Incidence of RDS by Birth Weight (BW) in the United States. Data from Vermont Oxford Network, 2003.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"4505",leadTitle:null,fullTitle:"Melanoma - Current Clinical Management and Future Therapeutics",title:"Melanoma",subtitle:"Current Clinical Management and Future Therapeutics",reviewType:"peer-reviewed",abstract:"Melanoma - Current Clinical Management and Future Therapeutics serves as an advanced course in melanoma or an addendum to further polish expertise. Sections of the book include a thorough introduction on epidemiology and disease, the current surgical management of melanoma and lymph node dissection, immunotherapy along with drug toxicities and emerging research topics, like RAGE and autotaxin, that have potential therapeutic applications. The chapters in this book explore the most common subtype of melanoma, cutaneous disease, as well as a rare form, acral lentiginous melanoma and even canine tumors. 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The delivery room (DR) is the setting where the baby is given birth and where the neonatologist may have to assist the newly born infant in optimizing the transition from dependent fetal to independent neonatal life.
\nThere is a wide consensus among clinicians about the importance of the DR management, especially regarding premature birth. In fact, the adequate management of unstable babies during the transition to extrauterine life can influence lifelong outcomes.
\nProviding optimal respiratory support is crucial to improve tissue oxygenation and guarantee normal gas exchanges. However, the physiological fetal-neonatal transition includes several crucial steps, which are difficult to achieve when the baby is extremely preterm. In fact, the lung and the chest wall of the preterm infants have essential characteristics making the newborn at the risk of developing respiratory distress syndrome (RDS).
\nThe respiratory transition is usually recognized as a three-phase process, which reflects the three physiological status of the lung during the transition to extrauterine life.
\nIn the first phase [1] of the respiratory transition, the lungs are fluid filled, and for this reason, no gas exchange can occur. Immediately after birth, with the first few deep breaths, a large tidal volume (VT) is generated, followed by a cascade of physiological events, promoting the clearance of the fluid from the lungs and the establishment of pulmonary gas exchanges.
\nAll these changes are critical for initiating postnatal circulation and for the achievement of an early and adequate functional residual capacity (FRC).
\nDuring the second phase, lung fluid should be prevented from re-entering the lung. In order to avoid the continuous opening and closing of the alveoli, endogenous surfactant and positive end-expiratory pressure (PEEP) play an important role in reducing surface tension and preventing alveoli collapse, respectively.
\nThe third phase, then, is characterized by the initiation of gas exchange and the subsequent establishment of cardio-respiratory homeostasis.
\nWhile all these transitions are made by the healthy full-term newborn by himself within a few minutes after birth, preterm infants must deal with several physiological impairments to properly aerate the lung.
\nIn fact, between the periods of viability (23 weeks’ gestation) to 35 weeks’ gestation, the preterm lung undergoes several complex anatomical and physiological changes, which include structural maturation, increase in surfactant production and storage, improved ability to clear fetal lung fluid, and enhanced epithelial barrier function. All these modifications progressively reduce the incidence of RDS, which falls to 5% when the baby is near term (> 36 weeks of GA).
\nRDS, also known as hyaline membrane disease, is the most frequent respiratory disorder in preterm infants. Over the last decades, the introduction of antenatal steroids and exogenous surfactant, besides significant improvements in ventilation strategies, have significantly improved survival rate, short-term complications, and long-term respiratory and neurodevelopmental outcomes of the preterm neonate.
\nRDS typically affects infants <35 weeks gestational age (GA) but older infants who have delayed lung maturation may be at risk as well. Low gestational age (GA) is the greatest risk factor for RDS (Figure 1), and its incidence varies inversely with birth weight among adequate for gestational age (AGA) infants (Table 1).
\nRisk of neonatal respiratory distress syndrome (RDS) as a function of gestational age and at different periods (current, from 1957–1963 prior to the introduction of antenatal steroids, and from 1983–1986 where ~40% of subjects received antenatal steroids). (da Caryn St. Clair “The Probability of Neonatal Respiratory Distress Syndrome as a Function of Gestational Age and Lecithin/Sphingomyelin Ratio”, Am J Perinatol. 2008 September; 25(8): 473–480).
Incidence of RDS by Birth Weight (BW) in the United States. Data from Vermont Oxford Network, 2003.
The clinical diagnosis is made in preterm infants with respiratory difficulty, which includes tachypnoea, retractions of the rib bones, grunting respirations, nasal flaring, and increasing O2 requirement. As shown in Figure 2, RDS plays a relevant role in premature infants’ outcome in the first weeks of life, underlying how the proper ventilatory management is crucial for survival.
\nProportionate mortality for major causes of death, According to postnatal age (da Ravi M. Patel et al, Causes and Timing of Death in Extremely Premature Infants from 2000 through 2011, N Engl J Med. 2015 January 22; 372(4): 331–340.).
Especially in preterm infants, maintenance of thermal homeostasis is crucial for the success of postnatal transition. This population, in fact, is particularly susceptible to cold stress and hypothermia, related to increased neonatal mortality [2, 3, 4].
\nThermoregulation after birth is mainly dependent on the capacity of the neonate to activate thermogenesis using brown adipose tissue. Unfortunately, preterm infants lack sufficient brown fatty tissue deposition, and for this reason, they are highly exposed to an unequivocal tendency toward hypothermia once they leave maternal milieu.
\nThe exact range within the newborn body temperature should be kept is not well defined, but using a target range of 36.5–37.5°C seems to be reasonable. On the contrary, mild neonatal hypothermia has been defined as mild when the body temperature is between 36.0 and 36.5°C, moderate at 32.0–35.9°C and severe below 32.0°C. There is a dose-related effect on mortality with an increased risk of approximately 30% for each degree below 36.5°C body temperature at admission.
\nBoth hypothermia and hyperthermia should be avoided during stabilization and upon admission to the neonatal intensive care unit. Of note, low temperature worsens the susceptibility of premature infants to hypoglycemia. Cold stress with following altered pulmonary vascular tone and metabolic acidosis can worsen respiratory transition and trigger respiratory failure onset.
\nSystematic monitoring of temperature during resuscitation (preferably skin and rectal) is therefore mandatory to prevent inappropriate uncontrolled temperature variations.
\nStrategies to minimize heat loss include occlusive wrapping, exothermic warming mattress, warmed humidified resuscitation gases, polyethylene caps, and adequate DR temperature.
\nIt is recommended that DR should be maintained at a temperature ranging 23–26°C, to the upper limits when expecting the birth of a very preterm infant (<28 weeks’ gestation) [5]. Then, all infants below 28 weeks’ gestation or <1500 g should be wrapped in polyethylene or polyurethane bags [6] up to their necks as soon as they are delivered, without being previously dried, to reduce heat loss and keep an adequate humidity [7]. The head coverage is fundamental, regardless of the material used for the hats, for two main reasons: the brain is a primary heat-producing organ and the head represents an extensive component of the neonatal body surface area.
\nExothermic mattresses and radiant heaters are also recommended, with an accurate control of the babies’ temperature especially after the first 10 minutes after birth, when the risk of hyperthermia substantially increases [5, 8].
