Cytokine concentrations and parasite copy number (×107)/ml in dogs with visceral leishmaniasis in different clinical staging.
\r\n\tfires. Infrastructure development and human settlements are blocking migratory corridors, thus suppressing their critical role of maintaining the ecological processes including allowing for the movement of animals and the continuation of viable populations. Human-wildlife conflicts are growing as a
\r\n\tresult of population growth and, therefore, increasing demand for natural resources and increased proximity to wildlife.
\r\n\tExotic and invasive species are outcompeting native species for resources or habitat and altering community structure with detrimental consequences on native species.
\r\n\tImpacts of climate change on wildlife are increasing and manifested through habitat destruction, increased human-wildlife conflicts, diseases and death of wild animals. Illegal and unsustainable hunting is increasing to cater for subsistence and commercial demands within and outside the national boundaries, thus leading to a dramatic drop of populations or extinction of species.
\r\n\tChapters presented in this book attempt to respond to four questions: How do the political, economic, social, ecological and technological changes influence the survival of wildlife? How do these changes shape the management policies and approaches? How effective are the existing strategies and options to coping with these changes? Which are the possible options to address these changes and secure a future for wildlife?
\r\n\r\n\tThis Book serves as an important platform for information and experience sharing among the scientists, academicians, students, conservationists and policy-makers from different parts of the world.
",isbn:"978-1-83880-976-8",printIsbn:"978-1-83880-975-1",pdfIsbn:"978-1-83880-977-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"a27827009edc70af81e12c10aa3e51dd",bookSignature:"Prof. Jafari Kideghesho",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/8834.jpg",keywords:"Wildlife, Conservation, Poaching, Law Enforcement, Protected Areas, Wildlife Habitats, Migratory Corridors, Wildlife Diseases, Invasive Species, Wildlife Utilization, Human-Wildlife Interactions, Wildlife Conservation Policies",numberOfDownloads:233,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 15th 2020",dateEndSecondStepPublish:"June 5th 2020",dateEndThirdStepPublish:"August 4th 2020",dateEndFourthStepPublish:"October 23rd 2020",dateEndFifthStepPublish:"December 22nd 2020",remainingDaysToSecondStep:"9 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Dr. Kideghesho served as a Deputy Director of Wildlife Division in Tanzania's Ministry of Natural Resources and Tourism for two years (2012-2014). 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(Agriculture) from Sokoine University of Agriculture (SUA), Tanzania in 1993. He has worked for over 25 years in various positions in the Wildlife Sector as Assistant Lecturer at CAWM, Mweka, Lecturer, Senior Lecturer and Associate Professor at the Department of Wildlife Management at SUA and Assistant Director (Wildlife Utilization) in the Ministry of Natural Resources and Tourism. Kideghesho has been involved in over 20 local and international professional committees and organizations as a member, moderator, external examiner and a reviewer of scientific journals. He has published about 60 scientific articles and book chapters in peer reviewed journals and edited books, several articles in Conference Proceedings and 9 in Tanzania’s popular Wildlife Magazine. He is an editor of a book titled - Wildlife Management: Failures, Successes and Prospects. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"63803",title:"Surgical Resection in HCC",doi:"10.5772/intechopen.81345",slug:"surgical-resection-in-hcc",body:'Hepatocellular carcinoma (HCC) is the second most lethal malignancy worldwide [1]. Despite the advent of effective antiviral drugs to eradicate hepatitis C infection, the prevalence of HCC is projected to increase secondary to increasing rates of fatty liver disease from diabetes and the obesity epidemic [2]. Unfortunately, there has been little to no change in the survivability of HCC over the last three decades [3] in spite of the increasing array of therapeutic options, leaving much room for improvement. The armamentarium for managing HCC is wide and includes surgical resection, orthotopic liver transplantation (OLT), ablative techniques using ethanol (percutaneous ethanol injection, PEI), microwave (MWA) or radiofrequency (RFA), catheter-directed transarterial chemoembolization (TACE) or radioembolization (TARE), external beam radiation therapy in the form of stereotactic body radiation therapy (SBRT) or proton beam therapy (PBT), systemic targeted small molecule tyrosine kinase inhibitors, check-point inhibitor immunotherapy and investigational agents. These modalities are often used together in a multidisciplinary approach.
Surgical resection, or partial hepatectomy (PH), is a potentially curative surgical treatment option for up to 15–20% of patients with HCC. The primary objective of PH is to remove the HCC with an adequate margin, while preserving as much functional liver parenchyma to avoid post-resection hepatic failure. With improvements in preoperative assessment, patient selection, surgical and anesthetic techniques, intraoperative ultrasound, PH for HCC is now routine and safe. Operative mortality has been reduced to less than 5% with a 5-year overall survival of 60–75%.
Several factors are considered in determining the eligibility for PH, including the patient’s health status (e.g. age, ECOG PS), tumor-specific factors (e.g. extent and tumor biology), and the reserve of the liver remnant. Determined by the degree of liver dysfunction and the size of the postoperative liver remnant. While there is no strict age limit, one must consider the liver’s regenerative capabilities in elderly patients, and the patient’s ability to tolerate the physiologic consequences of portal pedicle clamping and acute hemorrhage on their cardiopulmonary system. In addition, patients undergoing a minimally invasive approach must also be able to endure the effects of the pneumoperitoneum and reverse Trendelenburg positioning on their physiology.
Several different clinical staging systems exist to stratify patients according to prognostic variables [4]. One of the most commonly used is the Barcelona Clinic Liver Cancer (BCLC) system which incorporates tumor size, number of nodules and hepatic function as classified by the Child-Pugh score [5]. The system classifies patients into early, intermediate, advanced and terminal stages and proposes recommended treatment strategy. According to this staging system, only stage 0 or early stage patients with small tumors are recommended for surgical resection or liver transplant.
However, many view the BCLC criterion for resection to be restrictive. For patients with large tumors (beyond any down-staging or expanded OLT criteria) who are ineligible for OLT, PH is the only potentially curative treatment. With improvements in perioperative management, preoperative morphological assessment and manipulation of the future liver remnant, PH for large HCC has been safely performed with good oncologic outcome [6, 7]. Therefore, large tumor size alone is not a contraindication to PH, rather factors such as multiple or bilobar tumors, extrahepatic metastasis, involvement of the main bile duct, portal venous or other macroscopic vascular invasion, and portal hypertension are all relative contraindications to PH. When clinically not evident, portal hypertension can be evaluated by measuring the transjugular intrahepatic portosystemic gradient (PSG). PSG values greater than 10 mmHg are indicative of significant portal hypertension and these patients must be approached with caution.
85–90% of patients with HCC have concomitant liver dysfunction. It is critical to account for the degree of liver dysfunction in addition to the patient’s overall functional and nutritional status. Patients with liver disease are often malnourished with diminished performance status and comorbid conditions. To help stratify clinical liver dysfunction, patients are classified by the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) system. These two systems classify patients based on physical exam and laboratory data, with increasing scores associated with higher overall surgical risk. In general, patients with CTP score up to B7, MELD score <9 without significant portal hypertension can be considered for PH. Patients with more severe liver dysfunction and HCC can be considered for OLT if they meet specific criteria [8, 9].
Assessment of the hepatic function and future liver remnant (FLR) is important for patient selection prior to surgical resection [10]. The volume of the FLR and the regenerative capacity are key predictors of postoperative morbidity. Several laboratory tests have been used to evaluate hepatic reserve in cirrhotic patients including assessment of clearance of indocyanine green, sorbitol and 99mTc-galactosyl serum albumin scintigraphy [11]. Preoperative volumetric analysis can be performed with 3D computerized tomography volumetry [12]. To minimize the chance of post-hepatectomy liver failure, data suggest a liver remnant to be at minimum >20% of preoperative liver volume in a normal functioning liver, >30% for patients who have undergone >3 months systemic chemotherapy and >40% in those with advanced liver disease [13, 14].
Several techniques for preoperative optimization of the FLR exist including portal vein embolization (PVE) and the associated liver partition with portal vein ligation for staged hepatectomy (ALPPS) [15]. Initially developed in 1986, PVE results in atrophy of the embolized segments and compensatory hypertrophy of the perfused segments [16], within approximately 4–6 weeks, with at least >10% growth of the FLR predicting adequate regeneration post-PH. PVE has been shown to reduce the rate of postoperative complications in select patients with chronic liver disease [17], and can also be used safely in patients undergoing concurrent chemotherapy for colorectal metastases. One study demonstrated improved prognosis after PH in patients with impaired hepatic function [18].
ALPPS was developed in 2007 to induce liver hypertrophy in patients planned for extended liver resections with marginal FLR. A two-step operation, the initial data demonstrated it to be quite effective with rapid hypertrophy [15], however, it has not gained wide acceptance secondary to significant morbidity and mortality and the need for larger scale studies [19, 20, 21]. However, there are more recent reports of “mini-ALPPS” where the procedure is performed minimally invasively and with limited peripheral division of the parenchyma.
The surgical anatomy of the liver is based on Claude Couinaud’s classification system and further refined in the Brisbane 2000 Terminology of Liver Anatomy and Resections (Figure 1) [22]. In this classification, the liver is divided into first, second and third order divisions based on internal anatomy rather than surface landmarks. First order division splits the liver into a right and left hemiliver along Cantlie’s line, a plane extending from the middle of the gallbladder fossa to the center of the inferior vena cava. Second order divisions split the hemilivers into two respective sections or sectors, the medial and lateral sections/sectors on the left and anterior and posterior sections/sectors on the right. The third order division divides each section/sector into two segments, constituting the 9 individual hepatic segments defined by Couinaud. In general, each segment has a unique vascular inflow, outflow and biliary duct enabling segments to be removed without damage to other segments.
