corrosion process. Such ions are believed to break the bond between the coating and the metal surface, and consequently, the coating adhesion will be significantly degraded [2, 7, 8]. Considering all the above approaches, loss of adhesion, the diffusion of water and oxygen, and the transport of the charged species can potentially result in poor corrosion protection performance. In general, mass transfer (diffusion) of a material in a specific environment is a result of a natural process tending to reach equality in concentration between two points. In the case of gases, the diffusion process will be mainly based on the difference in partial pressure, which is the driving force pushing the gasses from one side to another.
\nIn case of polymeric coatings, the diffusion process will mainly depend on three factors: the nature of the polymeric coating, the magnitude of the driving force, and the nature of the diffusing species. The general mechanism of the permeability through the coating will follow three main steps: solution of small molecules in polymer, migrating through the polymer, and emergence of that molecule at the outer surface. Accordingly, the permeability can be presented mathematically as the product of solubility and diffusion as shown in Eq. (1) [9, 10]:
\nWhen a coating is exposed to an electrolyte, the diffusion of the electrolyte follows two processes, which can be classified as fast and slow diffusion [11]. The fast process can occur within a few minutes of exposure, while the slow step can take weeks or months. According to Scantlebury, during the fast process, the electrolyte can reach the surface of the metal, but its electrical properties do not support the corrosion process, while the amount of electrolyte can reduce the adhesion strength of the coating [3].
\nThere are many factors affecting the diffusion of the electrolyte and the corrosive species, namely water and oxygen. Considering the fact that the permeability of a coating depends on the amount of defect present, it can be concluded that the diffusion will be through areas of imperfection. These areas can be considered as free volume including pores and area of weak cross-linking density. The free volume concentration increases, as the temperature goes above the glass transition temperature (Tg) of the coating. Tg is known as the temperature at which the coating state changes from glassy or solid state to a rubbery state. Above the Tg, the energy of the coating molecules increases, leading to an increase in the movement of these molecules. As a result of this, the free volume can increase, providing more areas for the diffusing species to transport through the coating. Based on that, it is highly recommended to select a coating having Tg higher than the temperature of the process [2, 10]. Film thickness has a great effect on the permeability of the coating. As the film thickness increases, the penetration of the corrosive species through the coating can be delayed. Increasing the film thickness above a critical thickness can increase the probability of having cracks in the coating [2]. Certain pigments have a significant effect on the permeability of coating. It is believed that water and oxygen cannot pass through pigment particles; therefore, the permeability can be reduced with increasing the pigment volume concentration (PVC). The PVC value should not exceed the critical pigment volume concentration (CPVC). Above the value of CPVC, the pigments will introduce voids and gaps inside the coating. These defects can provide an easy way for water and oxygen to go through [2]. It was reported that the pigmentation of inert particles such as nanoclays inside the coating can act as a barrier to reduce the diffusion rate of water and the oxygen through the polymer-clay nanocomposite coatings.
\nThe nanoclays have evoked a great deal of attention lately for the preparation of novel nanocomposite materials for several applications [12]. The uniform dispersion of the layered silicates into polymers matrix leads to the preparation of nanocomposites with improved mechanical properties, thermal stability, and low flammability [13, 14]. This is attributed to their lamellar structures, which are distinguished by having high in-plane strength and stiffness, as well as a high aspect ratio [15]. Additionally, the clays possess excellent stability and low toxicity, and they are cheaper and widely available compared to other nonorganic fillers. Such advancement plays a major role in enhancing the coating industry, specifically for corrosion protection [16, 17]. One main factor attributing to coating failure is its inability to maintain low water and oxygen permeability throughout its service life. The penetration of these elements through the coating leads to corrosion initiation under the coating. The addition of clay to polymeric coatings has great potential to improve the corrosion protection performance of the coatings. This chapter will present the recent advancement in the preparation and utilization of polymer-clay nanocomposites as enhanced coatings for corrosion protection.
\nThe most commonly used layered silicates to produce the polymer-clay nanocomposites belong to a group of clays classified as 2:1 layered or phyllosilicates [18]. This structural family includes natural clays, such as montmorillonite, hectorite, and saponite. Their crystal structure consists of two-dimensional layers made up of two tetrahedral silicon sheets fused to octahedral sheet of alumina or magnesia by the tip so that the oxygen ions of the octahedral sheet also belong to the tetrahedral sheets. The layer thickness of a sheet is of the order of 1 nm, and the lateral dimensions vary from 300 Å to several microns depending on the specificity of the silicate. The relatively weak Van der Waals force ensures the stacking of the sheets between them and each layer called interlayer [19–21]. Stacking of the layers leads to a regular gap between each adjacent silicate layers called the interlayer or gallery. A negative surface charge is present on the layers due to the isomorphic substitution of tetrahedral silicon or aluminum and octahedral magnesium. The charge deficit is counterbalanced by alkali and alkaline earth cations situated inside the galleries [22].
\nThe most used layered silicates are montmorillonite, hectorite, and saponite [23]. Their chemical formulae are illustrated in the Table 1 [24]. All these layered silicates are characterized by a high surface area (700–800 m2/g in the case of montmorillonite) and a moderate cation-exchange capacity (CEC) generally expressed in milliequivalents per 100 g (mequiv. per 100 g). The charge indicated by the chemical formula is an average over the whole crystal because the charge varies from layer to layer. Only a small proportion of the charges are located at the surface of the crystal, the majority being mainly in the interlayer spaces [22]. These cations are then exchangeable in solution.
\nSilicate | \nChemical formula | \nLocation of isomorphic substitutions | \nCEC (mequiv./100 g) | \n
---|---|---|---|
Hectorite | \nMx(Mg6−xLix)Si8O20(OH)4a | \nOctahedral | \n120 | \n
Saponite | \nMxMg6(Si8−xAlx)Si8O20(OH)4a | \nTetrahedral | \n86.6 | \n
Montmorrillonite | \nMx(Al4−xMgx)Si8O20(OH)4a | \nOctahedral | \n110 | \n
General formula and characteristic parameters of phyllosilicates 2:1.
M = monovalent cation; x = degree of isomorphous substitution (between 0.5 and 1.3).
To produce the nanocomposite with the required properties, the silicate layers should be exfoliated before being dispersed inside the polymer. Indeed, the hydrophilic characteristic of the clay does not allow it to be dispersed in the polymer matrix, which is generally organophilic. To render the mixture compatible, it is necessary to modify the clay before it is dispersed. For this reason, a pretreatment process should take place to weaken the forces holding the structure [24–27]. The main goal of this process is to render the surface of the layered silicate more organophilic. This improves the dispersion process of the layers inside the polymer under well-defined experimental conditions [28]. Given the structure and properties of clay, there are several modification techniques. However, the most commonly used technique for organophilic modification of clay is the ion-exchange reactions with cationic surfactants, including primary, secondary, tertiary, and quaternary alkylammonium cations to replace the hydrated cations with the protonated amine with long-chain alkylammonium cations. Alkylammonium cations in the treated clay decrease the surface energy of the inorganic host and increase interlayer spacing, rendering the modified organoclay is more compatible with organic polymer [29–33]. The above treatment process is basically an intercalating process to increase the spacing and decrease the adhesion forces between the silicate layers. The amine has the ability to achieve such target by acting as an intercalating agent. The efficiency of the intercalating agent is mainly influenced by the agent properties such as its hydrocarbon chain length [1]. It is very important to stress that there are also other original and interesting methods for modifying 2:1 phyllosilicates, such as the use of ionomers or block copolymers, and the grafting of organic substances, such as organosilanes. In the clay, the hydroxyl functional groups are located on the surface of the layers and their edges, and so the silane agents possess the ability to form strong covalently bonds with inorganic clays.
\nVariations in the strength of interfacial interactions between the polymer matrix and layered silicates result in the formation of three main kinds of nanocomposites as described below [34].
Intercalated nanocomposites: When the polymer is not able to intercalate between the silicate layers, a biphasic composite is obtained, whose properties remain in the same range as the conventional microcomposites structure, in which the clay sheets are not swollen by the polymer and are in the form of clumps or agglomerates in the matrix.
Flocculated nanocomposites: Conceptually, this is similar as intercalated nanocomposites. More polymer molecules are getting inside the layers structure to give more spacing between the silicate layers.
Exfoliated nanocomposites: In this type of nanocomposite, the individual clay layers are separated in a continuous polymer matrix. Usually, the clay content of an exfoliated nanocomposite is much lower than that of an intercalated nanocomposite. The Figure 1 shows illustrations of the three types of polymer-clay nanocomposites.
The main types of nanocomposite. (a) Intercalated, (b) flocculated, and (c) exfoliated.