\nAn attractive way to promote thermoregulation is the application of skin-to-skin contact as a means of preventing heat loss at birth. This alternative is obviously applicable only to infants requiring minimal stabilization at delivery, assuming that techniques of skin-to-skin contact are carefully performed.
\nAs previously mentioned, the preterm neonate, particularly that of an extremely low gestational age (ELGAN), often has limitations in achieving and maintaining “adequate” lung volume, mainly because surfactant production and storage are not sufficient and the respiratory effort is not effective [9].
\nIn a preterm infant, lung volume optimization from the first breath should lead to a more physiological transition to neonatal life while maintaining adequate gas exchange and preventing, or at least limiting, lung injury [10].
\nThe achievement of an adequate FRC at birth seems to be a crucial point for noninvasive respiratory support success.
\nTo facilitate this achievement, reduced lung damage and improved oxygenation, continuous positive airway pressure (CPAP) has been advocated as the optimal strategy for the initiation of respiratory support [11, 12, 13]. If an infant fails to breathe spontaneously, current neonatal resuscitation guidelines recommend positive pressure ventilation (PPV) via a face mask [14].
\nDevices through which PPV can be applied are different according to the level of care provided by the unit.
\nVentilation bags are the most easily found in the delivery room, and given the small VT of neonates (4–8 mL/kg), they should not be larger than 750 ml to avoid excessive volume delivery and therefore volutrauma.
\nThere are two types of ventilation bags: self-inflating bags and flow-inflating bags. The first one is relatively easier to use, and the recoil of the bags allows refilling even with no compressed gas source. Most self-inflating bags have a pressure release valve to prevent excessive pressure build-up and should release at approximately 30–35 cmH2O. To deliver 100% oxygen, the bags must be connected to an oxygen reservoir. Otherwise, a maximum of 40% oxygen will be reached.
\nThe flow-inflating bag only inflates when compressed gas is flowing into it, and the patient outlet is occluded. Proper use of flow-inflating bag requires a relative more training and practice.
\nNeither of these devices is optimal for the stabilization of preterm infants needing CPAP, because self-inflating bags cannot deliver positive pressure continuously, and on the other hand appropriate levels of CPAP are difficult to achieve and maintain with a flow-inflating bag. The T-piece resuscitator is the most widespread device in neonatal units, and like the flow-inflating bag, depends upon a compressed gas source and requires a tight face mask or endotracheal tube to inflate the lungs. With T-piece, it is easier to set and maintain PEEP and to administer PPV. One example of a T-piece resuscitator is the Neopuff™, which is flow-controlled and pressure-limited and specifically designed for application in neonatal settings. There is no wide consensus about which is the optimal PEEP to start resuscitation with. However, the latest ERC guidelines suggest a value around 5–6 cmH2O [14], while the European Consensus recommends at least 6 cmH2O to be individualized according to clinical condition, oxygenation, and perfusion [8].
\nRecent studies on preterm lamb have shown that a stepwise PEEP strategy at birth emphasizing time- and pressure-based recruitment and titrated to the subject’s lung mechanics was feasible and demonstrated short-term beneficial results [15]. An observational study describing DR management with stepwise increments of PEEP (e.g., from 8 to 14 cmH2O) plus surfactant administration among infants <26 weeks GA was shown to improve the rates of survival and morbidity, and reduce the need for mechanical ventilation (MV) [16]. However, since this approach included other interventions that may have interfere the final outcomes, there is a need for further evidence from a randomized trial before gaining wide acceptance.
\nThere are several situations in which using bag and mask or a T-piece resuscitator is not sufficient to provide an efficient ventilation, which is the most important goal to achieve to guarantee normal perfusion and therefore normal gas exchange. The most likely cause for heart rate (HR) < 60 bpm, in fact, is deficient oxygenation of the cardiac tissue.
\nWhen ventilation with these devices does not show effects on chest expansion, HR and/or saturation of peripheral oxygen (SpO2) or when PPV mask ventilation is prolonged, endotracheal intubation must be considered.
\nSupplies and equipment for endotracheal intubation should be readily available in the DR.
\nIntubation can be performed orally or nasally, although the oral way is usually preferred in emergency intubation because it is faster and easier to perform. However, both these techniques have their unique complications and share a few as well.
\nThe tube size should be usually chosen according to the estimated weight of the newborn and/or to gestational age. Suggestions are shown in Table 2. However, other clinical considerations must be taken into account (e.g., nares size, malformations, glottis dimension, etc.).
\nTube size (internal diameter) | \nBirth weight (g) | \nGestational age (weeks) | \n
---|---|---|
2.5 | \n<1000 | \n<26 | \n
3 | \n1000–2000 | \n27–34 | \n
3.5 | \n2000–3000 | \n35–40 | \n
3.5–4 | \n>3000 | \n>38 | \n
Suggestions for ETT size (Wyllie P, Neonatal Endotracheal Intubation, Arch Dis Child Educ Pract Ed. 2008 Apr; 93(2):44-9).
To properly insert the tube at the right depth, a practical rule can be used:
\nWeight of the baby (kg) + 6 = position of the tube (cm); for example, 2 (kg) + 6 = 8 cm
\nAnother popular way to rapidly calculate the depth of the endotracheal tube insertion is the “7-8-9 rule,” which is translated into a baby weighing 1 kg intubated to 7 cm, an infant of 2 kg to 8 cm and one of 3 kg to 9 cm. This method should not be applied in neonates < 750 g [17].
\nAfter having achieved alveolar recruitment in the DR, with the initiation of gas exchanges and clearance of lung fluid, is of great importance to maintain a constant distending pressure in the airway using CPAP or PPV, to avoid losing the acquired FRC. For this reason, transport to the neonatal unit must be done with extreme care and should aim at guaranteeing a reliable administration of pressure in the recently recruited lung, always trying to limit the risk of lung injury.
\nDuring resuscitation maneuvers, HR and SpO2 are monitored continuously using pulse oximetry, because they reflect the efficacy of the fetal-neonatal transition process [5].
\nThe pulse oximeter should be placed on the right hand or wrist of the infant as soon as the baby is placed on the resuscitation trolley.
\nDuring neonatal resuscitation, an increase in HR is an indicator for effective ventilation [5, 18].
\nFor this reason, a quick and reliable detection of the cardio-respiratory parameters is crucial to optimize critical interventions [19]. In fact, it has been demonstrated that alternative methods such as evaluation of HR using the stethoscope or palpation of the umbilical cord are not as accurate, especially in extremely preterm infants and when the baby is bradycardic [20, 21, 22, 23].
\nRecently, besides the use of pulse oximetry, ECG monitoring has been proposed as an alternative to display HR during resuscitation [24]. However, challenging ECG lead placement on the wet skin, epidermal loss at the site of leads placement, and overestimation of HR in the setting of potential pulseless electric activity need a particular skill by the clinician to avoid delay in resuscitation maneuver.
\nSince in utero, the fetus is exposed to low relative blood oxygen tension, and thus fetal life occurs in a hypoxic environment, defining specific ranges for normal HR and SpO2 at birth has been a priority for a rational use of oxygen therapy in the DR.