Schematic of liver anatomy separating the parenchyma into 9 anatomic segments. Each segment has unique blood supply and biliary drainage. Source: Cho, Fong. Hepatic Resection. In: Ashley SW, editor. Scientific American Surgery. Hamilton: Decker. 7th ed; 2014. pp. 1094–1114.
The proper hepatic artery and portal vein bifurcate prior to the hilum of the liver and form the right and left hepatic artery and portal vein which supply the right and left hemiliver. Joined by the biliary duct, the portal triad generally runs centrally within hepatic segments. The right hepatic artery enters the parenchyma soon after branching while the left has a longer extrahepatic course. In contrast, the three hepatic veins run between section/sectors in three portal scissurae. The right hepatic vein drains directly into the inferior vena cava (IVC) while the middle and left hepatic veins often form a common trunk prior to entering the IVC.
The liver is encapsulated by a fibrous capsule, known as Glisson’s capsule. The capsule envelops the portal triads as they enter the liver parenchyma which makes it identifiable on intraoperative ultrasound. Furthermore, the dense capsule allows for control of the portal triad during dissection and enables pedicle ligation.
Some important perioperative anesthetic considerations should be accounted for to increase the safety of hepatectomy. To minimize the possibility of major intraoperative hemorrhage, the central venous pressure should be maintained at less than 5 mmHg to reduce the intrahepatic venous pressure. This is achieved using various anesthetic maneuvers and agents such as IVF restriction, and administration of isoflurane, fentanyl, mannitol, and cisatricurium. For open hepatectomy, the patient can be placed in slight reverse Trendelenburg position if pressures allow and switched to Trendelenburg position if there is significant hemorrhage with hemodynamic derangement to increase cardiac output and maintain end-organ perfusion. For laparoscopic/robotic hepatectomy, the patient is placed in reverse Trendelenburg position for a caudal approach which improves visualization of the vasculature, and the pneumoperitoneum creates a tamponade effect on the hepatic veins, which aids in limiting hemorrhage. Adequate vascular access should be obtained using large bore IVs, with appropriate invasive hemodynamic monitoring using A-line. Blood products should be readily available and resuscitation of operative blood loss should be with an appropriate combination of crystalloid, albumin and blood product as necessary. End-tidal CO2 is measured to monitor for CO2 embolism in the laparoscopic/robotic approach.
Resections are either “anatomic” or “non-anatomic”. Anatomic resection defines a resection that obeys Brisbane divisions and is preferred for malignant disease because it has been found to lower rate of positive margins, decrease regional recurrences and improve surgical outcome. Non-anatomic resection refers to parenchymal transection that does not respect segmental planes and is typically used for debulking procedures, benign tumors or when trying to preserve remnant parenchyma. Achieving a microscopic margin negative (R0) resection is paramount to reducing local recurrence. 1 cm surgical margins have historically been considered standard, but narrower margins have been safely demonstrated [23].
There are six standard, anatomic hepatic resections as defined by the Brisbane classification (Figure 2). Right hemi-hepatectomy consists of surgical resection of segments V-VIII and left hepatectomy includes segments II-IV and occasionally segment I. In an extended right hepatectomy or a right trisectionectomy/trisectorectomy, segments IV-VIII, and in an extended left hepatectomy or a left trisectionectomy, segments II-IV, V and VIII are resected. A left lateral sectorectomy involves resection of segments II-III and a right posterior sectionectomy includes segments VI-VII. Segmentectomies denote resection of any individual segment.
Schematic illustrations of the standard hepatic resections as labeled. Source: Cho, Fong. Hepatic Resection. In: Ashley SW, editor. Scientific American Surgery. Hamilton: Decker. 7th ed; 2014. pp. 1094–1114.
The common principle of anatomic hepatectomies involves parenchymal transection after both vascular inflow and outflow have been controlled. Given that each hepatic segment has their unique vascular inflow and outflow, each segment can be safely excised without damage to surrounding hepatic segments. Intraoperative ultrasonography is used routinely for identification of the vascular structures, evaluation of tumor location, extent and relationship to the surrounding vasculature.
After initial laparoscopic inspection excludes unresectable disease (in selected cases), the incision is made. In an open conventional approach, appropriate incision and exposure is critical to safe hepatectomy. There are several incisions used including the bilateral subcostal (Chevron), right/left subcostal, J-type or the inverted Y (Mercedes) incision.
Once the liver is mobilized by dividing ligamentous attachments, careful inspection, palpation and ultrasound examination are performed to evaluate for any missed tumors. Arterial aberrancies are identified and portal triad inflow is controlled with sutures and clips or staple ligation. The corresponding hepatic vein is isolated and ligated. Parenchymal transection is performed along the line of devascularization. Different techniques for parenchymal transection exist, varying from clamp-crushing, waterjet, monopolar/bipolar cautery, radiofrequency ablative devices, bipolar vessel sealing devices, ultrasonic dissection devices to staplers. The clamp-crush technique is rapid and has been associated with lower rates of blood loss compared to other methods [24]. Once the resected segment is removed, hemostasis is obtained with sutures, clips, argon beam coagulator and application of various hemostatic agents. Biliary leaks are controlled with clipping and suture ligation. Prior to abdominal closure, drains are placed if there is an infected operative field or if a biliary reconstruction is performed [25].
Although established as a safe and beneficial approach for numerous intra-abdominal operations, laparoscopic techniques were slow to be adopted for liver surgery for several reasons [26]. Concerns over technical feasibility of vascular dissection and control, organ mobilization, parenchymal dissection and management of intraoperative complications were prohibitive. Furthermore, it was unknown if port-site seeding, inadequate margins and poor oncologic outcomes would be more common in the minimally invasive approach.
The benefits of laparoscopic liver surgery are numerous. In addition to the generalized benefits of laparoscopic surgery including a more rapid functional recovery, smaller incisions which reduce the incidence of surgical site infections and postoperative pulmonary complications, there are additional advantages specific to laparoscopic liver surgery. Steep Trendelenburg positioning reduces intrahepatic venous pressure and the pneumoperitoneum exerts tamponade effect on vasculature leading to reduced intraoperative blood loss. Laparoscopy creates a caudal-cranial surgical view which affords improved visualization of major vascular structures compared to the ventral-dorsal angle of visualization of an open hepatectomy. For cirrhotic patients, small laparoscopic incisions avoid disruption of abdominal wall collaterals and the constraint on fluid shifts in a laparoscopic partial hepatectomy can decrease the incidence of liver-related complications. Minimally invasive hepatectomy also results in less adhesion formation which facilitates additional surgery in the future.
There have been numerous studies to date demonstrating the safety and efficacy of laparoscopic liver surgery. In 2009, a worldwide experience of 127 series including 2804 cases of laparoscopic partial hepatectomy demonstrated comparable 5-year overall survival and disease free survival compared to open hepatectomy [27]. Half of these cases were done for malignant disease with greater than 80% of resections boasting negative surgical margins. In 2015, a randomized control trial was published demonstrating safety and feasibility of laparoscopic liver resection with reduction in length of stay and intraoperative blood loss compared to open hepatectomy [28]. Numerous systematic analyses have substantiated these data, demonstrating that the laparoscopic partial hepatectomy is associated with decreased intraoperative blood loss, shorter length of hospital stay, and decreased number of positive resection margins. Overall, there were consistently fewer complications found in the laparoscopic group in these reviews [29]. A case–control propensity matched studies also found no difference in 1-, 3-, and 5-year overall survival and disease-free survival [30]. The National Surgical Quality Improvement Program database was evaluated to compare short-term outcomes among patients undergoing minimally invasive partial hepatectomy. Over 3000 patients were include in the study and it demonstrated lower postoperative morbidity and shorter length of stay compared with patients undergoing open liver resection [31].
Specific to the treatment of HCC, the safety and efficacy of the laparoscopic approach has been evaluated in several meta-analyses and propensity score analyses. These studies demonstrated the equivalent or superior perioperative outcomes of laparoscopic compared to open resection [32, 33]. In a propensity score analysis, the overall and disease-free survival were similar and for the secondary outcomes, the laparoscopic group had shorter hospital stay, lower morbidity, with fewer transient liver failure and wound complications, and a larger tumor margin [34].
Multiple meta-analyses and case control series were reviewed and analyzed at the second international conference for laparoscopic liver resection in Morioka in 2014. Minor resections were validated as standard practice in the assessment stage, while major or complex resections were considered to be in the exploration stage, with incompletely defined risks. The Jury at Morioka made strong recommendations for higher quality studies including registries to define the role and benefits of laparoscopic major hepatectomy.
Patient selection is critical to ensuring safe laparoscopic partial hepatectomy. Although is technically feasible, resection of lesions in right posterior sections or the hepatic dome can be challenging and should be approached with caution. The patient is placed in the supine position and securely fastened to the table to allow for safe intraoperative repositioning. Generally, five ports are required for laparoscopic resection including two 12 mm and three 5 mm ports. Port placement is dependent upon laterality of the lesion as shown in Figure 3. Some surgeons advocate using a hand access port to assist with intraoperative manipulation, intra-corporeal suturing as well as serve as the specimen removal site.