Despite the impressive progress that has been reported during the last few years regarding the use of polymer-clay nanocomposites for corrosion protection, its effect on the corrosion performance has rarely been investigated. Although most organo-modified clay nanocomposites reported so far are intercalated, exfoliated structures are more desirable in property improvement of the polymeric materials. In this context, Chen and co-workers described the processing of epoxy-layered silicate nanocomposites with different properties as corrosion resistant coatings on aluminum surfaces [35]. Based on their studies, they concluded that there is a slight enhancement in anticorrosion properties for the exfoliated nanocomposites coatings and no enhancement for the intercalated nanocomposites. Finding shows that these criteria are related to the better dispersion of silicate nanosheet in some epoxy matrix than the other grades of resin matrix. However, these findings were not very conclusive, and it appears that an epoxy with a lower barrier resistance or higher permeability will help in discriminating the corrosion behavior through the introduction of clay into the matrix. Similarly, Sakai and co-workers found that the exfoliated clay structures were more fixed in polymeric matrix compared to intercalated and conventional clay structures [36]. Additionally, exfoliated clay structures exhibited better corrosion performance compared to intercalated coatings nanocomposites. This is mainly attributed to the larger clay interlayer distance, smaller clay aggregate, and uniform homogeneity of exfoliated clay structures inside the epoxy matrix. In some case, a mixture of intercalated and exfoliated nanocomposites was obtained, and it was difficult to evaluate the effect of nanocomposite structures on the corrosion performance of the prepared nanocomposites [37].
\nSeveral methods were reported to prepare clay-based polymer nanocomposites. These include in-situ polymerization, melt intercalation, and solution casting, according to the starting materials and processing techniques:
Intercalation of polymer from solution. This is based on a solvent system, in which the polymer is soluble and the silicate layers are swellable. The layered silicate is first swollen in a solvent, such as water, chloroform, or toluene. When the polymer and layered silicate solutions are mixed, the polymer chains intercalate and displace the solvent within the interlayer of the silicate. Upon solvent removal, the intercalated structure remains, resulting in nanocomposite [38, 39].
In-situ intercalative polymerization. In this method, the layered silicate is swollen within the liquid monomers or a monomer solution so that the polymer formation can occur between the intercalated sheets. Polymerization can be initiated either by heat or radiation [40, 41]. This method technique was used to prepare nanocomposites based on polyamide, poly(e-caprolactone), polystyrene, polyolefien, and polyethylene terephthalate [41].
Melt intercalation. The melt intercalation involves annealing, statically or under shear, a mixture of the polymer and modified clays. This method has great advantages over either in-situ intercalative polymerization or polymer solution intercalation. Firstly, this method is environmentally benign due to the absence of organic solvents. Secondly, it is compatible with current industrial process [42, 43]. This process is widely used to design nanocomposites based on polyamide, such as polyethylene terephthalate and nylon 6 [12]. Table 2 shows the advantages and the limitations of different methods used to prepare the polymer-clay nanocomposites.
Processing methods | \nAdvantages | \nLimitations | \n
---|---|---|
Intercalation of polymer from solution | \n\n
| \n\n
| \n
In-situ intercalative polymerization | \n\n
| \n\n
| \n
Melt intercalation | \n\n
| \n\n
| \n
Summary of different methods used for the synthesis of nanocomposites.
Concerning the characterization of polymer-clay nanocomposites, the small-angle X-ray scattering (SAXS), transmission electron microscopy (TEM), and scanning electron microscopy (SEM) are the main techniques used to identify the structure of nanocomposites. Indeed, the SAXS allows to monitor the position, shape, and the intensity of the peak, while TEM provides information on the spatial disposition of the internal structure and the spatial distribution of the various phases. SEM is employed to identify the response of the clays to the cationic exchange reaction.
\nCorrosion is defined as the gradual oxidation of metallic materials by converting them to their original state of oxide, sulfide, carbonate, or other stable salts in the ambient environment. Corrosion results from a combination of reactions occurring at the metal-solution interface by involving electrons and the chemical species. More specifically, the oxidation of the metallic material naturally occurs at the metal-environment interface and constitutes the anodic reaction, whereas the reduction of oxygen typically takes place in solution and often constitutes the cathodic reaction [44]. The cathodic and anodic reactions form an electrical circuit, which is completed by conduction of electrons in the metal and by ionic conduction through the electrolyte. There are various forms of corrosion that can take place depending on the surrounding environment and the design of the equipment that suffers corrosion. The galvanic, pitting, intergranular, crevice, and uniform corrosions are the most investigated corrosion in the literature [45, 46]. In general, the corrosion protection methods commonly used are mainly organic and metallic coatings, inhibitors, cathodic, and anodic protection. This latter is relatively new, and it was first demonstrated and tested by Edeleanu 1954 [47].
\nThe use of organic coatings on metal is usually an effective way to protect metal surfaces from corrosion while still preserving the desirable physical and mechanical properties of the metal [47, 48]. Corrosion on a bare metal surface is very complex process in itself, as the morphology of the corrosion layers formed on the surface and corrosion rate depends on several factors [49]. To evaluate the performance of any organic coatings, several parameters must be taken into consideration such as the permeability to water and oxygen, adhesion performance to the metal, coating thickness, ionic conductivity, as well as pore size distribution [50]. Commonly, the corrosion mechanism of an organic coating to protect the metal against corrosion can be divided into three groups: the electrochemical effect, the physicochemical effect, and the adhesion to the substrate [8]. The organic coating is a complex formulation of variety of materials each having a specific function. Examples of those materials include, but not limited to the following: polymeric materials, solvents, pigments, and various additives. Organic coating simply acts as a barrier between the metal surface and the surrounding environment. The barrier ability of such coating might be attributed to its structure or due to some additives or pigments implemented inside the coating. For this reason, understanding the nature and the constituents of the coating to be applied is essential to predict the performance of this coating as a corrosion protective technique. There are several reasons that can lead to failures in the coating applied, and the most common failures and the reasons leading to such failures are the permeability of the coating, adhesion, blistering, and cathodic delamination. Importantly, it was reported that a poor coating applied to a well-prepared surface is better than a good coating applied to a poorly prepared surface [51]. Contaminations on the surface of the metal can cause a direct failure to the applied coating. These contaminations can be the reason for a poor coating adhesion, which is one of the most critical factors controlling the quality of the coating. It is also well known and documented that no matter how good the coating is, the corrosion still can take place under the coating if the surface is contaminated.
\nIt is well known that polymeric coatings are not permanently impenetrable, as the presence of defects in the coatings will lead to the formation of the pathways for the corrosive species to reach and attack the metallic surface, and a localized corrosion will be initiated. Various fillers such clays as were incorporated into the polymeric coatings to improve their barrier properties by reducing their permeability and increase the length of the diffusion pathways for oxygen and water species [52]. Indeed, the addition of clay as filler creates a maze that impedes the diffusion of corrosive molecules as illustrated in Figure 2. The use of clay as pigments appears to be one of the promising solutions to enhance the corrosion performance of nanocomposites. This section presents an overview on the recent advances of using of polymer-clay nanocomposites for corrosion protection.
\nThe difference between conventional composite and nanocomposites.
Different kinds of polymers were used to prepare nanocomposites coatings such as conjugated polymers and thermoplastic polymers [53]. Using the in-situ thermal polymerization, Yeh and colleagues prepared a series of polymer-clay nanocomposite by dispersing layered montmorillonite (MMT) clay into an organic poly(methyl methacrylate) matrix [54]. Firstly, methyl methacrylate monomers were intercalated into the montmorillonite that was exfoliated by cation-exchange reaction with quaternary alkylammonium cations or alkylphosphonium cations followed by a typical free-radical polymerization. The as-synthesized polymer-clay nanocomposites exhibited enhanced Tg compared to pure polymer. TEM analysis revealed that after the dispersion of the clay, the prepared nanocomposite displayed a mixed nanomorphology with well-exfoliated silicate layers into the polymer matrix. The electrochemical measurements using polarization resistance, corrosion current, and impedance spectroscopy revealed that nanocomposites coatings with the low clay loadings (e.g., 1 wt%) exhibited better anticorrosion protection for steel compared to the pure poly(methyl methacrylate). In an independent study, the same group has also designed several nanocomposite materials containing polyaniline (PANI) and layered montmorillonite clay and investigated their corrosion performance for cold-rolled steel [55]. Firstly, the organophilic montmorillonite was prepared via cation-exchange reaction with cocamide-propylhydroxysultaine before being mixed with aniline monomers in diluted hydrochloric acid followed by one-step oxidative polymerization. TEM analysis of as-synthesized nanocomposite revealed that the prepared materials possessed mixed nanomorphology, and the silicate layers were found to be well dispersed in the polyaniline matrix. The electrochemical measurements of potentiodynamic (e.g., Tafel plots) of a series of polyaniline nanocomposites with varying clay loadings at room temperature are illustrated in Table 3. Electrochemical corrosion current values of polyaniline nanocomposites were found to be decreasing progressively with further increment in clay loading. Importantly, visual inspection of the corrosion products revealed the presence of grayish oxide layer formed over polyaniline nanocomposites, showing better corrosion performance. It is very important to stress that the incorporation of the montmorillonite in polyaniline matrix resulted in a decrease in mechanical strength and in thermal decomposition temperature. This could be attributed to the significantly decreased molecular weight of polyanilines formed in the montmorillonite. Same research group evaluated the effect of adding organo-modified clay on the corrosion protection performance of conducting polymer/layered silicate, such as poly(o-methoxyaniline) and poly(3-hexylthiophene) [56]. The experimental findings revealed that the conducting polymer/layered silicate nanocomposites with low clay loading (3 wt.%) were found exhibiting better anticorrosion properties compared to the pure conducting polymer.