\nPreterm infants, in fact, are at high risk for hyperoxia-induced damages due to the immaturity of the mechanism that protects against oxygen free radicals. For this reason, avoid inappropriate O2 administration, and consequently useless interventions, are mandatory. With the aim of correctly titrating fraction of inspired oxygen (FiO2) in the DR, Dawson et al. have defined the range values for SpO2 and HR in the newly born infants, which are now incorporated into resuscitation guidelines (Figure 3).
\nNormal ranges of heart rate and SpO2 within the first 10 min of life in term and preterm infants who received no medical intervention at birth (Dawson et al.).
However, there is currently uncertainty about the optimal oxygen concentration at which starting resuscitation of preterm infants.
\nConsidering what is shown in a meta-analysis by Saugstad et al. [25], resuscitation of term infants in air reduced mortality in comparison with resuscitation with 100% oxygen. Thus, babies born at term and near-term should initially be resuscitated with air (FiO2 21%). On the other hand, very preterm infants who are initially resuscitated with air nearly always receive some supplemental oxygen in the subsequent minutes [18, 26]. Then, it seems that starting with intermediate FiO2 titrating in the course of resuscitation is more appropriate for very preterm infants. Pending further evidence, the latest International guidelines on resuscitation [5] now strongly recommend initiating stabilization of preterm infants less than 35 weeks gestation with lower initial FiO2 (21–30%). They also advocate against using high oxygen concentrations (65–100%), underlying instead the importance of not exposing these infants to additional oxygen without proven benefit.
\nSustained inflation (SI) is defined as “a positive pressure inflation designed to establish FRC and applied over a longer period of time than would normally be used to deliver subsequent tidal inflations” [27].
\nThe rationale behind SI relies on the concept that maintaining positive pressure for a prolonged time provides the lung with the necessary pressure gradient to drive the fluid along the airways distally and aiding transition in infants with inadequate respiratory effort.
\nFor this reason, the SI maneuver is an intriguing approach to allow premature infants to achieve an FRC rapidly. This experimental maneuver has been successfully used to recruit the lung in the early transitional phase to extrauterine life and in preventing repeated collapse and the opening of alveoli preterm animal models [28]. Reports of prompt increases in HR, as well as cerebral and systemic oxygenation in preterm infants exposed to SI in the DR, are signs suggestive of a positive effect of this maneuver [29].
\nStudying the resuscitation of asphyxiated near-term infants, Vyas et al [30] observed that the first inflations considered at the end of a 1” inflation gas were still entering the lung. Hence, they speculated that a longer inflation time would increase the Vt. They showed that in maintaining the initial inflation for approximately 5”, the Vt was doubled. According to these findings, the latest ERC neonatal guidelines recommend to maintain the initial pressure for 2–3” for the first five inflations [14].
\nSustained inflation can be delivered with a face mask or through an endotracheal tube. However, effects on infants [31, 32] using face masks have shown to be less impressive than using a tube in animal models [33], probably because of the tendency toward active closure of the glottis in infants during apnea or hypoxia [34, 35].
\nObservational studies analyzing the effect of SI in the have reported a significant reduction in rates of intubation and MV, bronchopulmonary dysplasia (BPD), and use of oxygen [36], which led to the design of several randomized controlled trials to compare SI with PPV alone [31, 37].
\nHowever, there is a lack of data regarding the optimal pressure to deliver and the best duration of the prolonged inflation. Thus, concerns regarding the safety of this technique still need to be clarified. A potential method could be end-tidal CO2 (ETCO2) monitoring, which have shown to be feasible to guide length of SI during resuscitation [38]. Also, the effectiveness of SI maneuver can be largely influenced by several factors, such as the different skill of the clinical team, interface through which a SI is delivered [39], the infant’s respiratory effort [35] and mask leak [32]. Given these findings, SI might not be the optimal approach in all apneic infants.
\nThis data, besides the paucity of large well-designed RCT on the routine use of SI, especially in the most premature infants, suggest that its application should be actually limited to research settings, in according with AAP [40] and ERC guidelines [14].
\nThe introduction of surfactant replacement therapy in early 1990s was a milestone in the treatment of preterm babies, leading to a significant reduction in mortality and to a different approach in respiratory problems of premature neonates. In fact, exogenous surfactant is nowadays routinely used in clinical practice to treat RDS.
\nThe types of surfactant currently commercialized are animal-derived and are obtained from either bovine or porcine lungs.
\nDue to its composition, surfactant can reduce surface tension on the inner surface of the alveoli, thus preventing alveoli from collapsing during expiration.
\nIn the last decades, the use of surfactant has changed consistently, and recommendations for its administration have been modified. For decades, the standard stabilization method for very preterm infants <29 weeks GA was endotracheal intubation and surfactant replacement therapy in the DR. However, a recent Cochrane meta-analysis [41] concluded that thanks to the widespread use of antenatal steroids and noninvasive respiratory support, routine prophylactic surfactant treatment provides no advantage over selective surfactant administration. In fact, prophylactic intubation and surfactant administration, compared with early noninvasive CPAP therapy, does not reduce BPD risk in preterm infants [12, 42, 43].
\nHowever, the efficacy of noninvasive respiratory support is closely related to GA. Among very low birth weight (VLBW) infants initially managed with N-CPAP about 50% of needs subsequent intubation and MV [11]. For this reason, in very preterm infants,
Providing early rescue surfactant (within the first 2 h of life) to mechanically ventilated preterm infants, as compared with delayed surfactant administration (after the second hour of life), reduces the risk of BPD and the composite of death or BPD (RR 0.83, 95% CI 0.75–0.91) [45].
\nAs mentioned previously, prenatal history must be carefully considered among the criteria for surfactant administration (especially prenatal steroids which promotes lungs’ maturation).
\nAs it is noted from literature MV, especially when prolonged, has been widely shown to be associated with BPD onset, neurodevelopmental impairment and death [12, 46]. With the aim to reduce these risks, limiting endotracheal ventilation, the so-called INSURE procedure was introduced in clinical practice. It combines intubation, surfactant treatment, then rapid extubation back to noninvasive respiratory support.
\nRecently, other strategies to administer surfactant avoiding endotracheal intubation and subsequent MV are gaining in popularity [47, 48, 49]. They are commonly called “LISA” (Less Invasive Surfactant Administration) or “MIST” (Minimally Invasive Surfactant Therapy). Kribs et al. perform direct laryngoscopy and using a Magill forceps place a feeding tube in the trachea, with no premedication [50, 51]. Overall, the need for MV was reduced; however, no differences in BPD or death were observed. [47]
\nThe MIST technique uses a narrow-bore tracheal catheter during direct laryngoscopy [48, 49] without using Magill forceps.
\nObservational studies using MIST reported a reduction in the need of MV in 25–28 weeks’ gestation babies with a similar trend at 29–32 weeks’ gestation.
\nAlthough these minimally invasive modes of administering surfactant are promising, their feasibility needs to be better established, especially in the periviable period.
\nThe early use of caffeine, which has been used for many years to treat apnea of prematurity, seems to be a promising approach. Early treatment (2 vs. 12 h of life) is associated with improved blood pressure and superior vena cava flow without any differences in need for intubation or vasopressors in a small cohort of preterm infants [52].