Suggested port placements for laparoscopic left lateral sectionectomy (a) and hand-assisted laparoscopic right hepatectomy (b). Source: Cho, Fong. Hepatic Resection. In: Ashley SW, editor. Scientific American Surgery. Hamilton: Decker. 7th ed; 2014. pp. 1094–1114.
Further advances in surgical technology has created new opportunities in minimally invasive liver surgery. Robotic surgical systems offer unique advantages to the liver surgeon that enhances the minimally invasive approach. There are several key improvements on the robotic surgical system including a camera with optics providing a 3-dimensional stereotactic visual field. In addition, the instruments allow for seven degrees of freedom in their motion, providing easier suturing for hemorrhage control. There is no fulcrum effect on the body wall of the patient as in laparoscopic surgery, and it has been associated with reduction in surgeon fatigue compared to the laparoscopic approach.
Similar to laparoscopic partial hepatectomy, the patient is placed in the supine position and in steep reverse Trendelenburg position. The table is tilted with right side up approximately 25 degrees for right-sided resections. Five ports are placed including four robot-controlled ports and one assistant port (Figure 4). The ports are placed based on the laterality of the resection. In general, for a right-sided hepatectomy, the camera port is placed to the right-side of midline. Once the ports have been placed, the robot is docked from the cephalad position (Figure 5). Intraoperative ultrasound is critical to establishing vascular anatomy and defining oncologic planes of resection. After vascular control and establishing the line of transection, parenchymal transection is performed using one of many published techniques [35].
Image of port placement for a robot-assisted surgeries left lateral sectionectomy. Blue dots denote da Vinci 8-mm reusable cannulas (3). Green dot denotes 12-mm camera port. Purple dot denotes AirSeal® assistant port. Costal margin and midline marked in dotted pen.
Standard operating room set up for robotic-assisted liver surgery. Head of bed is on left side of image, anesthesia equipment and personnel on right side of image.
Several large case series have been published demonstrating the success of robotic liver resection [36, 37]. The first large case series of 70 patients included 38.5% major liver resections without any mortalities [36]. An early systematic review of the literature demonstrated safety and feasibility of the robotic technique, with conversion to open rate of 4.6% and complication rate of 20.3% [38]. In 2018, an international, multicenter retrospective review of robotic liver surgery was published specifically evaluating long-term oncologic outcomes in patients with primary hepatobiliary malignancies after a median follow up of 75 months [39]. This study demonstrated comparable outcomes between robotic, open and laparoscopic liver surgery with 3-year overall survival of 90% for HCC. The majority of the cases were non-anatomic resections with an R0 resection achieved in 95% of HCC resections, 68% in cholangiocarcinoma and 82% in gallbladder cancer.
Minimally invasive approach to liver surgery, both laparoscopic and robotic-assisted, have their share of limitations. An important potential complication associated with the establishment of pneumoperitoneum and laparoscopic liver surgery is carbon dioxide gas embolism. Reports have demonstrated that this event rate is low, particularly if the pneumoperitoneal pressure is maintained below 12 mmHg [40]. Studies have published and event rate of as low as at 0.5~1.5% [41]. There is a learning curve with gaining proficiency in the laparoscopic technique of liver resection with expert centers estimating the learning curve for laparoscopic liver resection at approximately 45~70 cases with senior partner proctoring [42]. Other limitations include the need for a skilled bedside assistant, and the diminished tactile sense when dealing with friable tissue such as steatotic liver parenchyma or thin venules within a cirrhotic liver can make the case challenging. And in the rare event when massive venous bleeding ensues, it can be difficult to control.
Cost is one major barrier to the wide adoption of the robotic approach. There is a significant initial capital investment in addition to maintenance fees and costs of staff training. However, one study demonstrated that while perioperative costs are higher with the robot, the overall total direct hospital costs are lower at least in part due to the decrease length of stay with robotic minimally invasive resection [43]. There are several generations of the robot with older generation units best suited for an operation in a single work field, with cumbersome redocking steps to perform multi-quadrant operations. The majority of studies indicate a longer operating time secondary to robot set up and draping. Technically speaking, the robot does not provide haptic feedback challenging the surgeon to “feel with their eyes” and occasionally resulting in excessive tissue damage in inexperienced hands. Further studies are needed to examine the comparative effectiveness of robotic versus laparoscopic minimally invasive hepatectomy.
The main postoperative complications include postoperative hemorrhage, liver dysfunction, biliary leak and fluid collections. Postoperative hemorrhage is uncommon after liver resection if meticulous attention is given to confirmation of hemostasis at the conclusion of the case. Bleeding may occasionally occur from retroperitoneal structures, such as the adrenal gland, or diaphragmatic musculature. Argon beam coagulator and a variety of topical hemostatic applications are utilized to reduce liver surface related bleeding.
Post hepatectomy liver failure (PHLF) is a major postoperative complication with mortality of approximately 30%. The definition of post-hepatectomy liver is the impaired ability of the liver to maintain its synthetic, excretory and detoxifying functions, characterized by an increase in international normalized ratio and bilirubin on or after postoperative day 5 [44]. The most effective treatment of PHLF is liver transplantation but that is reserved for the most severe cases. Initial care is supportive and often includes mechanical ventilation, hemodynamic support and hemodialysis. Administration of colloid products and nutritional supplementation is also advocated.
The best way to treat post-hepatectomy liver failure is to prevent it. Preoperative weight loss, nutritional supplementation, careful preoperative selection and risk stratification are important to minimize the risk of PHLF [10]. Intra-operatively, minimizing blood loss and blood transfusion, close attention to hemostasis and minimizing skeletonization of the hepatoduodenal ligament will lower risk of PHLF. In the postoperative period, recognizing and aggressively treating postoperative hemorrhage, biliary obstructions or leaks and intra-abdominal infections will reduce the hepatic stress and likelihood of developing hepatic failure.
Postoperative fluid collections collect in the resected liver bed. These collections are varied in etiology but can include hematoma, seroma or biloma. They often to not result in symptoms, but occasionally they can cause pain or fullness requiring drainage. These collections also are at risk for infection and abscess formation. Biliary leakage from the raw surface of the resected liver can occur in up to 8% of patients after liver resection [45].
New technologies continue to be developed to enhance minimally invasive liver surgery. One example is intra-operative near-infrared fluorescence (NIF) imaging. NIF imaging has become commonplace in many laparoscopic and robotic camera systems enabling the identification of various dyes, such as indocyanine green, injected preoperatively. Indocyanine green is a green dye that is preferentially metabolized by hepatocytes and excreted in the biliary tree. It lights up the biliary tree and has been utilized for robotic and laparoscopic assisted cholecystectomy. It has been more recently utilized to guide parenchymal dissection after vascular control by identifying perfused from poorly perfused hepatic parenchyma.
Future directions within the realm of robotic liver surgery include the application of preoperative planning with virtual reality (VR) models and real-time augmented reality (AR) intraoperative endoscopic overlays to aid with surgical navigation on da Vinci ® surgical systems. The current practice standard for operative planning involves preoperative cross-sectional imaging using contrast-enhanced, multiphase liver protocol computed tomography (CT) or magnetic resonance imaging (MRI) scans to evaluate the tumor’s extent (size and number) and location with respect to critical structures including the major vasculature and biliary architecture. Surgeons rely on years of training to develop the ability to mentally reconstruct 2D images into a mental 3D model in order to preoperatively plan for a surgery while referencing the 2D images intraoperatively.
Computer-based three-dimensional (3D) reconstructions of liver tumors have been shown to increase accuracy of tumor localization and precision of operative planning for liver surgery [46]. While useful for operative planning, intraoperative review of 2D images on a traditional PACS system requires diversion of attention away from the operative field. Intraoperative ultrasound is routinely used for real-time localization of liver tumors and identification of vessels and biliary structures. However, its use is limited in minimally invasive liver surgery due to the need for an additional port site and the need to interpret the 2D ultrasound images and mentally reconstruct the 3D anatomy being projected based on the orientation of the ultrasound probe. Preoperative planning with a VR model (Figure 6) and the application of AR endoscopic overlay (Figure 7) of patient-specific anatomy into the robotic surgical system could potentially improve surgical efficiency in real-time with intelligent surgical navigation.
Virtual 3D model of the liver. Porcine experimental model with implanted radiopaque tumor within the liver parenchyma. Preoperatively, CT images were obtained of the porcine liver with 3D segmented reconstructions created from the DICOM images. The 3D reconstructions can be viewed for preoperative planning with intuitive Surgical’s da Vinci® Surgical System.
Real-time endoscopic overlay of 3D reconstruction over the surgical field on the da Vinci ® Xi Surgical System. The relationship between the tumor (light pink) and adjacent vasculature including the hepatic veins (light blue), hepatic arteries (red) and portal veins (blue) is present on the overlay. After initial registration, the overlay is mapped onto the patient-specific anatomy changing in real-time with camera movement.