\nCompound code | \nFeed composition (wt.%) | \nInorganic content found in the product (wt%)a | \nElectrochemical corrosion measurementsb | \n||||
---|---|---|---|---|---|---|---|
\n | PANI | \nMMT | \n\n | Ecorr (v) | \nRp (KΩ cm2) | \nIcorr × 10−6 (A/cm2) | \nRcorr (mm/year) | \n
Bare | \n— | \n— | \n— | \n−0.641 | \n0.8 | \n44.4 | \n86.1 | \n
PANI | \n100 | \n0 | \n0 | \n−0.590 | \n3.4 | \n12.0 | \n23.3 | \n
CLAN0.25 | \n99.75 | \n0.25 | \n0.70 | \n−0.581 | \n13.7 | \n2.9 | \n5.6 | \n
CLAN0.5 | \n99.25 | \n0.50 | \n1.50 | \n−0.568 | \n15.4 | \n2.7 | \n5.2 | \n
CLAN0.75 | \n99.00 | \n0.75 | \n3.80 | \n−0.555 | \n20.0 | \n2.4 | \n4.5 | \n
CLAN1 | \n99.00 | \n1.00 | \n4.70 | \n−0.551 | \n36.2 | \n1.1 | \n2.1 | \n
CLAN3 | \n97.00 | \n3.00 | \n7.10 | \n−0.543 | \n57.9 | \n0.5 | \n1.0 | \n
Relations of the composition of polyaniline (PANI)-MMT clay nanocomposite materials with the Ecorr, Rp, Icorr, and Rcorr measured from electrochemical methodsa.
As determined by thermogravimetric analysis.
Saturated calomel electrode was employed as reference electrode.
In a subsequent study, the same research group investigated the corrosion properties of polyaniline/clay nanocomposites prepared from Na+-montmorillonite or organo-modified montmorillonite with dodecylbenzene sulfonic acid using in-situ emulsion polymerization in the presence of aniline monomer [57]. The authors conducted a series of electrochemical measurements and concluded that the polyaniline nanocomposites coatings modified with low loading of Na+-montmorillonite exhibited better anticorrosion performance compared to conventional polyaniline on cold-rolled steel. This was attributed to the co-existence of the redox catalytic properties of polyaniline and the barrier effect of montmorillonite dispersed in the nanocomposites. Yeh and colleagues were also reported the anticorrosive properties of thermosetting polymer-layered silicate nanocomposites, such as polyimide and epoxy nanocomposites, prepared by solution dispersion procedure and thermal ring opening polymerization [58, 59]. The standard electrochemical measurements such as impedance spectroscopy, corrosion potential, and corrosion current revealed that the prepared thermosetting polymer/layered silicate nanocomposites exhibited enhanced protection against the corrosion on cold-rolled steel compared to bulk polymers. Danaee and co-workers investigated the effect of adding nanoclay on corrosion protection of zinc-rich epoxy coatings on steel [60]. The TEM findings revealed that the clay nanolayers were effectively dispersed and successfully separated between zinc particles in coating. The electrochemical measurements revealed that the incorporation of 1 wt.% clay enhanced the cathodic protection duration and sacrificial properties of the coatings. These findings clearly demonstrate that the incorporation of clay into the coating decreased the electrical contact between the zinc particles without affecting the zinc sacrificial properties. The authors indicated that high clay loadings lead to the increment of the porosity in coatings and the decrease in the intercalation of clay which could decrease the long-term protective performance of the coating. Spathis and co-workers investigated the performance of epoxy-clay nanocomposite coatings for steel protection [61]. The montmorillonite clay was firstly modified with quaternary or primary octadecylammonium cations before being mixed with the epoxy resin. The experimental findings revealed that the mechanical and thermomechanical of all epoxy-organoclay nanocomposites were enhanced compared to those of the pure epoxy polymer. The electrochemical impedance measurements indicated that the epoxy-montmorillonite clay modified with primary octadecylammonium cations exhibited better protection performance compared to those modified with quaternary octadecylammonium cations. Indeed, the total resistance value, Rtot, after 4 days exposure in the corrosive environment, improved from 1.03 × 102 of bare steel, to 5.34 × 103 in the case of pure epoxy resin, to 7.40 × 103 in the case of epoxy-loaded with clay modified with quaternary octadecylammonium ions, and to 2.96 × 104 (Ωcm2) in the case of nanocomposite made from modified clay with primary octadecylammonium ions. Importantly, the total resistance values decrease continuously in case of bare steel, with exposure time and the relation between these two factors were observed to be linear, indicating a constant corrosion rate. Importantly, the protective corrosion protection performance of the nanocomposite coatings was found to depend on the clay loading up to the saturation level. The excellent mechanical properties and thermal stability, as well as the high corrosion protection of these epoxy-clay nanocomposites, make them attractive candidates for various demanding coating applications. Al-Shahrani and colleagues demonstrated that the incorporation of modified bentonite with intercalating agents in the epoxy-based coatings resulted in the development of epoxy-bentonite nanocomposites with intercalated structures as shown in the Figure 3 [62]. The presence of the silicate layers was evident in the TEM images with different degree of intercalation. The corrosion resistance abilities of a series of epoxy-bentonite nanocomposites, as coatings on carbon steel, were evaluated by electrochemical impedance spectroscopy, in 3.5% NaCl solution, at room temperature and compared to unpigmented epoxy. The experimental findings indicated that the presence of nanolayers has successfully improved the corrosion protection of epoxy resin as shown in Table 4. Furthermore, the amount of bentonite has an influence of the performance of the coating as the epoxy modified with 3% of bentonite led to a high protection level. 5 wt% clay loading showed the lowest performance, indicating that it exceeded the saturation level of clay into the epoxy and consequently generated areas of agglomeration that can be identified as weaknesses in the coating. Such findings suggest that there is a critical loading value above which the coating might be affected [63, 64].
\nTEM micrographs of epoxy/bentonite nanocomposites: 3% (left) and 5% (right).
Coatings systems | \nResistance (KΩ.cm2) | \nCapacitance (F) | \n
---|---|---|
Neat epoxy | \n5.60 | \n4.00E-04 | \n
Epoxy and 1 wt.% clay nanocomposites | \n4.5E + 05 | \n1.04E-10 | \n
Epoxy and 3 wt.% clay nanocomposites | \n5.60E + 05 | \n9.65E-11 | \n
Epoxy and 5 wt.% clay nanocomposites | \n1.60E + 05 | \n5.00E-10 | \n
The resistance and capacitance of coated samples from electrochemical impedance spectroscopy calculations after 40 days of immersion.
Navarchian and co-workers prepared polyaniline and polyaniline/montmorillonite nanocomposites via in-situ oxidative polymerization, and the resulted nanoparticles were incorporated into the epoxy resins and coated on steel substrates [65]. The anticorrosion performance of prepared epoxy-based coatings was conducted through electrochemical Tafel and electrochemical impedance spectroscopy tests. It was reported that the epoxy coating modified by polyaniline/montmorillonite nanocomposite particles exhibited improved corrosion protection compared to unpigmented epoxy and epoxy/polyaniline coatings as it can be seen in Table 5. Furthermore, these findings indicated also that the incorporation of polyaniline and organo montmorillonite (OMMT) into epoxy coating improves its anticorrosion performance compared to polyaniline/montmorillonite and neat polyaniline. Similar findings were reported by Kalaivasan and Shafi using polyaniline/montmorillonite clay nanocomposites prepared by mechanochemical intercalation method [66].
\nSample code | \nIcorr × 106 (A/cm2) | \nEcorr × 103(v) | \nRp (KΩ cm2) | \nRcorr (mm/year) | \n
---|---|---|---|---|
Epoxy | \n1.170 | \n−483 | \n11.35 | \n0.013 | \n
Epoxy/PANI | \n0.798 | \n−463 | \n17.24 | \n0.009 | \n
Epoxy/PANI/MMT | \n0.651 | \n−459 | \n19.97 | \n0.007 | \n
Epoxy/PANI/OMMT | \n0.467 | \n−418 | \n28.51 | \n0.005 | \n
The Tafel plot data for steel panels coated with neat and modified epoxy in NaCl (3.5 wt. %) solution.
It is worth noting that the effect of clay in the polymer/layered silicate nanocomposites coatings was commonly evaluated at room temperature, and the investigation of the corrosion performance of these materials at higher temperature has attracted little attention. Do the coatings operated at high temperatures still maintain their good corrosion efficiency as even compared to that of electrode coated with neat polymer at room temperature? In this context, Yeh and colleagues performed the electrochemical corrosion parameter measurements of water-based conducting polyaniline/montmorillonite nanocomposites of polyaniline with raw Na+-montmorillonite clay [67]. In this study and based on the electrochemical tests such as corrosion potential, polarization resistance, corrosion current corrosion rate, and electrochemical impedance spectroscopy, the nanocomposite coating containing 1 wt% of clay exhibited an noticeable improved corrosion efficiency on cold-rolled steel electrode at high temperature of 50°C and was found even much better than that of no coated and electrode coated with unpigmented polyaniline at room temperature. Indeed, the Ecorr of polyaniline nanocomposites measured at 50°C (Ecorr = −572.5 mV) was lower than that of uncoated (Ecorr = −664.1 mV) and polyaniline-coated electrode measured at room temperature.