\nMoreover, when caffeine is administered early in the DR, it has shown to be effective in increasing spontaneous breathing. Moreover, Dekker et al have found that caffeine enhances the GA-related increase in minute ventilation, and that the stimulatory effect of caffeine on minute ventilation increases with GA [53].
\nTo date, international guidelines do not suggest caffeine administration in the DR, due to lack of extensive studies. However, further evidence is needed to verify its efficacy and benefits when used earlier.
\nProvide initial alveolar recruitment (using PEEP, short SI, prolonged SI in research setting)
Evaluate the presence and efficacy of spontaneous breathing and provide the ventilatory support accordingly:
CPAP:
PPV: peak inspiratory pressure (
Evaluate response to mask ventilation and titrate support accordingly
HR (>100 bpm)
SpO2 (consider postnatal range values)
If available, use ETCO2 device and RFM to verify gas exchange and exhaled VT (VTe)
Consider surfactant administration
Assure maintenance of recruitment during transport to NICU (PPV/CPAP delivered with mask or endotracheal tube or prongs)
The current neonatal resuscitation guidelines recommend in term infants delayed cord clamping (DCC) for at least 30 s, although the optimal timing is poorly studied. DCC as opposed to early cord clamping is associated with increased birthweights, hemoglobin levels at 24–48 h, iron stores at 3–6 months [54] and reduced hospital mortality [55]. However, there are some areas of concern surrounding DCC.
\nBabies undergoing DCC seem to be more likely to need phototherapy for jaundice. It is hypothesized that DCC babies will have a greater incidence of hyperbilirubinemia due to increased iron stores. Pending further evidence, this is an important aspect to consider in settings where kernicterus is common.
\nRegarding the influence of DCC on respiratory mechanics, there is lack of evidence. A Cochrane review found that babies receiving DCC babies are no more at risk than ICC infants of developing RDS [56], despite limited numbers of studies included and the small size population.
\nWhen a baby requires resuscitation or shows clinical conditions, which suggest medical interventions, DCC is not recommended. Thus, under specific circumstances (severe respiratory failure, asphyxia, etc.) an alternative maneuver called “
Whether cord milking is a valid alternative to cord clamping is still under investigation. However, in a population of term infants, early cord clamping with cord milking has shown to increase hemoglobin concentration and iron stores at 6 months of age [57]. The same procedure in late preterm infants is associated with improved iron stores at 6 weeks but also increases the risk of jaundice needing phototherapy [58].
\nThere is paucity of evidence regarding the effects of cord milking on neurodevelopmental outcomes.
\nAlthough the use of multiple devices monitoring resuscitation (pulse oximetry, ECG, respiratory function monitor-RFM, end-tidal CO2, NIRS) is still challenging in the DR, there is an increasing interest in monitoring physiologic changes during neonatal transition [59, 60, 61, 62].
\nWhen preterm infants need respiratory assistance in the delivery room, RFM is desirable to deliver adequate and gentle resuscitation maneuvers and to identify potential pitfalls during mask ventilation [63]. However, establishing this approach may be technically challenging.
\nDespite all the efforts to optimize resuscitation by the neonatologists, there are several situations in which the efficacy of PPV or CPAP mask ventilation is compromised.
\nMask leaks, airways obstructions (e.g., laryngeal closure [64]), interruptions of ventilation due to drying or hat placing are just some examples of how the ventilation can lose efficacy and be suboptimal [65] to deliver a safe and appropriate Vt.
\nMoreover, the majority of VLBW infants often show a respiratory effort, which is difficult to evaluate, making the decision to start PPV or use CPAP only particularly tricky. Especially in these babies, delivering the adequate Vt is fundamental, because of the high risk of damaging the lung with volutrauma. Measuring the Vt, in fact, is not currently possible without specific devices.
\nThe RFM (Figure 4) can integrate and show in real-time information about pulse oximetry and the main respiratory data, reflecting the efficacy of the resuscitation maneuvers. Particularly, a pneumotachometer connecting the resuscitator device and the patient interface provides data of delivered pressures and flows [66, 67] (Figure 5). Integration of the flow signal offers data on inspiratory and expiratory tidal volumes (Vti and VTe). This information helps the neonatologist in changing the PIP level to achieve adequate ventilation (Figure 2). Moreover, real-time observation of the flow signal is useful to detect face mask leaks or obstructions, which significantly influence a successful mask ventilation. In addition, the flow signal can help in verifying the efficacy of endotracheal intubation.
\nResuscitation setting with RFM.
The picture describes the signals recorded by an RFM during stabilization of a preterm infant in the DR. The signal of pressures delivered during mask PPV is indicated as Pmask, expired tidal Volume calculation (VTe), flow signal, pulse rate, and oxygen saturation (SpO2) are recorded concurrently. Pulse rate and SpO2 raise in this example is clearly related to raise in peak pressures during mask PPV with a following increase in VTe.
Upon informed parental consent, RFM can also be used in debriefing sessions of the resuscitation team or for educational purposes, since it is able to video-record the DR stabilization process.
\nHowever, RFM does not provide information about the success of lung aeration.
\nCarbon dioxide (CO2) levels are good indicators of efficacy in gas exchange [68], and for this reason, colourimetric CO2 detector is currently used to detect the correct placement of the endotracheal tube [69, 70, 71].
\nTo date, several observational studies have reported the value of using exhaled CO2 measurement to assess lung aeration and guide respiratory support in the DR [59, 68].
\nEven if it is a new technique, which must be further investigated to be standardized as a routine practice in the DR, ETCO2 monitoring has been recently shown to be a promising measurement to evaluate the degree of lung aeration and the onset of gas exchange. Moreover, it has been successfully used to monitor SI maneuver during resuscitation [38].
\nWhile peripheral oxygen saturation is easily monitored by pulse oximetry and is routine in the DR, Near-infrared spectroscopy (NIRS) allows noninvasive continuous real-time measurement of the regional tissue oxygen saturation. Hence, using NIRS has the potential to monitor cerebral oxygen delivery [72]. Having this information during resuscitation of preterm babies with RDS, could optimize the use of oxygen in the DR and reduce its potential damages.
\nAll the techniques described are potentially intriguing, but further evidence is needed to apply them into routine clinical practice in the DR.
\nPreterm infants at birth have to face with several limitations, which are inversely proportional to their gestational age. Moreover, prenatal factors play a crucial role in the prognosis and can guide the clinicians in the decision-making process, as early as in the DR.
\nAntenatal steroids prophylaxis, maternal complications (e.g., diabetes or gestosis) or intrauterine growth restriction may influence surfactant synthesis and storage, mode of delivery and use of general anesthesia may interfere in fetal-neonatal transition and therefore must be considered when the baby is about to be delivered and when resuscitation starts. If RDS signs are already present at birth, several interventions can be adopted to optimize cardio-respiratory management, to improve gas exchange and therefore oxygenation.
\nAn appropriate management from birth, in fact, should lead to the achievement of an early FRC and the following steps should aim at maintaining an adequate lung volume facilitating a more stable systemic and cerebral hemodynamics.
\nLiterature underlines the importance of a tailored respiratory management of preterm infants from birth and during the whole NICU stay to reduce mortality rate and occurrence of severe respiratory (e.g., BPD) and neurological sequelae (e.g., intraventricular hemorrage and periventricular leukomalacia).