AR may be developed to overlay accurate 3D reconstruction data onto the operative field itself, thereby eliminating the need to divert the attention from the operative field and to translate the 2D images into a 3D construct. These advancements with planning and guidance can potentially reduce the cognitive load burden on the surgeon. Augmented reality for spatial recognition has been shown to improve localization accuracy in an experimental model of uterine myomectomy [47],and our recent experience has shown promise and feasibility in an experimental porcine liver model (Figures 1 and 2). Next steps in the application of VR and AR to hepatobiliary surgery include overcoming technical obstacles of continuous co-registration to a mobile liver with tissue deformation while continuing to define the utility of the technology with patient education, tumor board evaluations, preoperative planning and intraoperative navigation.
Hepatocellular carcinoma (HCC) is a deadly disease that represents major challenges for patients and healthcare providers alike. Numerous therapeutic options exist for the treatment of HCC that are often used in combination for local and regional control. Surgical resection remains an important intervention that can be curative. Minimally invasive surgical technologies continue to improve increasing its safety and applicability for oncologic liver surgery.
We would like to acknowledge Drs. Kyle Miller and Jonathan Sorger of Intuitive Surgical Inc. for their collaboration on the emerging robotic surgical technologies.
The authors have no conflict of interest to report.
Visceral leishmaniasis (VL) is a parasitic zoonotic disease caused by the protozoan Leishmania infantum (syn. L. chagasi), an intracellular parasite of the phagocytic mononuclear system [1, 2]. In Brazil, VL is transmitted by sandflies, Lutzomyia longipalpis [1, 3, 4].
\nIn a global scenario, it is estimated that 300,000 new cases of VL occur with a rate of 20,000 deaths each year, with 94% new cases reported in Brazil, Ethiopia, India, Kenya, Somalia, South Sudan, and Sudan [5]. While in Latin America, LV spreads from Mexico to Argentina, with the largest number of cases concentrated in Brazil [6]. With the urbanization of VL in Brazil, annually, the country records approximately 3500 new cases, mainly in medium and large cities; probably, it is due to the disordered anthropic occupation of the geographic space [7]. Despite scientific advances, cases of VL are expanding, which has a major impact on public health, as dogs are the main reservoirs in the urban environment and therefore play an important role in the transmission cycle [8, 9].
\nCanine visceral leishmaniasis (CVL) is characterized by a broad clinical spectrum, from mild and moderate to fatal clinical manifestations. Major clinical signs in dogs include hepatosplenomegaly, lymphadenopathy, exfoliative dermatitis, alopecia, onychogryphosis, keratoconjunctivitis, apathy, anorexia, and severe weight loss [10, 11, 12, 13].
\nThe clinical manifestation of CVL depends on the interaction of the parasite with the host immune response [2]. In susceptible dogs, clinicopathological abnormalities are preceded by an evident humoral response and depression of the cellular response, mediated by a non-protective Th2 immune response associated with cytokines IL-4, IL-5, IL-6, and IL-10 [14, 15]. Dogs that do not develop the disease have a protective cellular response (Th1) [16, 17], related to INF-γ, TNF-α, IL-2, and IL-12 cytokines.
\nDifferent procedures are used for the diagnosis of CVL [18]. The Brazilian Ministry of Health recommends serology in the investigation of canine disease by the Dual-Path Platform (DPP®) rapid method as a screening test and ELISA as confirmatory test [19]. Other tests are used to demonstrate infection, such as cytology, histopathology [20], and real-time PCR (RT-PCR) [21].
\nSimilarly, determination of parasitic index has become important for early detection, but also evaluation of treatment efficacy and monitoring of relapses [22]. Thus, the aim of this study was to associate parasitic index to serum cytokine concentration in dogs naturally infected by L. infantum at different clinical stages of infection.
\nThe procedures were previously approved by the Ethics Committee on the Use of Animals (ECUA)/UFMT, Brazil (n° 23108.019567/14-1), and collection of clinical samples was authorized by the dog owners by signing the informed consent form.
\nThis study was conducted over a 16-month period, evaluating 42 male and female dogs of different ages and breeds from Barra do Garças, Mato Grosso State, Brazil (latitude, −15.893; longitude, 52.2599; south,15° 53′ 35″; west 52° 15′ 36″). Dogs with canine visceral leishmaniasis (n = 21) were classified into clinical stages at diagnosis as described by Solano et al. [23] and confirmed using the Dual-Path Platform Rapid Test (RT DPP®) and polymerase chain reaction (PCR). A control group (n = 21) was also formed, comprising dogs with no clinical changes and negative results for RT DPP® and conventional PCR.
\nBlood samples (5 mL) were collected by cephalic or jugular venipuncture, placed in tubes without anticoagulant to obtain serum. Serum was obtained by centrifuging the blood sample at 300× g for 5 minutes and was then transferred to 2 mL microtubes and stored at −80°C for cytokine dosing.
\nAfter dog restraint and local anesthesia with 2% lidocaine, bone marrow samples were obtained from the sternal manubrium, placed in microtubes with 0.5 mL 0.9% sterile NaCl solution, and stored at −20°C for subsequent molecular techniques.
\nThe immunochromatographic rapid test for detection of anti-Leishmania infantum antibodies (DPP®—Canine Visceral Leishmaniasis-Bio-Manguinhos/FIOCRUZ, Rio de Janeiro, Brazil) that uses the recombinant protein K39 (rK39) as an antigen, a cloned 39 amino acid sequence of the specific L. infantum kinase region, was performed according to the manufacturer’s guidance.
\nDNA extraction from blood samples was performed by the phenol-chloroform method. The polymerase chain reaction assay was performed using the primers RV1 (sense) 5′-CTT TTC TGG TCC CGC GGG TAG G-3′ and RV2 (antisense) 5′-CCA CCT GGC TAT TTT ACA CCA-3′ [24], which amplifies the DNA fragment of a 145 bp region of conserved kDNA present in L. infantum. Amplification used 200 mM dNTP, 1 pM from each primer, a buffer solution (10 mM Tris–HCl and 50 mM KCl, pH 8.3), 2 mM MgCl2, 1.5 U Taq DNA polymerase, and 2 μl of the DNA sample in the final volume of 25 μl. Assays were performed for one cycle at 94°C for 4 minutes, followed by 30 cycles at 94°C for 30 seconds, 60°C for 30 seconds, and 72°C for 30 seconds, and final extension of one cycle at 72°C for 10 minutes. The amplification product was fractionated by 2.0% agarose gel electrophoresis, stained with red gel spot, and visualized on a transilluminator (UV, 300 nm).
\nQuantitative PCR (qPCR) was performed in triplicate using the StepOne™ Real-Time PCR System Sequence Detection System (Applied Biosystems) targeting RV1–5′-CTT TTC TGG TCC GGG TAG G-3′ primers and RV2–5′-CCA CCT GGC TAT TTT ACA CCA-3′ amplifying a 145 bp sequence of L. infantum-specific kDNA [24]. Reactions were prepared in a 25 μl final volume containing SYBR Green Master Mix, 0.3 μM of each primer, and 2 μl of target DNA. Amplification conditions included an initial incubation step at 94°C for 10 minutes, followed by 40 cycles of amplification, 94°C for 15 seconds, and 60°C for 60 seconds. The standard curve was established for each assay using known amounts of TOPO PCR 2.1 plasmid (Invitrogen Corp.) containing L. infantum kDNA gene. Serial (10×) dilutions of the recombinant plasmid containing 2.9×104–2.9×108 copies of the plasmid were performed and used on the standard curve.
\nSerum cytokine concentration (IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ, and IL-17) was assessed using the Cytometric Bead Array (CBA) Kit (BD Bioscience, USA) and evaluated by a flow cytometer (FACSCalibur®, BD Bioscience, USA). The reading was done using the CellQuest. Data were analyzed in FCAP array software version 5.0.
\nImmunoglobulin concentrations (IgM and IgG) in the sera were determined by turbidimetric method. For 1:11 (v/v) IgM and 1:15 (v/v) IgG, antibody concentrations were determined using IgM (Bioclin®, Brazil, Ref K063) and IgG (Bioclin®, Brazil, Ref K062) antiserum diluted with 1:12 (v/v). The calibration curve obtained from the Multical calibrator (Bioclin®, Brazil, Ref K064) was used to determine the standard curve for each immunoglobulin. Positive and negative serum samples, standards, and controls were placed in 500 μl buffer solution (0.15 mol/L sodium chloride, Tris 50 mmol/L, 6.0000 PEG 50 g/L, and sodium azide 15.38 nmol/L). The suspensions were mixed and incubated at 37°C for 10 minutes. Reactions were read on a spectrophotometer at 340 nm.
\nFor the analysis of the concentration of cytokines and immunoglobulins (IgG and IgM), the Student t-test independent samples were used. For the quantification of parasitic index of the bone marrow and cytokines when compared by clinical stage, Kruskal-Wallis analysis of variance was used. Parasite load correlation analysis of IgG in the presence of cytokines was also performed by calculating the Spearman correlation coefficient. Data were expressed as mean ± standard error. Values less than 0.05 (p < 0.05) were considered significant.
\nMost of the 21 dogs in the control group were mongrel dog (15/71%), Labrador retriever (1/5%), dachshund (1/5%), pinscher (3/14%), and rottweiler (1/5%). Age ranged from 14 months to 8 years (average 3.4 years). Thirteen dogs were female (13/62%) and eight dogs were male (8/38%). Most of the 21 dogs with leishmaniasis were dogs from mongrel dog (12/57%), Labrador retriever (1/05%), American pit bull (1/05%), poodle (1/05%), and shih tzu (6/28%). Age ranged from 12 months to 11 years (mean 4.3 years). Six dogs were female (6/29%) and 15 dogs were male (15/72%).