\nYeh and colleagues recently reported the anticorrosive properties of water-based polyacrylate/layered silicate nanocomposites [68]. Raw Na+-montmorillonite clay and organo montmorillonite clay were used for the preparation of nanocomposites. The anticorrosion performance of cold-rolled steel coupons coated with as-prepared unpigmented polyacrylate (denoted PMBS) and a series of nanocomposite latexes were evaluated by operating sequential electrochemical corrosion parameters, such as corrosion potential, polarization resistance, corrosion current, and corrosion rate as illustrated in Table 6. It should be noted that nanocomposite latexes with Na+-MMT clay exhibit better corrosion protection efficiency on cold-rolled steel coupons than that of with organo-MMT clay based on the studies of Ecorr, Rp, Icorr, Rcorr, and Rct.
\nCompound code | \nFeed composition (wt.%) | \nInorganic content found in the product (wt.%)a | \nElectrochemical corrosion measurementsb | \n||||
---|---|---|---|---|---|---|---|
\n | PMBS | \nMMT | \n\n | Ecorr (v) | \nRp (KΩ cm2) | \nIcorr × 10−6 (A/cm2) | \nRcorr (mm/year) | \n
Bare | \n— | \n— | \n— | \n−0.670 | \n1.91 | \n80.00 | \n37.24 | \n
PMBS | \n100 | \n0 | \n4.56 | \n−0.644 | \n13.87 | \n31.40 | \n14.62 | \n
CLMA1 | \n99.00 | \n1.00 | \n6.13 | \n−0.568 | \n20.86 | \n11.60 | \n5.40 | \n
CLMA3 | \n97.00 | \n3.00 | \n7.05 | \n−0.528 | \n67.36 | \n10.20 | \n4.75 | \n
CLMA3 (M) | \n97.00 | \n3.00 | \n7.28 | \n−0.575 | \n50.33 | \n15.20 | \n7.08 | \n
Relations of the composition of polyacrylate-latex clay nanocomposite materials with the Ecorr, Rp, Icorr, and Rcorr measured by electrochemical methods.
As determined by thermogravimetric analysis.
Saturated calomel electrode was employed as reference electrode.
In conclusion, an impressive progress has been reported during the last few years regarding the preparation and the use of polymer-clay nanocomposites for corrosion protection. These materials offer a number of advantages, such as excellent mechanical and thermal stability, improved anticorrosion protection, and wide accessibility of clay. The corrosion protection properties of these materials were found influenced by the type of the clay and curing agents used to process the nanocomposites. Despite the significant progress of research efforts, a number of challenges remain untapped to understand the complex structure in clay-based nanocomposites. For example, exfoliation of clay layers into polymers matrix is still ambiguous to understand. This is very critical to prepare new nanocomposite with enhanced corrosion properties. A highly exfoliation of the clay inside the polymer matrix is usually difficult to attain. In addition, the most of works reported in the literature revealed the absence of direct relationship between the nanocomposite structures and their final anticorrosive properties most probably, thanks to negligence of the interface properties in determination of final anticorrosion performance. An in-depth understanding of the effect of morphology of clays on the corrosion performance of nanocomposites is necessary to design an ideal coating. With these present challenges combined with emergent interest in the use of polymer-clay nanocomposites for corrosion protection, it is certain that this field will continue to be a fast-moving research topic for the next several years.
\nWe thank Philip J. Embleton from our Internal Relations Unit and Corporate Relations Division for his careful and critical reading of this manuscript.
\nEscherichia coli strains compose, physiologically part of the microflora of the gastrointestinal tract [1, 2, 3, 4]. Belonging to the Enterobacteriaceae family, fermentative, non-sporulated and facultative anaerobic commensals, they are mainly from the large intestine [5, 6].
Despite being commensal microorganisms, they are the Gram-negatives which are most often a cause of human infections, having pathogenic strains that cause a wide variety of intestinal or extra-intestinal infections, such as urinary tract, intra-abdominal and soft tissue, sepsis, neonatal meningitis, gastrointestinal infection, and pneumonia, often leading to bacteremia [3, 7]. Although Gram-positive microorganisms have been increasing as a cause of sepsis due to the instrumentation of medical care—understood as the use of invasive devices or tools for the treatment or diagnosis of patients, and to infections associated with health care—E. coli continues to be an important and perhaps the most frequent cause of threatening infections in our environment [8, 9].
They are classified as Gram-negative bacteria and divided into 3 main groups: commensal lines, intestinal pathogenic lines (enteric or diarrhea) and extra-intestinal pathogenic lines [10].
Furthermore, Gram-negative bacteria produce large molecules consisting of a lipid and a polysaccharide, known as lipopolysaccharides (LPS), lipoglycans and endotoxin, which increases their pathogenicity in relation to Gram-positive bacteria [11].
E. coli is one of the most commonly isolated bacteria in the bloodstream (responsible for approximately 20% of all clinically significant isolates) and is the Gram-negative organism most frequently isolated in adult patients with bacteremia [12]. In the United States of America, E. coli sepsis was associated with approximately 40,000 deaths in 2001, a number that corresponds to 17% of all cases of sepsis [13].
Studies have shown an increasing incidence of E. coli early-onset sepsis in all age groups, overruling group B Streptoccocus for the last 10 years. Beyond that, E. coli resistant strains also increased equally in all age groups, with high resistance rates to first line antibiotics available (ampicillin and gentamicin).
Very low birth weight newborns remained the group with higher incidence (10.4 cases per 1000 live births) and mortality (35.3%). Systematic use of PCR increased E. coli early-onset sepsis diagnosis, mainly in the term newborn group. There was also an increase in resistant E. coli strains causing early-onset sepsis, with especially high resistance to ampicillin and gentamicin (92.8 and 28.6%, respectively) [14].
Several hospital-based studies have suggested that a number of comorbid illnesses, including diabetes, malignancy, chronic lung disease, cirrhosis and heart disease, may increase the risk of E. coli bacteremia. Previous researches have also identified age (very young and very elder), hospital acquisition, comorbid illnesses, presence of shock, non-urinary focus, and antimicrobial resistance in conjunction with inadequate treatment as being associated with higher rates of death [15, 16, 17].
Dialysis, solid organ transplantation and neoplastic disease were important risk factors for acquiring E. coli bacteraemia. Ciprofloxacin resistance and non-urinary focus were independently associated with an increased risk of death [18]. For males, urinary catheterization and incontinence were associated as risk factors to Escherichia coli bloodstream, and for females, cancer, renal failure, heart disease and urinary incontinence were risk factors reported [19]. Several risk factors which have significantly mortality due to E. coli bacteremia are age, severe sepsis or shock, non-urinary origin, Charlson index, inadequate empirical treatment (Table 1).
Mortality risk factor | P | OR (95% CI) |
---|---|---|
Age | 0.03 | 1.04 (1–1.08) |
Severe sepsis or shock | <0.0001 | 14.64 (6.14–30.86) |
Non-urinary origin | 0.013 | 2.78 (1.24–6.2) |
Charlson index | 0.006 | 1.31 (1.08–1.59) |
Inadequate empirical treatment | 0.006 | 2.98 (1.25–7.11) |
Results of multivariate analyses examining risk factors for mortality associated with bacteraemia due to E. coli [15].
The human gastrointestinal tract is normally inhabited by Escherichia coli, which is why they are the bacterial species most commonly found in the isolation of fecal culture [20, 21]. By the time the strains acquire additional genetic material, they can become pathogenic and circulate widely throughout the body. Pathological clones are divided into two major groups: intestinal (among the most virulent enteric pathogens) and extraintestinal (less present, but not less dangerous) [22, 23].
Typical enteropathogenic Escherichia coli (tEPEC) contains a virulence plasmid (pEAF) that encodes the bundle-forming pilus (BFP), the primary factor for colonization [24, 25]. In addition, EPEC carries the crossomic island of locus for enterocyte effacement, which features the eae gene, which is the encoder of a colonization factor in the outer membrane protein called intimin [26, 27]. Only the E. coli strain that has pEAF and the eae gene can be considered tEPEC, one that has only the eae gene and is called atypical EPEC (aETEC) [28].
The small intestine is the most likely place for EPEC infection to occur. For the onset of diseases, tEPEC obeys the following steps:
Initial localized adhesion of organisms to enterocyte via BFP.
Induction of signal transduction in the enterocyte by secretion of protein toxins.
Development of intimin-mediated intimate adhesion to the enterocyte.
Around 20 protein toxins are injected directly into the target epithelial cell, made, together with the intimin, by the chromosomal island LEE and expressed by both tEPEC and aEPEC [29]. The complex nanomachine called type III secretion injector is the one that injects protein toxins. It is assumed that some modifications happen to the epithelial stem cells, which is physiologically absorbent, and through a pathological process, it becomes a secretory dynamo [30].
What is believed is that type III ejection toxins are responsible for binding to protein elements of the cell’s signal transduction apparatus. This event is accompanied by the mobilization of calcium from the intracellular compartment, activation of protein kinase C, kinase light chain myosin and induction of protein phosphorylation by tyrosine. The rearrangement of cytoskeletal proteins is induced by effectors, which results in the classic lesion "attaching and erasing," changes in the secretion of water and electrolytes and increased permeability of the tight intestinal junctions [31].