\nAcute pancreatitis (AP) refers to the sudden inflammation of the pancreas, and it may be confined to the pancreas, or more life-threatening, affecting all organs and systems [1, 2, 3, 4, 5]. Recurrence is experienced in 15–30% of patients, and 5–25% can develop chronic pancreatitis. It progresses mildly in 80% of patients and resolves with treatment, but in cases of severe AP, complications such as organ failure and pancreatic necrosis may develop, with mortality of around 30% recorded in this group [2, 4, 5]. AP is an acute gastrointestinal disease that requires hospitalization, and is the most common cause of admission to the emergency room worldwide [1, 6, 7]. Hospital admissions for AP in the United States are in the region of 270,000/year, with a mortality rate of 30% in severe cases. Death is due to systemic inflammatory response syndrome (SIRS) and organ failure in the first two weeks, while death after two weeks can be attributed to sepsis and complications [3, 6, 8, 9].
Gallstones are the most common etiology of AP, being responsible for 40–70% of AP cases [10, 11, 12]. The ease at which small gallstones can pass into the bile duct make AP more common in this patient group [13]. Although alcohol is commonly blamed as the second most common cause, the link between alcohol and AP is unclear, as AP is seen in only a small number of alcoholics [2, 14, 15]. Recent studies have suggested that alcohol increases the oxidative metabolism in the acinar cells of the pancreas, thereby causing mitochondrial dysfunction and cell death. This increases also the production of acetaldehyde in the pancreatic stellate cells, and increases circulating lipopolysaccharide and tumor necrosis factor alpha (TNFα), leading to fibrosis in the pancreas [16, 17]. Alcohol has also been reported to increase the viscosity of pancreatic juice and to cause ductal obstructions. That said, it has also been suggested that genetic factors play a role in the development of AP,based on the low incidence of AP in people with chronic alcohol consumption [2, 15, 18]. Other causes have been identified as Hypertriglyceridemia (HTR), and diabetes, hypothyroidism, pregnancy and obesity that cause HTR [1]. Patients with a body mass index (BMI) >35 are at risk of both HTR and AP, while those with serum triglyceride levels >1000 mg/dl are at greater risk [19, 20, 21]. Following endoscopic retrograde cholangiopancreatography (ERCP) performed by inexperienced practitioners, patients with Sphincter of Oddi dysfunctions may develop AP following ERCP due to difficult cannulation [22].
AP can also occur due to drugs at a rate of 0.1–0.5% [2, 23, 24, 25]. Many drugs have been identified that cause acute pancreatitis. Drugs cause AP by different mechanisms. While some drugs cause direct toxicity to the pancreas (eg, diuretics, sulfonamides), some drugs cause acute pancreatitis by causing an immunological reaction (eg, 6-mercaptopurine, amino salicylates, sulfonamides). Diuretics and azothiopurine cause direct ischemia, while hormones such as steroids and estrogen cause vascular thrombosis or ischemic pancreatitis by decreasing the viskosity of the pancreatic juice. Toxic metabolites of drugs such as valproic acid and tetracycline may accumulate in the pancreas and cause pancreatitis [2, 26, 27].
AP cases have been reported associated with such infectious diseases as Mumps, Coxsackievirus, Hepatitis B, Cytomegalovirus, Varicella-Zoster, herpes simplex and human immunodeficiency virus (HIV) among the viruses; with Mycoplasma, Legionella, Leptospira and Salmonella among the bacteria; with Aspergillus among the fungi; and with Toxoplasma and Cryptosporidium among the parasites [2, 27, 28]. There have been reports of cases of AP with the recent SARS-CoV-2 infection at the heart of the current global pandemic [29, 30]. In a review of current literature, AP was found to be detected in 17% of patients hospitalized due to Covid-19 [29]. Although tests for specific infectious agents are not generally recommended in AP patients, Covid-19 infection should also be kept in mind in AP cases during the pandemic [30].
Concerning other rare causes, pancreatic injury following trauma is an extremely rare condition due to its retroperitoneal nature. Pancreatic duct injuries may occur due to blunt or penetrating traumas [31], while AP may occur due to gallbladder sludge, tumors, autoimmune pancreatitis, hypercalcemia, anatomical and physiological anomalies (pancreatic divisum, biliary cysts, pancreaticobiliary malunion, large juxta-ampullary diverticula, annular pancreas and Sphincter of Oddi dysfunction), and vasculitis [27, 32, 33, 34, 35, 36]. Ischemic AP can also be seen after major cardiovascular operations [27, 37, 38]. Patients with an unknown etiology after history-taking, physical examination, laboratory tests, imaging methods and advanced tests are classified as idiopathic. In the event of recurrent AP attacks in this patient group and AP at a young age, genetic factors should be investigated [27, 39].
As its main mechanism, AP blockades the secretion of enzymes while the synthesis of enzymes continues [2, 40]. Under normal conditions, trypsinogen is produced in the pancreas and secreted into the duodenum where it is converted into protease trypsin, but in cases where secretion is blocked, trypsin continues to be produced in pancreatic acinar cells. While activation continues, elimination is inhibited, and the active trypsin damages the vascular endothelium, interstitium and acinar cells [2, 40, 41]. As a result, autodigestion begins in the pancreas,and ischemia occurs at a tissue level in the pancreas due to the vasoconstriction and stasis of the capillary vessels. The activation of granulocytes and macrophages in response to these events causes a release of proinflammatory cytokines (tumor necrosis factor, interleukins 1, 6 and 8), arachidonic acid metabolites (prostaglandins, platelet activating factor and leukotrienes), proteolytic and lipolytic enzymes, and reactive oxygen metabolites [2, 27, 42, 43]. All of these factors together cause damage to the pancreatic tissue. In general, the inflammation is locally self-limiting, buton occasions, inflammatory agents may cause a systemic response, leading to the damage and failure of distant organs. This, in turn, may result in Acute Respiratory Distress Syndrome (ARDS), pleural effusion, acute renal failure, shock, and even death [2, 27, 44, 45].
Patients withAP present to the emergency room with sudden and severe abdominal pain that usually starts in the epigastric region. In patients with gallstones, the pain spreads to the right upper quadrant and is more sharply limited. In 50% of patients, the pain spreads to the back, and is felt around the entire abdomen, like a belt. Nausea and vomiting may accompany,and in rare cases there may be pain on the left side of the abdomen [2, 46, 47, 48, 49].
Physical examination findings can vary, depending on the severity of AP and any accompanying diseases. Initial findings typically include mild or generalized tenderness upon abdominal palpation, distension and diminished bowel sounds. In cases of obstruction due to gallstones, jaundice may be observed, while in severe AP, fever, hypotension, tachycardia, tachypnea and hypoxemia may be observed. In cases of pancreatic necrosis, ecchymotic lesions can be seen in the periumbilical region (Cullen’s sign) or on the flanks (Gray Turner’s sign) [2, 27, 50, 51].
Diagnosis is established based on the presence of two of three criteria: 1) Presence of clinical findings consistent with AP, 2) serum lipase or amylase levels three times greater than normal, and 3) characteristic findings of AP on imaging [2, 27, 47, 48, 52].