\nAt the time of clinical evaluation, all dogs diagnosed with VL had several clinicopathological findings typical of the disease. Clinical symptoms in seropositive animals (CVL) included lymphadenopathy (17/13%), skin ulcers (12/10%), onychogryphosis (11/09%), ear ulceration (11/09%), scaling (10/08%), weight loss (9/07%), dermatopathy (8/06%), ophthalmopathy (8/06%), muscle atrophy (4/03%), splenomegaly (7/06%), alopecia (6/05%), lethargy (5/04%), periocular alopecia (4/03%), skin nodules (3/02%), hepatomegaly (3/02%), cachexia (3/02%), and hyperkeratosis (2/01%).
\nDogs were classified into three clinical stages: stage I, mild disease (n = 5/24%); stage II, moderate disease (n = 9/43%); and stage III, severe disease (n = 7/33%). Stage II dogs were not subclassified.
\n\nLeishmania infantum DNA was detected in all dogs of the group with CVL up to a concentration of 1 fg/μl. Real-time PCR of bone marrow samples was positive in all dogs in the CVL group (100%). There was no statistical difference in the distribution between clinical stages and parasitic index, as shown in Table 1.
\nCytokines/parasitemia | \nI | \nII | \nIII | \np-Value | \n
---|---|---|---|---|
IL-2 | \n6.62 ± 1.18 | \n12.01 ± 7.99 | \n15.09 ± 6.34 | \n0.152 | \n
IL-4 | \n10.50 ± 2.05 | \n11.38 ± 3.81 | \n9.90 ± 2.73 | \n0.9044 | \n
IL-6 | \n2.14 ± 0.57 | \n2.72 ± 0.66 | \n3.12 ± 0.50 | \n0.0350 | \n
IL-10 | \n2.47 ± 0.97 | \n2.85 ± 0.96 | \n2.39 ± 0.84 | \n0.8973 | \n
IL-17 | \n2.22 ± 0.22 | \n12.38 ± 9.63 | \n13.27 ± 7.51 | \n0.4345 | \n
TNF-α | \n4.52 ± 2.12 | \n4.65 ± 2.31 | \n6.14 ± 1.43 | \n0.0462 | \n
IFN | \n3.07 ± 0.99 | \n28.19 ± 23.21 | \n2.58 ± 0.28 | \n0.4648 | \n
Parasite copy number (×107)/ml | \n4.96 ± 1.00 | \n4.63 ± 1.37 | \n4.55 ± 1.49 | \n0.9467 | \n
Cytokine concentrations and parasite copy number (×107)/ml in dogs with visceral leishmaniasis in different clinical staging.
The results were expressed in mean and standard error.
The mean and standard error of concentrations (pg/ml) of IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ, and IL-17 cytokines based on clinical staging in CVL-infected dogs are shown in Table 1. It was observed that IL-6 and TNF-α concentrations increased in serum of infected dogs with significant statistical difference between the clinical stages of CVL, although most infected dogs had moderate and severe clinical manifestations of the disease.
\nAmong dogs with CVL and uninfected dogs, an increase of IL-4 and TNF-α concentrations in serum from dogs infected with CVL was observed. Similar serum concentrations of IL-2, IL-10, IL-17, and IFN-γ were observed between the groups studied (Table 2).
\nCytokines | \nControl | \nCVL | \np-Value | \n
---|---|---|---|
IL-2 | \n9.18 ± 6.14 | \n11.75 ± 6.89 | \n0.3199 | \n
IL-4 | \n7.43 ± 2.50 | \n12.56 ± 5.37 | \n0.0469 | \n
IL-6 | \n2.87 ± 0.95 | \n2.71 ± 0.67 | \n0.3326 | \n
IL-10 | \n2.98 ± 1.39 | \n2.62 ± 0.87 | \n0.2807 | \n
IL-17 | \n11.12 ± 12.12 | \n11.63 ± 9.66 | \n0.4570 | \n
TNF-α | \n2.80 ± 0.52 | \n5.12 ± 2.33 | \n0.0009 | \n
IFN | \n13.26 ± 16.88 | \n16.15 ± 19.01 | \n0.3589 | \n
Cytokine concentrations in dogs noninfected and dogs with canine visceral leishmaniasis.
The results were expressed in mean and standard error.
When comparing immunoglobulin means, IgG levels were elevated in the CVL group when compared to IgM levels. A significant difference (p = <0.0001) was observed. Similarly, IgG concentration between the control and CVL groups was evaluated. IgG levels were found to be higher in serum from dogs with CVL (2300.75 ± 678.463) when compared to control group IgG concentrations (636.94 ± 312.8 mg/dl), showing a significant difference between groups (p = <0.0001). Regarding the comparison of IgM concentration (mg/dl) in the CVL group (279.74 ± 37.755) compared to the control group (241.12 ± 59.835), there was no difference (Table 3).
\nGroup | \nControl | \nCVL | \np-Value | \n
---|---|---|---|
IgG | \n636.94 ± 255.52 | \n2288.04 ± 610.08 | \n<0.0001 | \n
IgM | \n241.12 ± 51.81 | \n282.42 ± 33.99 | \n0.0773 | \n
Immunoglobulin concentrations (IgG and IgM) in serum from dogs with canine visceral leishmaniasis.
The results were expressed in mean and standard error.
Correlations of IL-6 and TNF-α concentrations were analyzed according to clinical staging with parasitic index according to stage I, IL-6 (rs = 0.400, p = 0.5046) and TNF-α (rs = 0.700, p = 0.1881); stage II, IL-6 (rs = 0.7000, p = 0.1881) and TNF-α (rs = −0.1590, p = 0.6828); and stage III, IL-6 (rs = −0.3571, p = 0.4316) and TNF-α (rs = −0.4643, p = 0.2939). There was no correlation between the other parameters evaluated.
\nThe correlation between the parasitic index of dogs with CVL in the presence of cytokine IL-4 and TNF-α in the blood of dogs infected with CVL presented the IL-4 (rs = 0.0240, p = 0.9176) and TNF-α (rs = 0.0825, p = 0.7221). No additional significant correlations were found. Antibody levels were positively correlated with IL-4 expression (rs = 0.5997, p = 0.0040) (Table 4).
\n\n | IgG | \n\n |
---|---|---|
Parameters | \nrs | \np-Value | \n
IL-4 | \n0.5997 | \n0.0040 | \n
TNF-α | \n0.4164 | \n0.0603 | \n
Parasitic index | \n−0.2243 | \n0.3282 | \n
Correlation between IgG concentrations with IL-4 and TNF-α and parasitic index of dogs infected with CVL.
rs, correlation coefficient of Spearman.
In this study, as shown in Table 5, the correlation of the evolution of clinical signs between the stages presented below was analyzed. There was a significant positive correlation of IL-6 cytokine levels between stage I and stage III.
\nStage | \nI and II | \nI and III | \nII and III | \n|||
---|---|---|---|---|---|---|
\n | rs | \np | \nrs | \np | \nrs | \np | \n
IL-6 | \n0.6031 | \n0.0855 | \n0.8469 | \n0.0162 | \n0.5630 | \n0.1144 | \n
TNF-α | \n0.0350 | \n0.9288 | \n0.3784 | \n0.4026 | \n0.0168 | \n0.9658 | \n
Correlation of IL-6 and TNF-α cytokine levels of dogs with canine visceral leishmaniasis by clinical staging of serum from dogs of the CVL group.
rs, correlation coefficient of Spearman.
In this study the most dogs in the control group and CVL were mixed breed. The clinical symptoms of seropositive dogs (CVL) included lymphadenopathy, skin ulcers, onychogryphosis, ear ulceration, scaling, weight loss, and others. Dogs were classified into three clinical stages: stage I, mild disease; stage II, moderate disease; and stage III, severe disease. There was no statistical difference in the distribution between clinical stages and parasitic index. IL-6 and TNF-α concentrations increased in serum from infected dogs with a statistically significant difference between the clinical stages of CVL. Between the dogs with CVL and the control group, there was a statistical difference in the serum concentrations of cytokines IL-4 and TNF-α. IgG levels were elevated in the CVL group when compared to IgM levels. Antibody levels were positively correlated with IL-4 expression (rs = 0.5997; p = 0.0040). There was a significant positive correlation of IL-6 cytokine levels between stage I and stage III.
\nThe clinical signs of CVL are important for the diagnosis. In the present study, the most prevalent clinical signs were lymphadenopathy, skin ulcers, onychogryphosis, ear ulceration, and scaling. However, prevalence is highly variable across studies, but generally these clinical signs are the most commonly reported in the literature. These results corroborate the findings of several authors [25, 26].
\nRegarding gender, there was a greater predominance of males in infected dogs and females in dogs in the control group. Regarding age, it did not present large variations. This fact seems to be associated with the higher risk of male exposure. However, the study shows no statistically significant differences for age and gender between healthy and sick dogs [27].
\nBone marrow samples were taken from 21 dogs serologically positive for L. infantum. According to the clinical signs, dogs were classified as stages I, II, and III. Real-time PCR detected no parasite copies (×1010)/μl L. infantum DNA in all animals of the CVL group, distributed as follows: stage I mean (4.964), stage II average (4.63), and stage III (4.55). No statistically significant difference was found in the average amount of DNA copy number between the different clinical stages (p = 0.9467). In bone marrow samples from dogs that are cytologically positive, a high parasitic index is detected [21].