Enterotoxigenic Escherichia coli (ETEC) consists of ingestion of bacteria, intestinal colonization and production of virulence factors. Colonizing fimbriae (CFs) must be expressed by ETEC to allow the consolidation of the bacteria in the intestine [32].
After colonization, ETEC produces two classes of secretory toxins encoded by plasmids: heat-labile toxin (LT) and heat-stable toxin (ST). To be classified as ETEC, E. coli must contain one or both classes of toxins [33, 34].
LT toxin is related to Vibrio cholera toxins in terms of structure, function and mechanism. It works by stimulating adenylate cyclase and increasing adenosine intracellular cyclic monophosphate (AMP), a fact that stimulates chloride secretion from intestinal crypt cells and inhibits the absorption of sodium chloride at the ends of the villi. After that, the water secretion is free in the intestinal lumen, clinically developing watery diarrhea [35].
STa toxin, the only ST variant that causes disease in humans, activates cyclic GMP of enterocytes, leading to increased chloride secretion and decreased sodium chloride absorption. As a final result, the secretion of free water in the intestinal lumen clinically appears as watery diarrhea [36].
Among the pathotypes that cause the most severe conditions, the strains classified as enterohemorrhagic (EHEC) stand out, which are the most common to cause disease in developed countries [29].
They are bacteria responsible for food infections and represent a risk to the health of the population, so they must be monitored frequently. Thus, good hygiene practices, as well as the use of quality tools, are extremely important to help reduce the risk of cross-contamination and human infection.
EHEC has the ability to attach itself to the host and to produce shiga-toxins, which gives the strain pathogenicity. The toxins produced by EHEC cause damage to the mucosa of the large intestine, where they are absorbed by reaching the bloodstream, which makes it possible to affect other organs, such as the kidneys [37]. An average of 5–10% of patients confirmed with EHEC infection develop potentially fatal complications, such as hemolytic uremic syndrome (HUS), which leads to sudden renal failure and hemolytic anemia [38].
Outbreaks are related to the ingestion of contaminated food and water, causing watery diarrhea and hemorrhagic colitis to those infected. The disease has a sudden onset with severe abdominal cramps and watery diarrhea that progresses to bloody, on average after 24 hours, lasting between 1 to 8 days.
The treatment consists of supportive therapy for fluid replacement, since the use of antibiotics is not indicated, as there is no proven efficacy. In fact, it could increase the risk of developing HUS, since the death of the bacteria would increase the release of toxins, predisposing to the syndrome [39].
Enteroinvasive E. coli (EIEC) is very close to Shigella and develops a colitis similar to shigellosis. The intestinal cell is invaded by the EIEC which multiplies intracellularly and reaches the adjacent intestinal cells [40].
To differentiate Shigella from EIEC it is necessary to analyze the strains, those from EIEC ferment glucose and xylose, this differentiates them. Nucleic acid tests, including multiplexed panels, are used to detect organisms [41].
Diffusely adherent E. coli is associated with diarrhea, which is characterized as watery and can become persistent in children between 1 and 5 years of age, occurring more frequently in developing and developed countries. In addition, this bacterium is also related to urinary tract infections and complications during the pregnancy period.
The pattern of diffuse adhesion in HEp-2 or HeLa cells is a characteristic that differentiates this pathotype from the others, although DAEC strains are quite heterogeneous. This adhesion is mediated by fimbrial and afimbrial adhesins, which can cause damage to microvilli due to the disorganization of the cytoskeleton. However, some strains produce an adhesin involved in diffuse adhesion (AIDA-I), instead of encoding the diffuse adhesion pattern, which is why they are called atypical DAEC [42].
In addition, DAEC can also provide a pro-inflammatory effect [43].
The type of E. coli responsible for the invasion, colonization and induction of diseases in body sites outside the gastrointestinal tract is the extraintestinal pathogenic Escherichia coli (ExPEC). It is noteworthy that diseases caused by ExPEC range from urinary tract infections, neonatal meningitis, sepsis, pneumonia, surgical site infections to infections in other extraintestinal sites, representing a burden in terms of medical costs and lost productivity [44].
Thereto, the ExPEC strains were isolated from food products, in particular raw meat and poultry, indicating that these organisms potentially represent a new class of foodborne pathogens [45].
Almost 25% of sepsis cases originate from the urogenital tract. [46, 47, 48]. Considering this percentage, the most common pathogen that causes urinary tract infection (and, consequently, urosepsis) is Escherichia coli (50%) [49]. It is known that this condition is better managed with an interprofessional team of health professionals—a nephrologist, infectious disease expert, urologist, intensivist, a nurse and a pharmacist [50, 51]. The outcomes after urosepsis depend on the cause and severity of the infection, and if the patient has a complicating factor in the urinary tract that is identified and warrants treatment, it should be performed as soon as possible. As an example, the literature reveals Foley catheter placement to relieve urinary retention or stent placement to bypass an obstructing ureteral calculus causing urosepsis. Moreover, the prognosis also depends on the type of bacteria, antimicrobial resistance, and patient comorbidity.
In addition to early antibiotics, there are some important parts of the management of sepsis. Initial fluid resuscitation with crystalloid is still recommended at a minimum of 30 mL/kg. Consider early administration of vasopressor support to maintain a mean arterial pressure greater than 65 mm Hg. The first choice for vasopressor support in sepsis is norepinephrine (with epinephrine and vasopressin 2 and 3). Tight glucose control is also recommended, with corticosteroids and blood products being more controversial in the literature [52].
Although Escherichia coli is one of the most-studied microorganisms worldwide, its characteristics are constantly changing. Elseways, one important global problem is the increase of antimicrobial resistance shown by bacteria, being considered as “threatens the achievements of modern medicine” [53, 54].
E. coli resistant strains increased equally in all age groups, with high resistance rates to our first line antibiotics (ampicillin and gentamicin), with relevant highlight in neonatal E. coli isolates from invasive infection [55]. Table 2 shows the temporal trends for antibiotic resistance to E. coli.
Agent or phenotype [n (%)] | 1997 n = 58 | 1998 n = 49 | 1999 n = 52 | 2000 n = 83 | 2001 n = 86 | 2002 n = 70 | 2003 n = 87 | 2004 n = 122 | 2005 (January–June) n = 56 | Total n = 663 | P |
---|---|---|---|---|---|---|---|---|---|---|---|
Ampicillin | 27 (46.6) | 24 (49) | 24 (46.2) | 50 (60.2) | 54 (62.8) | 46 (65.7) | 55 (63.2) | 70 (57.9) | 35 (62.5) | 385 (58.2) | 0.02 |
Trimethoprim/sulfamethoxazole | 14 (24.1) | 11 (22.4) | 13 (25.0) | 28 (33.7) | 21 (24.4) | 28 (40) | 32 (36.8) | 41 (33.6) | 20 (35.7) | 208 (31.4) | 0.02 |
Ciprofloxacin | 9 (15.5) | 7 (14.3) | 10 (19.2) | 7 (8.4) | 14 (16.3) | 16 (22.9) | 22 (25.3) | 27 (22.1) | 13 (23.2) | 125 (18.9) | 0.02 |
Amoxicillin/clavulanate | 9 (15.5) | 4 (8.2) | 9 (17.3) | 16 (19.3) | 8 (9.3) | 7 (10) | 11 (12.6) | 15 (12.3) | 20 (35.7) | 99 (14.9) | 0.1 |
Gentamicin | 4 (6.9) | 6 (12.2) | 5 (9.6) | 5 (6.0) | 8 (9.3) | 6 (8.6) | 7 (8.0) | 8 (6.6) | 8 (14.3) | 57 (8.6) | 0.8 |
Piperacillin/tazobactam | 1 (1.7) | 4 (8.2) | 1 (1.9) | 8 (9.6) | 6 (7.0) | 4 (5.7) | 5 (5.7) | 2 (1.6) | 2 (3.6) | 33 (5) | 0.4 |
Cefotaxime | 11 | 2 (4.1) | 0 | 2 (2.4) | 3 (3.5) | 5 (7.1) | 3 (3.4) | 12 (9.8) | 4 (7.1) | 31 (4.7) | 0.001 |
ESBL production | 0 | 0 | 0 | 2 (2.4) | 3 (3.5) | 3 (4.3) | 2 (2.3) | 9 (7.4) | 3 (5.4) | 22 (3.3) | 0.002 |
MDR | 4 (6.9) | 4 (8.2) | 5 (9.6) | 9 (10.8) | 9 (10.5) | 12 (17.1) | 15 (17.2) | 17 (13.9) | 12 (21.4) | 87 (13.1) | 0.006 |
Number, yearly percentages, and P values for temporal trend of non-susceptible cases of E. coli bacteraemia.
The sepsis’ diagnosis confirmation is done from the evaluation of the clinical status of the patient, analyzing some criteria. For adult patients, it is confirmed or a diagnosis of sepsis is made when two criteria are present: hyperthermia>38.3 °C or hypothermia <36°C, tachycardia>90 bpm, leukocytosis (>12,000 μL-1) or leukopenia (<4000 μL-1) or >10% bands, acutely altered mental status, tachypnea > 20 bpm, hyperglycemia (>120 mg/dl) in the absence of diabetes [56].