In AP, enzymes pass from the basolateral membrane to the interstitial area, and then on to the systemic circulation due to the blockade of the secretion ofpancreatic enzymes, while the synthesis of enzymes continues, resulting in increased levels of pancreatic enzymes in the blood.
At the onset of AP, serum amylase starts to increase within 6–12 hours, peaks at 48 hours, and returns to normal within 3–5 days, although no increase in amylase levels will be observed in alcohol-induced pancreatitis and AP due to hypertriglyceridemia. Sensitivity and specificity in diagnosis are 67–83% and 85–98%, respectively [2, 27, 48, 53, 54]. Elevated amylase levels may also be seen in non-pancreatic diseases, such as renal failure, salivary gland diseases, acute appendicitis, cholecystitis, perforations, intestinal obstructions or intestinal ischemia, and gynecological diseases. For these reasons, amylase alone is not sufficient for a diagnosis of AP [2, 48, 49]. The increase in serum lipase levels in AP is more specific. Following the onset of symptoms, the levels begin to increase within 8–10 hours, peak at 24 hours, return to normal within 8–14 days, with a sensitivity of 82–100% [2, 48, 53, 55], and may increase in alcohol-induced AP and AP due to hypertriglyceridemia. It is useful in delayed patients who present 24 hours after the onset of pain [48, 55, 56]. Aside from amylase-lipase, liver and kidney tests,a complete blood count should also be made in AP, as this will allow the assessment of the patient’s clinical condition, the early identification of complications and the detection of organ failure, and will aid in a therapeutic evaluation. An alanine aminotransferase (ALT) liver function test value in excess of 150 U/L indicates gallstones [2, 47, 52]. There are also specific tests for AP that are not routinely used. Among the enzymes with early elevation are trypsinogen-activating peptide, urinary and serum trypsinogen and trypsin, phospholipase, carboxypeptidase, carboxyl ester lipase, colipase and pancreatic isoamylase [57, 58, 59], and an increase is also observed in inflammatory mediators such as C-reactive protein (CRP), interleukin IL-6, IL-8, IL-10, tumor necrosis factor (TNF) and PMN elastase. The elevation of inflammatory mediators is usually proportional to the severity of AP. A CRP level above 150 mg/dl within the first 48 hours has been associated with severe AP [60, 61].
Imaging can aid in determining the etiology of AP, or complications due to AP. Abdominal and chest radiographs may reveal appearances of pleural effusion, atelectasis and ileus accompanying AP. Radiographs should be evaluated to rule out other causes of abdominal pain. Abdominal ultrasound should be performed on every patient with suspected AP, and USG can detect findings that support AP, if present, such as gallstones, obstructions in the common bile duct, intraabdominal free fluid and diffuse enlarged and hypoechoic appearance in the pancreas, as well as peripancreatic fluid, necrosis and abscesses. A normal USG cannot exclude AP [2, 27, 47, 48, 52, 62], while Contrast-Enhanced Computed Tomography (CECT) has a sensitivity of 90% in the diagnosis of AP. However, AP is not routinely recommended for diagnosis, since it is mild and uncomplicated in most patients [2, 47, 48, 52], but may be recommended in cases where other causes of acute abdomen cannot be excluded, or for patients who show no improvement within 48–72 hours [48, 63, 64].
Among the patients considered for CECT, MRI is recommended rather that CECT for those with renal failure, pregnant patients and those with allergies to IV contrast agents [48, 63].
Serum triglyceride levels must be examined in patients with normal test results, but with a strong suspicion of AP, in those with pancreatic tumors aged over 40 years, in the presence of genetic factors in patients under the age of 30 and in recurrent AP cases [39, 48].
Other diseases that may cause abdominal pain should be excluded in a differential diagnosis. In particular, peptic ulcer disease, choledocholithiasis, cholangitis, biliary obstruction, cholecystitis, perforated viscus, intestinal obstruction, mesenteric ischemia and hepatitis should be considered in differential diagnosis due to their clinical similarities to AP [2, 27].
AP can be classified into two groups as mild AP, in which patients have no accompanying organ failure, and recover and can be orally fed within 48 hours; and severe AP, which is accompanied by organ failure and a lack of response to treatment. Most patients with severe AP have not suffered organ failure at the time of admission to emergency room, and so may be evaluated as mild AP,but deteriorate rapidly due to inadequate hydration and inadequate treatment. As such, the severity of the disease should be determined along at the time of diagnosis in the emergency room, and treatment should be planned accordingly [47, 48, 52, 65].
According to the Atlanta classification, severe AP is characterized by resistant/persistent organ failure with no improvement within 48 hours, although in the absence of organ failure, the presence of local complications alone is an indicator of severe AP [66]. Patients who develop transient organ failure alongside local complications are classified as moderately severe AP (Table 1). The Atlanta classification evaluates the presence of organ failure based on Marshall’s organ failure criteria. Accordingly, the presence of shock (systolic BP <90 mmHg), pulmonary failure (PaO2 < 60 mmHg), renal failure (creatinine >2 despite adequate hydration), and/or the presence of gastrointestinal bleeding (>500 ml blood loss within 24 hours) should be evaluated as organ failure [48, 52, 67].
Mild AP | Moderately AP | Severe AP |
---|---|---|
Absence of local complications | Peripancreatic fluid collection Pancreatic or peripancreatic necrosis(sterile or infected) Gastric outlet disfunction Splenic or portal vein thrombosis Colonic necrosis AND/OR | GI bleeding (>500 cc/24 hr) Shock – SBP < 90 mmHg PaO 2 < 60% Creatinine >2 mg/d |
Absence of organ failure | ||
GI bleeding (>500 cc/24 hr) Shock – SBP < 90 mmHg PaO 2 < 60% Creatinine >2 mg/d |
Atlanta classification 2015.
Besides the Atlanta classification, several scoring systems have been proposed for the determination of the severity in AP. These include Ranson’s criteria,Acute Physiology and Chronic Health Examination-II, modified Glasgow score, Bedside Index for Severity in Acute Pancreatitis and the Balthazar CT Severity Index,none of which has been shown to be superior to any other, and they have only limited use in the emergency room, as they rely on too many parameters, and some give results only after 48 hours [68, 69]. The assessment of the patient in the emergency department is of utmost importance, with patient-related risk factors such as age, weight, comorbidities and vital signs as well as laboratory findings all being evaluated together (Table 2) [47, 52, 56, 65].
Patient characteristics | The systemic inflammatory response syndrome (SIRS) | Laboratory findings | Radiology findings |
---|---|---|---|
Age > 55 years Obesity (BMI >30 kg/m2) Altered mental status Comorbid disease |
| BUN >20 mg/dl Rising BUN HCT >44% Rising HCT Elevated creatinine | Pleural effusions Pulmonary infiltrates Multiple or extensive extrapancreatic collections |
Initial assessment for risk of severe AP.