\nPrevious studies report that quantitative PCR on bone marrow samples from positive dogs in conventional tests contained a higher number of Leishmania kDNA copies than peripheral blood, although no significant differences were detected between symptomatic and asymptomatic dogs in terms of parasite load [28]. This literary quote converges with the findings of this study.
\nPCR can be used for detection of Leishmania in naturally infected dog samples, and PCR-RFLP (restriction fragment length polymorphism) is sensitive for identification of Leishmania species [28]. In addition, qPCR is effective in quantifying Leishmania DNA loading in clinical samples [29]. The blood sample from dogs infected by L. infantum was found by real-time PCR to have a sensitivity of 100% and specificity of 96.4% [30].
\nMost cytokines remain partially conserved between species; in this sense, the amino acid sequence of humans and canine cytokines shows 49–96% homology, suggesting a high probability of cross-reactivity between monoclonal antibodies; thus antibodies against human cytokines may be recommended as immunological biomarkers under pathological conditions by flow cytometry in human [31] and dogs [32] as used in this study.
\nIn the present work, the serum concentration of cytokines (IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ, and IL-17) was compared between the control groups and the group with CVL. In addition, cytokine levels were compared within the CVL group with clinical staging I, II, and III. When comparing the groups, IL-4 and TNF-α were higher in infected dogs than in the control group, showing significant difference between IL-4 (p = 0.0469) and TNF-α (p = 0.0009) groups. In the group with CVL there were differences between stages I and III with significant differences only for cytokines IL-6 (p = 0.0350) and TNF-α (p = 0.0462).
\nElevated levels of IL-6 were found in serum from dogs with active leishmaniasis compared to healthy dogs [33]. These results corroborate the findings of this study. However, other authors reported that IL-6 production did not vary significantly between the groups studied [34]. On the other hand were described in the literature that elevated levels of IL-6 in dogs without clinical signs or symptoms in CVL dogs [35], and also highlights that, among other factors, it may indicate a balance between the parasite elimination effort and the active disease. Increased IL-6 levels suggest a restricted ability to control infection [36]. Even in the absence of clinical signs or symptoms, the animals showed granulomas on histopathological evaluation, suggesting chronicity and therefore a longtime course of infection [35]. Innate immune effector cells primarily neutrophils, monocytes, and macrophages produce and respond to IL-6, which may result in amplification of inflammation and a change from an acute inflammatory state to a chronic state [37].
\nIL-6 expression increases in dogs with active visceral leishmaniasis and may be a useful marker for active disease [33, 35]. Increased IL-6 production is not directly related to anti-Leishmania antibody titers, suggesting that other cytokines may be involved with hypergammaglobulinemia [33].
\nAs shown in this work, it was observed that there was correlation of IL-6 expression between stages I and III of bone marrow aspirate of dogs infected with CVL. IL-6 production in dogs with active leishmaniasis appears to be associated with severe disease [33]. This statement converges with the findings in this study, as the dogs used in the control group were mostly stage II and III. IL-6 is essential for terminal B-cell differentiation and immunoglobulin production [38].
\nTNF-α concentration was higher in infected dogs than in the control group, as detected by de Lima et al. [33]. CVL susceptibility is closely associated with downregulation of key cytokines such as IFN-γ, TNF-α, and IL-17A, thus impairing iNOS activation and NO production and favoring parasite replication and disease development [39].
\nThe increased activity of TNF-α in the liver of infected dogs compared to healthy canines has been reported [37, 40]. Higher TNF-α levels in infected dogs indicate that the presence of L. infantum induces an immune response with relevant TNF-α expression when the protozoan is present [40].
\nStudies suggest that decreased survival of L. infantum in canine macrophages is associated with increased TNF-α and IFN-γ production and decreased IL-10 production [41].
\nIn dogs naturally infected with L. infantum, increased hepatic TNF-α may be associated with increased parasite load on this organ [42]. The cytokines IL-2, IL-4, IL-10, IFN-γ, TNF-α, and IL-12 may be used as markers in epidemiological studies conducted in endemic areas to distinguish between different clinical forms of VL [15]. However, Lima et al. [33] indicate that TNF-α is not considered a good marker of active disease in dogs with VL.
\nA study has reported a significant relationship between bone marrow IL-4 detection in naturally infected dogs with and without clinical signs and disease severity, suggesting that IL-4 production is associated with pathology [43]. Increased expression of IL-4 cytokine is associated with both severe clinical signs and a high parasitic index on skin lesions [44]. In bone marrow aspirates, IL-4 was elevated in naturally infected dogs with more severe symptoms [43].
\nThe study points to evidence that IL-4 cytokine polymorphism may contribute to innate immunity to L. infantum infection [45].
\nAntibody levels were positively correlated with IL-4 expression (rs = 0.5997; p = 0.0040). IgG is also linked to chronic infection in patients with VL, where high levels of IgG are predictive of the disease. This finding is in line with the study by Lima et al. [33] suggesting that other cytokines, such as IL-10 or IL-4, may be associated with hypergammaglobulinemia observed in dogs with CVL. Previous studies have detected increased serum IgG levels in symptomatic dogs compared with healthy dogs and are related to pathophysiological disorders and active disease [33].
\nResponse to natural infection of L. infantum is linked to the presence of IgG [43] and Leishmania-specific IgM antibodies that can be detected in infected dogs [46]. Some studies have reported that increased total protein is frequent in dogs infected with visceral leishmaniasis due to increased antibody production [47, 48].
\nThese results may contribute to a better understanding of the immune response in dogs infected with L. infantum. Antibody levels were positively correlated with IL-4 expression. There was a significant positive correlation of IL-6 cytokine levels with the evolution of stages I and III. However, this cytokine can be used as a marker to distinguish between different clinical stages.
\nThis research received grants from the Mato Grosso Research Support Foundation (FAPEMAT No. 299032/2010) and from the National Council for Scientific and Technological Development (CNPq No. 447218/2014–0 and No. 305725/2018–1), in Brazil.
\nThe authors declare that there is no conflict of interest and nonfinancial competitors.
IntechOpen aims to ensure that original material is published while at the same time giving significant freedom to our Authors. To that end we maintain a flexible Copyright Policy guaranteeing that there is no transfer of copyright to the publisher and Authors retain exclusive copyright to their Work.
',metaTitle:"Publication Agreement - Chapters",metaDescription:"IN TECH aims to guarantee that original material is published while at the same time giving significant freedom to our authors. For that matter, we uphold a flexible copyright policy meaning that there is no transfer of copyright to the publisher and authors retain exclusive copyright to their work.\n\nWhen submitting a manuscript the Corresponding Author is required to accept the terms and conditions set forth in our Publication Agreement as follows:",metaKeywords:null,canonicalURL:"/page/publication-agreement-chapters",contentRaw:'[{"type":"htmlEditorComponent","content":"The Corresponding Author (acting on behalf of all Authors) and INTECHOPEN LIMITED, incorporated and registered in England and Wales with company number 11086078 and a registered office at 5 Princes Gate Court, London, United Kingdom, SW7 2QJ conclude the following Agreement regarding the publication of a Book Chapter:
\\n\\n1. DEFINITIONS
\\n\\nCorresponding Author: The Author of the Chapter who serves as a Signatory to this Agreement. The Corresponding Author acts on behalf of any other Co-Author.
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\\n\\nBook: The publication as a collection of chapters compiled by IntechOpen including the Chapter. Chapter: The original literary work created by Corresponding Author and any Co-Author that is the subject of this Agreement.
\\n\\n2. CORRESPONDING AUTHOR'S GRANT OF RIGHTS
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\\n\\n2.2 The Corresponding Author (on their own behalf and on behalf of any Co-Author) reserves the following rights to the Chapter but agrees not to exercise them in such a way as to adversely affect IntechOpen's ability to utilize the full benefit of this Publication Agreement: (i) reprographic rights worldwide, other than those which subsist in the typographical arrangement of the Chapter as published by IntechOpen; and (ii) public lending rights arising under the Public Lending Right Act 1979, as amended from time to time, and any similar rights arising in any part of the world.
\\n\\nThe Corresponding Author confirms that they (and any Co-Author) are and will remain a member of any applicable licensing and collecting society and any successor to that body responsible for administering royalties for the reprographic reproduction of copyright works.
\\n\\nSubject to the license granted above, copyright in the Chapter and all versions of it created during IntechOpen's editing process (including the published version) is retained by the Corresponding Author and any Co-Author.
\\n\\nSubject to the license granted above, the Corresponding Author and any Co-Author retains patent, trademark and other intellectual property rights to the Chapter.
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\\n\\n3. CORRESPONDING AUTHOR'S DUTIES
\\n\\n3.1 When distributing or re-publishing the Chapter, the Corresponding Author agrees to credit the Book in which the Chapter has been published as the source of first publication, as well as IntechOpen. The Corresponding Author warrants that each Co-Author will also credit the Book in which the Chapter has been published as the source of first publication, as well as IntechOpen, when they are distributing or re-publishing the Chapter.
\\n\\n3.2 When submitting the Chapter, the Corresponding Author agrees to:
\\n\\nThe Corresponding Author will be held responsible for the payment of the Open Access Publishing Fees.
\\n\\nAll payments shall be due 30 days from the date of the issued invoice. The Corresponding Author or the payer on the Corresponding Author's and Co-Authors' behalf will bear all banking and similar charges incurred.