Collect a careful history from patient, addressing information such as previous illnesses, surgeries, how long ago the symptoms started, if there are comorbidities, if it have traveled to a place recently and other details, added to a complete physical examination, which provides very relevant information and leads to a line of rationality, it is extremely important to start the development of a preliminary differential diagnosis of the patient’s complaints.
All this information collected is recorded and saved in medical records, more recently, electronics, which are more organized, more readable and allows a better comparison, in relation to written records [57].
Some of the most frequent reasons that lead patients to go to a medical consultation are dyspnea, cough with or without hemoptysis and chest pain, as these symptoms can be indications of serious illnesses, it shows the importance of asking questions and exams in a way attentive and careful [58].
Ventilator-associated pneumonia (VAP) is the most common fatal hospital infection [59]. One of the bacteria most involved in the clinical picture in question is Enterobacteriaceae Escherichia coli [60, 61] and there is little awareness when it comes to the pathophysiology of E. coli pneumonia.
Studies show that these E. coli pathogenic islands (PAIs) are involved differently in the pathogenicity of the lung compared to those present in urinary tract and bloodstream infections [62]. In addition, research on mice has also shown that these isolated strains are highly virulent extra-intestinal pathogens that express virulence factors, representing potential targets for new therapy. A French national study also demonstrated that, despite the genomic and phylogenetic characteristics of E. coli pneumonia isolates from critically ill patients, they belong to the same extra-intestinal pathogen as E. coli, they have specific distinct characteristics when lungs [63].
E. coli meningitis is rare in adult forms of the disease [64, 65, 66], but it is a frequent pathogen in the pediatric field [67]. Despite its rarity, it has a serious clinical course [64, 65, 66]. It is usually diagnosed based on clinical signs and cerebrospinal fluid (CSF) analysis.
Due to the severity of the disease, early diagnosis, adequate antibiotic treatment and hemodynamic control are essential [68].
E. coli meningitis follows a high degree of bacteraemia and invasion of the blood–brain barrier. With mortality rates ranging from 15 to 40%, Meningitis due to this bacterium leaves approximately 50% of survivors with some type of neurological sequelae [69, 70, 71, 72, 73, 74, 75, 76, 77, 78].
Although the process is unknown, it is known that, for the onset of the disease, it is necessary to have an invasion of the blood–brain barrier by E. coli, which requires specific microbial and host factors such as specific signaling molecules for microbes and hosts. Thus, blocking these microbial and host factors that contribute to the invasion of the blood–brain barrier by E. coli is effective in preventing the penetration of E. coli into the brain.
With the complete discovery of this mechanism, it is likely that new targets for the prevention and therapy of Escherichia coli meningitis will be achieved [79].
Regarding treatment, it is currently known only that antimicrobial chemotherapy has limited efficacy [79, 80, 81].
Intra-abdominal infections (IAI) are invasive and bacterial multiplications in the hollow organ walls and beyond. Usually, it is located in the abdominal cavity, in the retroperitoneum and in the abdominal organs, being a common complication in the post-surgical period [82]. In addition, they have a wide variety of pathological conditions, from appendicitis to fecal peritonitis, which makes IAI generally have a poor prognosis (especially in high-risk patients) and is an important cause of morbidity [83]. Mostly, the most common source of this infection is the appendix, followed by gastroduodenal perforations. The Gram-negative bacteria E. coli is the most common causative agent of IAI. Therefore, it is important to know that they have great sensitivity to imipenem, meropenem, mainly, and to amoxi-clavulanate, amikacin and piperacillin-tazobactam, next [84, 85]. However, amici-clavulanate is prescribed as a first-line drug in developing countries, due to cost factors [86].
Although E. coli strains have been isolated as part of the normal beneficial flora of the intestine, some strains have developed pathogenic mechanisms to cause disease in humans and animals. One of these strains capable of causing diseases is enteric Escherichia coli (E. coli), comprising important pathogens, since they cause significant morbidity and mortality worldwide. Traditionally enteric E. coli was divided into 6 pathotypes, however two other divisions were proposed by several studies (as mentioned individually in topic 4) [87].
Although there are many etiological agents responsible for diarrhea, pathogenic E. coli is a major contributor. On the other hand, the onset and complications of enteric E. coli vary significantly, despite there are many common features in the pathogenic process of colonizing the intestinal mucosa and the onset of disease [88].
Outbreaks are common all over the world, with fatal consequences mainly in children under 5 years of age living in underdeveloped countries, where diarrheal diseases can lead to death more frequently [89].
The transmission of enteric E. coli is also a public health concern, related to the development of countries, since its transmission is through contaminated water and food. Thus, the seriousness in relation to the microorganism can be exemplified by national and international surveillance programs, created by developed countries that aim to constantly monitor outbreaks [90]. In developing countries ETEC, EPEC and EAEC are considered to be the main causes of childhood diarrhea, and when left untreated, they have potentially fatal consequences. However. in developed countries, these infections are mild and self-limiting, with EHEC and, more recently, EAEC and STEAEC being the main E. coli pathotypes associated with food poisoning outbreaks [91, 92].
Among the most common types of bacterial infections that occur both in the community and in hospitals, urinary tract infections (UTI) stand out. Urinary tract infections can be associated with the hospital (HAUTIs) and the community (CAUTIs). In the case of CAUTIs, it is known whether women are the predominant group of patients.
Although the UTI is multifactorial, the main bacteria related to the diagnosis is E. coli, predominant in both community and nosocomial UTIs [93].
Co-trimoxazole (trimethoprim/sulfamethoxazole), nitrofurantoin, ciprofloxacin and ampicillin are the antibiotics commonly recommended for the treatment of UTIs. However, there is an overall increase in antibiotic resistance among pathogens in the urinary tract, which is a limitation on treatment options [94, 95].
Since the evidence suggests a significant relationship between the extensive use of antibiotics and antimicrobial resistance, it is necessary to prescribe and use antibiotics in order to reduce their complications and costs [96].
For this reason, in order to guide the selection of empirical therapy, surveillance of antibiotic resistance is crucial for determining the pattern of antimicrobial resistance [97].
It aims to check the presence of fungi and bacteria in the urine, being carried out from a urine sample, which was placed in Petri dishes. The urine culture is placed in an incubator (1–2 days) and if there is any microorganism in the tested material, colonies grow and are visible on the plate. When the result is positive for some bacteria, a test antibiogram is performed, which determines the type of antibiotic needed to act against the pathogen [98].
The culture of urine is important precisely because it allows the precise recognition of the bacteria and, consequently, the best antibiotic to be used [99].
As urine culture is most frequently requested when UTI is suspected, the most common bacteria found are Escherichia coli (between 47.5% and 56.4% of all urine culture) [100, 101].
Blood culture is part of the routine assessment of patients with suspected bloodstream infection, and is crucial to guide therapeutic intervention. The ideal method for collecting blood culture is venepuncture, since it increases diagnostic yield, and has lower rates of contamination, according to some studies [102].
Since the timing of blood culture collection does not influence the detection of clinically relevant microorganisms, most authorities recommend collecting several sets simultaneously or for a short period of time, with the exception of patients with endovascular infection who need documented continuous bacteremia [103, 104].
Two to four sets of blood samples should be collected, whenever possible, at independent locations [103, 104, 105, 106]. For adults, the volume required for the examination varies between 40 and 160 mL of blood, and for babies and children, the volume is age-based and does not exceed 1% of the patient’s total blood volume [103, 107].
The importance of blood culture, as well as urine, is related to the determination of the bacteria and the antibiogram, which directs the treatment to the best antibiotic to be used [108].
In some cases, it is possible to suspect a complicated urinary tract infection/urosepsis without being serious urological abnormalities. In such cases, there are some screening options that can be performed to assist in the management of the patient. Thus, simple abdominal radiography, intravenous urography, ultrasound, computed tomography and magnetic resonance imaging are cited [109].
The anatomical identification of most areas of infection has become common with the development of high resolution cross-sectional images, which allow visualization of bacterial and viral metabolism, early diagnosis and treatment. Thus, the cross-sectional image was included as part of the routine investigation of unidentified infection sites and sources of sepsis. The trend is that the use of these images will become increasingly widespread and become part of standard clinical care in the near future [110].
When abdominal sepsis is suspected, ultrasound is a valuable tool. As it is a portable scanning technique, it is ideal for clinically unstable patients who cannot be transported to an examination room [110].
Ideal for the diagnosis of liver sepsis and gallbladder, ultrasound identifies and indicates the presence and location of intra-abdominal fluids (subphrenic space, in pericological calculations or pelvis) [110, 111, 112, 113]. Intrahepatic fluids are also well visualized, and can even be drained percutaneously with ultrasound guidance [110].
The main obstacle for ultrasound responses is air interference, highlighted in loop regions of the intestine with intraluminal gas, since the USG image is darkened and makes it difficult to visualize interloop abscesses or peri-pancreatic collections. The intestine in patients with disease due to sepsis or recent intra-abdominal surgery is also capable of compromising the quality of the ultrasound [114].
The availability of CT scanners with multiple detectors allows rapid acquisition of images, making this method the most common in the diagnosis and detection of intra-abdominal abscesses [114, 115]. It is an interesting option especially for sick patients who have difficulty holding their breath, obese or with abdominal or chest bandages.