The initial approach to AP involves aggressive fluid therapy, pain management and nutritional support. In AP, there is a large amount of fluid deficit due to losses from vomiting, reduced oral intake, passage of fluid into the third space, respiration and sweating. If the patient has no additional cardiovascular or renal disease, fluid replacement should be initiated at 5–10 ml/kg/hour. For patients presenting with evidence of hypovolemia and shock, 3 ml/kg of fluid should be given for 8–12 hours following a fluid bolus of 20 ml/kg in 30 minutes, with isotonic normal saline preferred as the fluid [47, 48, 52, 70, 71, 72]. A prospective study found hydration with Ringer’s lactate solution to be more beneficial, although Ringer’s lactate solution has been shown to activate trypsin in acinar cells, thereby making the patient more susceptible to injury due to its low pH. With normal saline, there is a risk of developing non-anion gap metabolic acidosis, and patients should be monitored accordingly during fluid replacement [2, 72]. An assessment should be made after 6, 24 and 48 hours to as certain whether the fluid administered is sufficient. With adequate hydration, the heart rate should drop below 120/min, mean arterial pressure (MAP) should be maintained between 65 and 85, and hematocrit (HCT) should be 35–44%. If the BUN value is initially high, a decrease upon hydration is an indicator of adequate hydration. Changes in blood urea nitrogen (BUN) values within the first 24 hours are particularly important [27, 47, 48, 73, 74]. If the BUN values continue to be high, or increase even further, acute tubular necrosis or resistant volume deficit should be suspected [27, 47, 52, 65, 75]. Another parameter that should be monitored during hydration is hematocrit. Continued hemoconcentration for more than 24 hours suggests the development of necrotizing pancreatitis, and so the patient’s urine output, BUN and HCT values should be closely monitored. The development of severe pancreatitis should be considered in patients who do not respond to aggressive hydration for 6–12 hours [47, 48, 52].
Adequate hydration and the resolution of hypovolemia relieve ischemic pain secondary to hemoconcentration. Nevertheless, opioid analgesics are recommended for rapid pain management. Fentanyl can be used safely, especially in patients with kidney failure, in which intravenous (IV) fentanyl of 20–50 microgram is administered slowly over 10 minutes. Meperidine can be used as an alternative to morphine due to the spasm effect of morphine on the Sphincter of Oddi [2, 27, 76, 77].
AP patients should be followed closely for 24 hours, with continued monitoring of blood pressure, temperature, pulse, oxygen saturation and urine output. Blood tests should be monitored for hematocrit, BUN and electrolytes (calcium, magnesium), and blood glucose should be maintained between 180 and 200 mg/dl [2, 27, 52]. Intensive care follow-up is required for patients whose vital signs and laboratory values are unstable and / or continue (Table 3) [52].
Vital signs | Laboratuary findings | Patient condition |
---|---|---|
pulse <40 or > 150 beats/min; systolic arterial pressure < 80 mmHg (<10.7 kPa) or mean arterial pressure < 60 or diastolic arterial pressure > 120 mmHg respiratory rate > 35 breaths/min; | serum sodium <110 mmol/l or > 170 mmol/l; serum potassium<2.0 mmol/l or > 7.0 mmol/l; paO2 < 50 mmHg pH < 7.1 or > 7.7; serum glucose >800 mg/dl (>44.4 mmol/L); mmol/L); serum calcium >15 mg/dl (>3.75 | coma. Furthermore, a patient with severe acute pancreatitis as defined by the revised Atlanta Classification (i.e. persistent organ failure) |
Assessment for intensive care.
It is no longer recommended to stop oral intake until the AP has fully resolved and the enzymes have returned to normal limits in order to put the pancreas at rest. Patients ceasing oral intake may develop atrophy in the mucosa of gastrointestinal tract [27, 47, 48, 52, 78, 79], and so oral feeding should be initiated in patients without nausea, vomiting or ileus and with relieved pain, as soon as they can tolerate [47, 48, 52, 79, 80, 81]. Liquid, light and low-fat foods should be given at first [82]. In cases of severe AP, enteral feeding may be initiated in patients who are still unable to tolerate oral feeding after 5 days, and in those with complications. For enteral nutrition, a nasojejunal or nasogastric tube should be used for feeding. A nasogastric tube insertion may be easy, but there is a risk of aspiration, while a nasojejunal tube requires an operation. Depending on the conditions, both methods can help provide effective nutrition [47, 48, 82]. If the goal of enteral nutrition is not achieved within 48–72 hours, or if the patient cannot tolerate, parenteral nutrition should be initiated [80, 81, 83].
20% of patients develop extrapancreatic infections that may be cholangitis, catheter infection, urinary tract infection or pneumonia. Prophylactic ABs, even if severe, are not routinely recommended in AP without an unidentified focus of infection or presence of infection. ABs for infective necrosis prophylaxis are not recommended, even for patients with sterile necrosis [2, 27, 47, 48, 52, 65, 84, 85].
If, during the follow-up of moderately severe or severe AP patients, signs of sepsis appear, no improvement occurs within 72 hours or the condition deteriorates gradually, then complications should be suspected and a CECT should be performed.
Acute peripancreatic fluid collection occurs early, and has no specific wall. It resorbs spontaneously [27, 48].
Necrotizing pancreatitis can involve both the pancreas and peripancreatic tissues. A variable amount of fluid and necrotic tissue may develop within the necrosis,and is known as Acute Necrotic Collection (ANC) when a clear wall cannot be defined, and as Wall-off Necrosis (WON) when there is a mature, encapsulated and well-defined wall. WON is a pancreatic pseudocyst that occurs around 4 weeks after an AP attack, and that has a noticeable wall, for which drainage may be required. In either case, the necrotic area may be sterile or infected, and the type of treatment is determined based on the presence or absence of infection [84, 86, 87, 88].
Infection should be suspected in patients with pancreatic or extrapancreatic necrosis upon clinical deterioration or a lack of improvement within 7–10 days of hospitalization. Infectious agents are usually of intestinal origin (such as Escherichia coli, Pseudomonas, Klebsiella and Enterococcus), and may be suspected with the emergence of clinical signs of infection in patients and the presence of gas around the pancreas on imaging [89, 90]. Empirical AB may be initiated in these patients, with ABs that can penetrate the pancreas well (carbapenem alone; or quinolone, ceftazidime, or cefepime combined with an anaerobic agent such as metronidazole)being recommended [27, 47, 48]. Fine needle aspiration (FNA) or sampling is not recommended in such patients. Necrosectomy may be scheduled for patients who show no improvement, but should be delayed as much as possible, since many patients respond well to AB therapy [48, 90, 91, 92]. Antibiotic therapy should have been completed 4 weeks prior to a decision of necrosectomy. For the necrestomy, endoscopic or invasive percutaneous procedures should be tried first, and if these fail, surgery should be scheduled [47, 48, 52, 91, 92, 93].
In patients with necrotizing pancreatitis, sterile necrotizing pancreatitis should be suspected when there is no improvement despite treatment, and no clear clinical or imaging findings of infection. In such cases, FNA sampling is indicated, and if the collected material is sterile, there is no need to continue the ABs. Even ABs cannot prevent sterile necrosis from turning into infected necrosis [47, 52, 94]. In sterile necrosis in the absence of any sign of infection, interventions will be required in the following cases:
Continued obstruction of the gastric outlet, intestine or bile ducts, caused by mass effects after 4–8 weeks following the onset of acute pancreatitis.
Persistant symptoms (e.g. abdominal pain, nausea, vomiting, anorexia or weight loss) identified more than eight weeks following the onset of acute pancreatitis.