\\n\\n3.3 The Corresponding Author shall obtain in writing all consents necessary for the reproduction of any material in which a third-party right exists, including quotations, photographs and illustrations, in all editions of the Chapter worldwide for the full term of the above licenses, and shall provide to IntechOpen upon request the original copies of such consents for inspection (at IntechOpen's option) or photocopies of such consents.
\\n\\nThe Corresponding Author shall obtain written informed consent for publication from people who might recognize themselves or be identified by others (e.g. from case reports or photographs).
\\n\\n3.4 The Corresponding Author and any Co-Author shall respect confidentiality rights during and after the termination of this Agreement. The information contained in all correspondence and documents as part of the publishing activity between IntechOpen and the Corresponding Author and any Co-Author are confidential and are intended only for the recipient. The contents may not be disclosed publicly and are not intended for unauthorized use or distribution. Any use, disclosure, copying, or distribution is prohibited and may be unlawful.
\\n\\n4. CORRESPONDING AUTHOR'S WARRANTY
\\n\\n4.1 The Corresponding Author represents and warrants that the Chapter does not and will not breach any applicable law or the rights of any third party and, specifically, that the Chapter contains no matter that is defamatory or that infringes any literary or proprietary rights, intellectual property rights, or any rights of privacy. The Corresponding Author warrants and represents that: (i) the Chapter is the original work of themselves and any Co-Author and is not copied wholly or substantially from any other work or material or any other source; (ii) the Chapter has not been formally published in any other peer-reviewed journal or in a book or edited collection, and is not under consideration for any such publication; (iii) they themselves and any Co-Author are qualifying persons under section 154 of the Copyright, Designs and Patents Act 1988; (iv) they themselves and any Co-Author have not assigned and will not during the term of this Publication Agreement purport to assign any of the rights granted to IntechOpen under this Publication Agreement; and (v) the rights granted by this Publication Agreement are free from any security interest, option, mortgage, charge or lien.
\\n\\nThe Corresponding Author also warrants and represents that: (i) they have the full power to enter into this Publication Agreement on their own behalf and on behalf of each Co-Author; and (ii) they have the necessary rights and/or title in and to the Chapter to grant IntechOpen, on behalf of themselves and any Co-Author, the rights and licenses expressed to be granted in this Publication Agreement. If the Chapter was prepared jointly by the Corresponding Author and any Co-Author, the Corresponding Author warrants and represents that: (i) each Co-Author agrees to the submission, license and publication of the Chapter on the terms of this Publication Agreement; and (ii) they have the authority to enter into this Publication Agreement on behalf of and bind each Co-Author. The Corresponding Author shall: (i) ensure each Co-Author complies with all relevant provisions of this Publication Agreement, including those relating to confidentiality, performance and standards, as if a party to this Publication Agreement; and (ii) remain primarily liable for all acts and/or omissions of each such Co-Author.
\\n\\nThe Corresponding Author agrees to indemnify and hold IntechOpen harmless against all liabilities, costs, expenses, damages and losses and all reasonable legal costs and expenses suffered or incurred by IntechOpen arising out of or in connection with any breach of the aforementioned representations and warranties. This indemnity shall not cover IntechOpen to the extent that a claim under it results from IntechOpen's negligence or willful misconduct.
\\n\\n4.2 Nothing in this Publication Agreement shall have the effect of excluding or limiting any liability for death or personal injury caused by negligence or any other liability that cannot be excluded or limited by applicable law.
\\n\\n5. TERMINATION
\\n\\n5.1 IntechOpen has a right to terminate this Publication Agreement for quality, program, technical or other reasons with immediate effect, including without limitation (i) if the Corresponding Author or any Co-Author commits a material breach of this Publication Agreement; (ii) if the Corresponding Author or any Co-Author (being an individual) is the subject of a bankruptcy petition, application or order; or (iii) if the Corresponding Author or any Co-Author (being a company) commences negotiations with all or any class of its creditors with a view to rescheduling any of its debts, or makes a proposal for or enters into any compromise or arrangement with any of its creditors.
\\n\\nIn case of termination, IntechOpen will notify the Corresponding Author, in writing, of the decision.
\\n\\n6. INTECHOPEN’S DUTIES AND RIGHTS
\\n\\n6.1 Unless prevented from doing so by events outside its reasonable control, IntechOpen, in its discretion, agrees to publish the Chapter attributing it to the Corresponding Author and any Co-Author.
\\n\\n6.2 IntechOpen has the right to use the Corresponding Author’s and any Co-Author’s names and likeness in connection with scientific dissemination, retrieval, archiving, web hosting and promotion and marketing of the Chapter and has the right to contact the Corresponding Author and any Co-Author until the Chapter is publicly available on any platform owned and/or operated by IntechOpen.
\\n\\n6.3 IntechOpen is granted the authority to enforce the rights from this Publication Agreement, on behalf of the Corresponding Author and any Co-Author, against third parties (for example in cases of plagiarism or copyright infringements). In respect of any such infringement or suspected infringement of the copyright in the Chapter, IntechOpen shall have absolute discretion in addressing any such infringement which is likely to affect IntechOpen's rights under this Publication Agreement, including issuing and conducting proceedings against the suspected infringer.
\\n\\n7. MISCELLANEOUS
\\n\\n7.1 Further Assurance: The Corresponding Author shall and will ensure that any relevant third party (including any Co-Author) shall, execute and deliver whatever further documents or deeds and perform such acts as IntechOpen reasonably requires from time to time for the purpose of giving IntechOpen the full benefit of the provisions of this Publication Agreement.
\\n\\n7.2 Third Party Rights: A person who is not a party to this Publication Agreement may not enforce any of its provisions under the Contracts (Rights of Third Parties) Act 1999.
\\n\\n7.3 Entire Agreement: This Publication Agreement constitutes the entire agreement between the parties in relation to its subject matter. It replaces and extinguishes all prior agreements, draft agreements, arrangements, collateral warranties, collateral contracts, statements, assurances, representations and undertakings of any nature made by or on behalf of the parties, whether oral or written, in relation to that subject matter. Each party acknowledges that in entering into this Publication Agreement it has not relied upon any oral or written statements, collateral or other warranties, assurances, representations or undertakings which were made by or on behalf of the other party in relation to the subject matter of this Publication Agreement at any time before its signature (together "Pre-Contractual Statements"), other than those which are set out in this Publication Agreement. Each party hereby waives all rights and remedies which might otherwise be available to it in relation to such Pre-Contractual Statements. Nothing in this clause shall exclude or restrict the liability of either party arising out of its pre-contract fraudulent misrepresentation or fraudulent concealment.
\\n\\n7.4 Waiver: No failure or delay by a party to exercise any right or remedy provided under this Publication Agreement or by law shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy. No single or partial exercise of such right or remedy shall preclude or restrict the further exercise of that or any other right or remedy.
\\n\\n7.5 Variation: No variation of this Publication Agreement shall be effective unless it is in writing and signed by the parties (or their duly authorized representatives).
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\\n\\nAny modification to or deletion of a provision or part-provision under this clause shall not affect the validity and enforceability of the rest of this Publication Agreement.
\\n\\n7.7 No partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Corresponding Author or any Co-Author, nor authorize any party to make or enter into any commitments for or on behalf of any other party.
\\n\\n7.8 Governing law: This Publication Agreement and any dispute or claim (including non-contractual disputes or claims) arising out of or in connection with it or its subject matter or formation shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of or in connection with this Publication Agreement (including any non-contractual disputes or claims).
\\n\\nLast updated: 2020-11-27
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The Corresponding Author (acting on behalf of all Authors) and INTECHOPEN LIMITED, incorporated and registered in England and Wales with company number 11086078 and a registered office at 5 Princes Gate Court, London, United Kingdom, SW7 2QJ conclude the following Agreement regarding the publication of a Book Chapter:
\n\n1. DEFINITIONS
\n\nCorresponding Author: The Author of the Chapter who serves as a Signatory to this Agreement. The Corresponding Author acts on behalf of any other Co-Author.
\n\nCo-Author: All other Authors of the Chapter besides the Corresponding Author.
\n\nIntechOpen: IntechOpen Ltd., the Publisher of the Book.
\n\nBook: The publication as a collection of chapters compiled by IntechOpen including the Chapter. Chapter: The original literary work created by Corresponding Author and any Co-Author that is the subject of this Agreement.
\n\n2. CORRESPONDING AUTHOR'S GRANT OF RIGHTS
\n\n2.1 Subject to the following Article, the Corresponding Author grants and shall ensure that each Co-Author grants, to IntechOpen, during the full term of copyright and any extensions or renewals of that term the following:
\n\nThe aforementioned licenses shall survive the expiry or termination of this Agreement for any reason.
\n\n2.2 The Corresponding Author (on their own behalf and on behalf of any Co-Author) reserves the following rights to the Chapter but agrees not to exercise them in such a way as to adversely affect IntechOpen's ability to utilize the full benefit of this Publication Agreement: (i) reprographic rights worldwide, other than those which subsist in the typographical arrangement of the Chapter as published by IntechOpen; and (ii) public lending rights arising under the Public Lending Right Act 1979, as amended from time to time, and any similar rights arising in any part of the world.
\n\nThe Corresponding Author confirms that they (and any Co-Author) are and will remain a member of any applicable licensing and collecting society and any successor to that body responsible for administering royalties for the reprographic reproduction of copyright works.