In addition, CT is essential in the diagnosis of interloop and retroperitoneal pathologies (including retroperitoneal abscesses or pancreatitis or intra-biliary stones), in addition to being highly sensitive in the detection of chest pathologies (pneumonia, pleural effusion and localized collections) [113, 115, 116, 117]. For intra-abdominal fluids and abscesses, CT showed a sensitivity of 90–100%, while ultrasound showed sensitivity between 80% and 85% [115, 118, 119].
Due to the contemporary contrast protocols available, it is possible to identify by CT even small infected collections [110].
With the development of hybrid cameras, the combination of PET and magnetic resonance imaging was introduced, which despite having interesting advantages and clinical applications, is still such an expensive tool.
The simultaneous acquisition of PET and magnetic resonance imaging can provide quantitative molecular functional information about the inflammatory lesion and precise location, in addition to anatomical changes with movement correction, improving the differential diagnosis and guiding anti-inflammatory treatment strategies.
Since MRI cannot visualize all parts of the body at once, the new hybrid technique may require collaboration between radiologists and nuclear medicine doctors to interpret the image and can be more expensive than PET/CT (capital and operational costs).
The functional image of inflammation and infection was mainly restricted to the flat image and SPECT, however, with the increasing development of PET radiopharmaceuticals, the detection and quantification of specific aspects of inflammatory processes became more sensitive. Precisely for this reason, there is an interesting potential in the application of hybrid whole body PET/MRI in the context of the investigation of infectious and inflammatory diseases [120].
Imaging technique that uses biological radionuclides to track hidden infections and improve the specificity of the infection diagnosis that allows the detection of early pathophysiological changes even when there are no apparent anatomical changes. When compared to ex vivo techniques (blood culture), in vivo biological screening is preferred since it is accurate, does not require a sterile environment and does not expose the health team to the risk of contamination by blood-borne pathogens.
This type of tool is used mainly in patients suspected of infection or abscess, but who have had negative results for the cross-sectional image. Thus, the use of marked leukocyte traffic allows a response to hidden sites, based on the recognition of white blood cells marked with radionuclides. The marked leukocytes travel to the infection sites and allow noninvasive images in areas of hidden infection, such as osteomyelitis, orthopedic prosthesis, endocarditis or inflammation and intestinal disease [110].
Adequate organ perfusion must be ensured. Hypotension should be managed initially with intravenous fluid administration and the goal should be maintenance of pulmonary capillary wedge pressure at 12–16 mm Hg or central venous pressure at 8–12 cm H2O. Urine output rate should be kept at greater than 0.5 mL/kg/hr. A mean arterial blood pressure of greater than 65 mmHg (systolic blood pressure greater than 90 mmHg) and a cardiac index of greater than or equal to 4 L/min/m2 should be maintained. Vasopressor therapy should be initiated in the event of failure to achieve these goals with iv fluids alone. These include dopamine, dobutamine and norepinephrine [109].
Ventilatory support should be provided for patients with progressive hypoxemia, hypercapnia, altered sensorium or respiratory muscle fatigue. A study of “early goal directed therapy” (EGDT) found that prompt resuscitation to maintain SvO2 > 70% was associated with improved survival in patients of severe sepsis [121]. In this study, failure to maintain saturation after fluids and vasopressors was followed by erythrocyte infusion to raise hematocrit to 30%. Patients requiring mechanical ventilation should be adequately sedated and stress ulcer prophylaxis should be administered.
Blood glucose levels should be maintained at less than 150 mg/dL during initial few days of severe sepsis and normoglycemic range could be targeted later. Frequent blood glucose monitoring should be done to avoid hypoglycemia in patients on intensive insulin therapy. Multi-organ dysfunction, if any should be managed. Disseminated intravascular coagulation, if accompanied by major bleeding, should be treated with fresh-frozen plasma and platelet transfusion. Hypercatabolic individuals with acute renal failure benefit substantially from hemodialysis or hemofiltration. Prophylaxis for deep vein thrombosis and nutritional supplementation should be undertaken [109].
Considering the limited knowledge about the combination of antibiotics, the susceptibility of these pathogens to drugs and the lack of evidence to support the routine use of combined antimicrobial therapy, the decision regarding the ideal therapy is the responsibility of medical professionals [122]. Regarding the most appropriate approach, it is prioritized in the literature that the optimization of antimicrobial therapy includes adaptation of the appropriate antibiotics in terms of class, dose, frequency, route and duration [123].
The combination of different antibiotics has been widely used by large centers when it comes to invasive infections by multi-resistant Gram-negative bacteria [122].
The various positive and negative aspects of combination therapy are depicted in Table 3.
Positive aspects of combination therapy for treatment | Negative aspects of combination therapy for treatment |
---|---|
1. Greater probability of choosing an effective agent and well-founded theoretical reasons to support its use 2. Considering the increase in mortality related to the delay in the establishment of treatment and delays in appropriate and effective antimicrobial treatment, it is prudent to initiate empirical broad-spectrum antimicrobial treatment in the first suspected infection in critically ill patients 3. Indicated for patients with compromised immune systems, previous ICU admissions or who have recently received broad-spectrum antibiotics [124] | 1. Increased toxicity in treatment by combining antibiotics (nephrotoxicity and ototoxicity). In such cases, it is suggested to discontinue the old therapy and introduce a new one, based on the clinical evolution of the patient and the results of the culture and susceptibility profile 2. This type of therapy has not been shown to be effective by clinical data (meta-analyses performed with the evaluation of randomized clinical trials demonstrate that there was no difference in clinical results between the two strategies for definitive treatment of Gram-negative bacteria infections) [124] |
Comparison of positive and negative aspects of combination therapy.
Antibiotics such as colistin are the last resort to deal with infections by carbapenem-resistant Enterobacteriaceae (CREB), and when the pathogen does not respond to colistin, therapeutic options are severely restricted. Thus, it becomes necessary to restore the sensitivity of the pathogen to the drug [125].
The combination of colistin + salicylate + potent efflux pump inhibitor (BC1) has been documented with highly positive results, providing a connection between colistin and the efflux pump inhibitor (BC1), which prevents extrusion of colistin [126].
The reduction in affinity between the drug and Gram-negative bacteria is due to the modification of lipid A, linked to the appearance of the gene that confers resistance to bacteria, which is present in animals that receive colistin and are part of human food. Despite this, there is still no complete explanation of the mutation and resistance of Gram-negative bacteria (especially Enterobacteriaceae) in patients who received administered colistin [127].
Due to the increased resistance of bacteria to cephalosporin (and aminopenicillins), the use of narrow-spectrum β-lactamases, especially carbapenems, has increased considerably, being the only β-lactamase antibiotics with proven effectiveness in serious infections due to ESBL-producing bacteria [128, 129, 130].
With the discovery of E. coli isolates capable of producing new b-lactamases, a new strain of E. coli was found capable of resisting the action of carbapenems, mediated by plasmids.
These enzymes are able to confer resistance to drugs of the class b-lactamases, and in relation to E. coli specifically, the main types of enzymes are CMY, CTX-M and NDM of b-lactamase [131].
Tigecycline is a new expanded-spectrum antimicrobial agent in the glycylcycline class. Developed with the objective of overcoming the most common processes of bacterial resistance, the drug has emerged as a great therapeutic option in the treatment of serious infections, which endanger the patient’s life, and which no longer respond to traditional antibiotics. The use of tigecycline is mainly interesting for the initial therapy of major infections, and is largely effective in the action against multi-resistant Gram-negative bacteria [132].
Aminoglycosides are natural or semi-synthetic drugs obtained from actinomycetes, used as an antibiotic since the beginning of bacterial treatment. As it was replaced in the 1980s by cephalosporins, carbapenems and fluoroquinolones, aminoglycosides had little use.
With the increase in the number of cases of multidrug-resistant bacteria, aminoglycosides were again considered for their ability to synergize with a variety of other classes of antibacterials, improving the safety and effectiveness of the class through optimized dosing regimens, being broad-spectrum and quickly bactericidal.
Enzymatic modification by acetylation of an amino group, impaired uptake and phosphorylation of aminoglycosides are the most commonly reported processes that confer resistance to bacteria in relation to aminoglycosides [133].
Fosfomycin is an antibiotic from the 1969s, prescribed mainly in its oral form for the treatment of uncomplicated urinary tract infections (UTI), and considered as an option in the treatment of bacteria with advanced resistance, causing serious infections [134].
For E. coli NDM-producing strains, fosfomycin, colistin and tigecycline are more effective than other antibiotics [135].
The best pharmacological approach to E. coli infections resistant to carbapenems is still an obstacle to be overcome, since patients infected with this type of bacteria have more limited clinical results and when compared to patients infected with bacteria susceptible to drugs [136].
The duration of treatment for infection caused by Escherichia coli varies in the literature, but most patients require treatment for about 14–21 days [109]. For E. coli perinephric abscesses or prostatitis, it is recommended that the minimum antibiotic use time should be 6 weeks, intra-abdominal infections 14–21 days, and pneumonia 14 days (Table 4) [137].
Condition | General | Perinephric abscesses | Prostatitis | Intra-abdominal infections | Pneumonia |
---|---|---|---|---|---|
Duration | 14–21 days | 42 days | 42 days | 14–21 days | 14 days |
Recommended duration of antibiotic therapy depending upon the type of infection.