\n\nSubject to the license granted above, copyright in the Chapter and all versions of it created during IntechOpen's editing process (including the published version) is retained by the Corresponding Author and any Co-Author.
\n\nSubject to the license granted above, the Corresponding Author and any Co-Author retains patent, trademark and other intellectual property rights to the Chapter.
\n\n2.3 All rights granted to IntechOpen in this Article are assignable, sublicensable or otherwise transferrable to third parties without the Corresponding Author's or any Co-Author’s specific approval.
\n\n2.4 The Corresponding Author (on their own behalf and on behalf of each Co-Author) will not assert any rights under the Copyright, Designs and Patents Act 1988 to object to derogatory treatment of the Chapter as a consequence of IntechOpen's changes to the Chapter arising from translation of it, corrections and edits for house style, removal of problematic material and other reasonable edits.
\n\n3. CORRESPONDING AUTHOR'S DUTIES
\n\n3.1 When distributing or re-publishing the Chapter, the Corresponding Author agrees to credit the Book in which the Chapter has been published as the source of first publication, as well as IntechOpen. The Corresponding Author warrants that each Co-Author will also credit the Book in which the Chapter has been published as the source of first publication, as well as IntechOpen, when they are distributing or re-publishing the Chapter.
\n\n3.2 When submitting the Chapter, the Corresponding Author agrees to:
\n\nThe Corresponding Author will be held responsible for the payment of the Open Access Publishing Fees.
\n\nAll payments shall be due 30 days from the date of the issued invoice. The Corresponding Author or the payer on the Corresponding Author's and Co-Authors' behalf will bear all banking and similar charges incurred.
\n\n3.3 The Corresponding Author shall obtain in writing all consents necessary for the reproduction of any material in which a third-party right exists, including quotations, photographs and illustrations, in all editions of the Chapter worldwide for the full term of the above licenses, and shall provide to IntechOpen upon request the original copies of such consents for inspection (at IntechOpen's option) or photocopies of such consents.
\n\nThe Corresponding Author shall obtain written informed consent for publication from people who might recognize themselves or be identified by others (e.g. from case reports or photographs).
\n\n3.4 The Corresponding Author and any Co-Author shall respect confidentiality rights during and after the termination of this Agreement. The information contained in all correspondence and documents as part of the publishing activity between IntechOpen and the Corresponding Author and any Co-Author are confidential and are intended only for the recipient. The contents may not be disclosed publicly and are not intended for unauthorized use or distribution. Any use, disclosure, copying, or distribution is prohibited and may be unlawful.
\n\n4. CORRESPONDING AUTHOR'S WARRANTY
\n\n4.1 The Corresponding Author represents and warrants that the Chapter does not and will not breach any applicable law or the rights of any third party and, specifically, that the Chapter contains no matter that is defamatory or that infringes any literary or proprietary rights, intellectual property rights, or any rights of privacy. The Corresponding Author warrants and represents that: (i) the Chapter is the original work of themselves and any Co-Author and is not copied wholly or substantially from any other work or material or any other source; (ii) the Chapter has not been formally published in any other peer-reviewed journal or in a book or edited collection, and is not under consideration for any such publication; (iii) they themselves and any Co-Author are qualifying persons under section 154 of the Copyright, Designs and Patents Act 1988; (iv) they themselves and any Co-Author have not assigned and will not during the term of this Publication Agreement purport to assign any of the rights granted to IntechOpen under this Publication Agreement; and (v) the rights granted by this Publication Agreement are free from any security interest, option, mortgage, charge or lien.
\n\nThe Corresponding Author also warrants and represents that: (i) they have the full power to enter into this Publication Agreement on their own behalf and on behalf of each Co-Author; and (ii) they have the necessary rights and/or title in and to the Chapter to grant IntechOpen, on behalf of themselves and any Co-Author, the rights and licenses expressed to be granted in this Publication Agreement. If the Chapter was prepared jointly by the Corresponding Author and any Co-Author, the Corresponding Author warrants and represents that: (i) each Co-Author agrees to the submission, license and publication of the Chapter on the terms of this Publication Agreement; and (ii) they have the authority to enter into this Publication Agreement on behalf of and bind each Co-Author. The Corresponding Author shall: (i) ensure each Co-Author complies with all relevant provisions of this Publication Agreement, including those relating to confidentiality, performance and standards, as if a party to this Publication Agreement; and (ii) remain primarily liable for all acts and/or omissions of each such Co-Author.
\n\nThe Corresponding Author agrees to indemnify and hold IntechOpen harmless against all liabilities, costs, expenses, damages and losses and all reasonable legal costs and expenses suffered or incurred by IntechOpen arising out of or in connection with any breach of the aforementioned representations and warranties. This indemnity shall not cover IntechOpen to the extent that a claim under it results from IntechOpen's negligence or willful misconduct.
\n\n4.2 Nothing in this Publication Agreement shall have the effect of excluding or limiting any liability for death or personal injury caused by negligence or any other liability that cannot be excluded or limited by applicable law.
\n\n5. TERMINATION
\n\n5.1 IntechOpen has a right to terminate this Publication Agreement for quality, program, technical or other reasons with immediate effect, including without limitation (i) if the Corresponding Author or any Co-Author commits a material breach of this Publication Agreement; (ii) if the Corresponding Author or any Co-Author (being an individual) is the subject of a bankruptcy petition, application or order; or (iii) if the Corresponding Author or any Co-Author (being a company) commences negotiations with all or any class of its creditors with a view to rescheduling any of its debts, or makes a proposal for or enters into any compromise or arrangement with any of its creditors.
\n\nIn case of termination, IntechOpen will notify the Corresponding Author, in writing, of the decision.
\n\n6. INTECHOPEN’S DUTIES AND RIGHTS
\n\n6.1 Unless prevented from doing so by events outside its reasonable control, IntechOpen, in its discretion, agrees to publish the Chapter attributing it to the Corresponding Author and any Co-Author.
\n\n6.2 IntechOpen has the right to use the Corresponding Author’s and any Co-Author’s names and likeness in connection with scientific dissemination, retrieval, archiving, web hosting and promotion and marketing of the Chapter and has the right to contact the Corresponding Author and any Co-Author until the Chapter is publicly available on any platform owned and/or operated by IntechOpen.
\n\n6.3 IntechOpen is granted the authority to enforce the rights from this Publication Agreement, on behalf of the Corresponding Author and any Co-Author, against third parties (for example in cases of plagiarism or copyright infringements). In respect of any such infringement or suspected infringement of the copyright in the Chapter, IntechOpen shall have absolute discretion in addressing any such infringement which is likely to affect IntechOpen's rights under this Publication Agreement, including issuing and conducting proceedings against the suspected infringer.
\n\n7. MISCELLANEOUS
\n\n7.1 Further Assurance: The Corresponding Author shall and will ensure that any relevant third party (including any Co-Author) shall, execute and deliver whatever further documents or deeds and perform such acts as IntechOpen reasonably requires from time to time for the purpose of giving IntechOpen the full benefit of the provisions of this Publication Agreement.
\n\n7.2 Third Party Rights: A person who is not a party to this Publication Agreement may not enforce any of its provisions under the Contracts (Rights of Third Parties) Act 1999.
\n\n7.3 Entire Agreement: This Publication Agreement constitutes the entire agreement between the parties in relation to its subject matter. It replaces and extinguishes all prior agreements, draft agreements, arrangements, collateral warranties, collateral contracts, statements, assurances, representations and undertakings of any nature made by or on behalf of the parties, whether oral or written, in relation to that subject matter. Each party acknowledges that in entering into this Publication Agreement it has not relied upon any oral or written statements, collateral or other warranties, assurances, representations or undertakings which were made by or on behalf of the other party in relation to the subject matter of this Publication Agreement at any time before its signature (together "Pre-Contractual Statements"), other than those which are set out in this Publication Agreement. Each party hereby waives all rights and remedies which might otherwise be available to it in relation to such Pre-Contractual Statements. Nothing in this clause shall exclude or restrict the liability of either party arising out of its pre-contract fraudulent misrepresentation or fraudulent concealment.
\n\n7.4 Waiver: No failure or delay by a party to exercise any right or remedy provided under this Publication Agreement or by law shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy. No single or partial exercise of such right or remedy shall preclude or restrict the further exercise of that or any other right or remedy.
\n\n7.5 Variation: No variation of this Publication Agreement shall be effective unless it is in writing and signed by the parties (or their duly authorized representatives).
\n\n7.6 Severance: If any provision or part-provision of this Publication Agreement is or becomes invalid, illegal or unenforceable, it shall be deemed modified to the minimum extent necessary to make it valid, legal and enforceable. If such modification is not possible, the relevant provision or part-provision shall be deemed deleted.
\n\nAny modification to or deletion of a provision or part-provision under this clause shall not affect the validity and enforceability of the rest of this Publication Agreement.
\n\n7.7 No partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Corresponding Author or any Co-Author, nor authorize any party to make or enter into any commitments for or on behalf of any other party.
\n\n7.8 Governing law: This Publication Agreement and any dispute or claim (including non-contractual disputes or claims) arising out of or in connection with it or its subject matter or formation shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of or in connection with this Publication Agreement (including any non-contractual disputes or claims).
\n\nLast updated: 2020-11-27
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I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. 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After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. 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