In general, infectious diseases occur more frequently and cause greater concern when dealing with diabetic patients. This occurs because the environment offered by the organism is rich in glucose, which favors immune dysfunction, including decreasing the antibacterial activity of the urine and its motility [138].
Moreover, when comparing E. coli isolated in the urine of diabetics and non-diabetics, the same virulence factors and the same resistance to antimicrobials are found, inferring that there is no difference in the causative bacteria. This way, what makes the prevalence of urinary infections to be higher in diabetic patients is the greater adhesion of E. coli bacteria to diabetic uroepithelial cells, the reduction of urinary cytokine secretion and the number of leukocytes [139].
Hence, to treat the disease, the most commonly prescribed antimicrobials are used—amoxicillin, nitrofurantoin, trimethoprim/sulfamethoxazole (TMP/SMX) and ciprofloxacin. It is understood that the same treatment choice used by nondiabetic patients can be made, depending only on the local resistance patterns of the commonly found uropathogens [140, 141].
Generally, most uropathogens have a high resistance to TMP/SMX, in addition, this antimicrobial can cause hypoglycemia, which makes it not a good first choice of treatment for this portion of patients [142].
As for the treatment, it is recommended to consider the urinary tract infection complicated, it is advisable to keep the treatment for a period of 7 to 14 days [143].
Acute pyelonephritis is an infection located in the upper urinary tract, which accommodates either parenchyma and renal pelvis, with Escherichia coli being the most common etiological agent [144, 145].
Approximately 250,000 cases of this disease are reported each year, with more than 100,000 eventually requiring hospitalization [146].
In order to confirm the diagnosis of the disease, the patient’s urine culture is performed before the start of antibiotic therapy [147]. In addition, it is recommended to perform a microbial susceptibility test in order to select the most appropriate antimicrobial regimen [148, 149].
If the diagnosis is uncertain or the patient is immunocompromised and suspected of having a hematogenic infection, blood culture analysis is requested [150, 151].
In the last few decades, there has been an increasing rate of resistance of E. coli bacteria to beta-lactam antibiotics of extended spectrum [152]. Thus, for patients with mild and uncomplicated acute pyelonephritis, fluoroquinolone is a good choice for initial outpatient antibiotic therapy, if the drug resistance rate is 10% or less in the community [153].
On the other hand, in cases of complicated infections, sepsis or failed outpatient treatment, hospital treatment is best indicated [154]. After antibiotic therapy, urine culture should be performed again after 1–2 weeks to conclude whether the treatment was successful or not [155].
Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma and its surrounding tissues—resulting in the presence of gas in the renal parenchyma, collecting system or perinephric tissue—and is caused in 70% of cases by Escherichia coli (isolated in cultures of urine or pus from patients with the condition) [156].
The clinical evolution of EPN when not recognized and treated immediately can be serious and pose a risk to the patient’s life. Another fact that should be mentioned is that up to 95% of the cases of EPN are underlyingly associated with uncontrolled diabetes mellitus [157, 158].
In addition to the risk of developing EPN primarily, the risk of developing secondary to an obstruction of the urinary tract is considerably relevant, about 25–40% can be considered as positive findings in EPN [159, 160].
The combination of percutaneous drainage (PCD) and medical management (MM) revealed a significant reduction in mortality rates [161, 162]. Thus, it is recommended that PCD be performed in patients with localized areas of gas and the presence of functional renal tissue. Another approach that can be used in association with treatment is emergency nephrectomy, classified as simple, radical or laparoscopic [163].
Being caused by kidney stones, structural abnormality, history of urological surgery, trauma or any other cause of obstruction, renal abscess can also be related to pathogens [164]. The predominant organisms causing renal abscesses are Gram-negative organisms, and the most common is Escherichia coli [165, 166, 167].
Among the various intra-abdominal abscesses, renal abscess is a rare entity, especially in children and accounts for a number of cases of “missed diagnoses” [166, 168].
With regard to the symptoms of pediatric patients, the presentation of fever, flank pain, with or without a palpable mass, has been established in the literature; increased leukocyte count and increased erythrocyte sedimentation rate [169].
Early diagnosis is a key factor in the management of these patients, which can be aided by Ultrasound (USG). Drainage of pus and appropriate antibiotic therapy is the gold standard for treatment, being able to treat a great amount of cases. Thereby, the most successful combination of antibiotics was ceftriaxone, being associated with amikacin. Cases that cannot be resolved by the conventional approach can be treated with surgery, such as nephrectomy. Thus, complications such as extension of the peritoneal cavity, skin or chest can be avoided [166, 167].
Perinephric abscess results from perirenal fatty necrosis, usually a complication of urological infection (more than 75%) [170]. Most of these abscesses have Escherichia coli as the main responsible, about 51.4% [171]. Perinephric abscess, when more diffuse, is capable of affecting the renal capsule and also Gerota’s fascia [170]. Since the condition has an insidious onset of nonspecific protein symptoms, it is necessary for a clinical physician to maintain a high level of attention to avoid possible delay in diagnosis, since perinephric abscesses are associated with significant morbidity and mortality [172].
Renal papillary necrosis (NPN) is a condition defined as ischemic necrobiosis of the papilla in the kidney medulla. Among several etiological factors important for the involvement of papillary necrosis, pyelonephritis due to bacterial uropathogens such as E. coli is one of those mentioned in the literature [173].
In order to improve the prognosis of the disease and reduce morbidity, the ideal is that the diagnosis of the disease is as early as possible. In this sense, it is clear that the radiological image is able to offer an early diagnosis and guidance in relation to the immediate treatment of papillary necrosis, thus minimizing the decline in renal function [174].
Failure to respond to standard therapy for acute bacterial prostatitis can lead to complications, such as prostate abscess or fistula [175].
Acute bacterial prostatitis is a common and clinically important genitourinary disorder that has a higher incidence in patients with diabetes, cirrhosis and suppressed immune system. Usually caused by an ascending infection, it can also be triggered by organisms that cause other common genitourinary infections that may also be responsible for acute bacterial prostatitis. Being introduced during transrectal prostate biopsy, the clinical presentation ranges from mild symptoms of the lower urinary tract to total sepsis, and Escherichia coli is one of the main bacteria related to the clinical picture.
Regarding the therapeutic approach, oral or intravenous antibiotics are most effective in curing the infection. In this sense, the progression to chronic bacterial prostatitis is uncommon. It should be noted that special attention is needed in relation to immunosuppressed patients, whereas bacterial prostatitis in these patients may be caused by atypical infecting organisms and, therefore, may require additional therapies [176].
It is already known that iron is an essential micronutrient for most bacteria and hosts, in this thought line, it is also known that there are relatively rare classical siderophilic pathogens that cause an increase in hepcidin in the body, responsible for the sequestration of iron for macrophages and enterocytes and, consequently hypoferremia [177, 178, 179, 180]. So, current studies investigate if this mechanism used by the body against rare siderophilic bacteria, it also works for a wider set of bacteria. Results of these studies are shown to be positive, by demonstrating that excess iron allows rapid bacterial replication and spread, which means a susceptibility to infection caused by E. coli and that hepcidin is essential to protect against infections caused by Escherichia coli. [181, 182]. Thus, the use of hepcidin agonists promises to be an effective early intervention in patients with infections and dysregulated iron metabolism to avoid complications.
With regard to urinary tract infection, an effective preventive measure is the characterization and correction of the underlying genitourinary abnormalities that promote the infection. Another alternative mentioned in the literature is the future development of catheters whose material limits the growth of biofilm [109].
Early symptom recognition, followed by appropriate investigations, accurate diagnosis and early goal-directed therapy, is essential to improve results. Patient management includes an interprofessional team approach, with microbiologists, radiologists, surgeons and intensive care physicians [109].
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She performed research in perioperative autotransfusion and obtained the degree of PhD in 1993 publishing Peri-operative autotransfusion by means of a blood cell separator.\nBlood transfusion had her special interest being the president of the Haemovigilance Chamber TRIP and performing several tasks in local and national blood bank and anticoagulant-blood transfusion guidelines committees. Currently, she is working as an associate professor and up till recently was the dean at the Albert Schweitzer Hospital Dordrecht. She performed (inter)national tasks as vice-president of the Concilium Anaesthesia and related committees. \nShe performed research in several fields, with over 100 publications in (inter)national journals and numerous papers on scientific conferences. \nShe received several awards and is a member of Honour of the Dutch Society of Anaesthesia.",institutionString:null,institution:{name:"Albert Schweitzer Hospital",country:{name:"Gabon"}}},{id:"83089",title:"Prof.",name:"Aaron",middleName:null,surname:"Ojule",slug:"aaron-ojule",fullName:"Aaron Ojule",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Port Harcourt",country:{name:"Nigeria"}}},{id:"295748",title:"Mr.",name:"Abayomi",middleName:null,surname:"Modupe",slug:"abayomi-modupe",fullName:"Abayomi Modupe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Landmark University",country:{name:"Nigeria"}}},{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94191/images/96_n.jpg",biography:"Prof. Moustafa got his doctoral degree in earthquake engineering and structural safety from Indian Institute of Science in 2002. He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. 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