Disconnected duct syndrome (full transection of the pancreatic duct) with persistent symptomatic collections with necrosis (e.g., pain, obstruction) more than 8 weeks following the onset of acute pancreatitis.
Aside from these, CT and FNA should be repeated 5–7 days later in patients with sterile necrosis detected by CECT and FNA, but with signs of systemic toxicity [48, 52].
The much rarer complications include peripancreatic vascular complications, splanchnic vein thrombosis, abdominal compartment syndrome and pseudoaneurysm. Furthermore, patients may risk developing diabetes in the following periods [27, 52, 95].
Respiratuar insufficiency includes pneumonia, atelectasis, and ARDS. Renal complications are prerenal azotemia, hypotansion and acute tubuler necrosis. Shock is caused by third space losses, vomiting and interstitial edema. Hypo-hyperglicemia, coagulation disorders, fat necrosis and pancreatic encphalophaty are other rare systemic complications of AP [27].
The detection and treatment of the underlying diseases that cause AP are as important as AP itself. Most gallstones that pass into the common bile duct advance to the intestines, and are excreted with feces. However, stones that cause obstructions to the pancreatic duct and/or biliary ducts may result in severe AP and/or cholangitis. ERCP is recommended within the first 24 hours for AP patients with stones detected as causing an obstruction. The removal of stones by via a sphincterotomy with ERCP prevents both severe AP and the cholangitis and future development of biliary AP. ERCP should be performed within the first 24 hours in AP patients due to gallstones accompanied by acute cholangitis. A papillotomy, or the surgical removal of stones, with ERCP reduces the severity of AP [48, 52, 96, 97, 98]. It has been reported that mortality decreases with early ERCP in patients with no cholangitis, with biliary duct obstructions, and with elevated liver function test scores. That said, it is unnecessary to perform ERCP within the first 24 hours on patients with no increase in liver function tests, with therapeutic ERCP recommended for such patients before or during the cholecystectomy. It is recommended that EUS and MRCP be performed prior to ERCP in patients without cholangitis or jaundice, but with suspected choledocholithiasis, pregnant women and patients on whom ERCP cannot be performed anatomically [47, 48, 52, 65, 99].
The removal of stones through the use of ERCP in patients without cholangitis can prevent the development of AP in the future, but it cannot prevent the development of biliary colic or cholecystitis. Accordingly, cholecystectomy is recommended prior to discharge in patients with mild AP and with gallstones [47, 48, 52, 65, 100, 101, 102, 103]. Preoperative MRCP or EUS, or intraoperative cholangiography may be carried out for the selection of patients with common bile duct stones who need to be treated through an operative bile duct exploration or endoscopic sphincterotomy during a cholecystectomy [48, 52, 99]. A cholecystectomy may be avoided in ineligible elderly patients (>80 years of age), particularly if a sphincterotomy has already been performed [48, 52, 96, 97]. A cholecystectomy should be performed in patients with gallbladder sludge and AP. In patients with necrotizing biliary AP, cholecystectomies should be delayed until the active inflammation subsides and fluid collections have resolved or stabilized. If collection takes longer than 6 weeks to resolve, the cholecystectomy should be delayed until it can be performed safely [47, 48, 52, 65]. Asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis require no surgical intervention, regardless of the size, location and/or extension. In asymptomatic patients with infected necrosis, surgical, radiological and/or endoscopic drainage should be delayed for more than 4 weeks to allow for the liquefaction of the content and the development of a fibrous wall around the necrosis (WON). Minimally invasive necrosectomy methods are preferred in symptomatic patients with infected necrosis [47, 48, 52, 84, 87]. Percutaneous drainage and/or endoscopic drainage/debridement are minimally invasive alternatives to open surgery [104].
Although new guidelines have been published, there are several knowledge gaps identified in the initial management of the AP. Risk stratification of patients with AP is important to ensure the appropriate level of care. Therefore, there is a need to develop fast, easy and practical systems that can be used in the emergency room. There is also a need to define targeted therapies in AP. Future research will enable prevention of relapse, chronicity, and cancer development, improvement of quality of life and reduction of mortality.
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All published Book Chapters are licensed under a Creative Commons Attribution 3.0 Unported License. Monographs are licensed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) license granted to all others. Our Copyright Policy aims to guarantee that original material is published while at the same time giving significant freedom to our Authors. IntechOpen upholds a flexible Copyright Policy meaning that there is no copyright transfer to the publisher and Authors hold exclusive copyright to their work.
\n\n\n\nWith the purpose of protecting our Authors' copyright and the transparent reuse of Open Access content, IntechOpen has developed an Attribution Policy for works published under Creative Commons licenses.
\n\n\n\nIntechOpen is committed to disseminating high-quality scientific research in a manner that exemplifies the best practice in scholarly publishing. IntechOpen is an official member of the Committee on Publication Ethics (COPE), which advocates the maintenance of the highest ethical standards for all parties involved in the act of publishing, including Authors, Academic Editors of the book, Peer Reviewers, the publisher and Societies, where applicable.
\n\nIn line with publication ethics practices recommended by COPE, ICMJE, and other similar organizations, IntechOpen's contributing Authors, Academic Editors, and Peer Reviewers are required to declare fully all possible conflicts of interest.
\n\n\n\nIntechOpen's Authorship Policy is based on ICMJE criteria for authorship. In order to be identified as an Author, the following requirements must be met:
\n\nAll scientific works are subject to Peer Review prior to publishing. IntechOpen is a member of the Committee on Publication Ethics (COPE) and all participating referees and Academic Editors are expected to review submitted scientific works in line with the COPE Ethical Guidelines for Peer Reviewers where applicable.
\n\n\n\nThe Internet has changed the dynamics of scholarly communication and publishing which is why we find it necessary to clearly indicate our stance on what we consider to be a published scientific work. A significant number of working papers, early drafts, and similar works in progress are shared openly online between members of the scientific community. It has become common practice for researchers to announce their work on a personal website or a blog in order to gather comments and suggestions from other researchers. Such works and online postings are ‘published’ in the sense that they are made publicly available, but this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
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\n\nIntechOpen's advisors are professionals and scholars with broad knowledge and understanding of different aspects of the scientific publishing process: editorial, authorship, and reviewing roles; publication ethics, copyright, and general legal issues; as well as bibliographic and technical standards.
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\n\nIntechOpen publishes books in the English language. If you are interested in the translation of Book Chapters, please check IntechOpen's Translation Policy.
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\n\nChapters will remain listed as Online First until the final versions of the books are published online. Following publication of the full monograph, Chapters will be redirected from the Online First version and will be available only through the final link of the official published page.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr.",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Rheinmetall (Germany)",country:{name:"Germany"}}},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. His research interests include the application of agent technology for achieving agile control in the manufacturing environment.",institutionString:null,institution:null},{id:"605",title:"Prof",name:"Dil",middleName:null,surname:"Hussain",slug:"dil-hussain",fullName:"Dil Hussain",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/605/images/system/605.jpg",biography:"Dr. Dil Muhammad Akbar Hussain is a professor of Electronics Engineering & Computer Science at the Department of Energy Technology, Aalborg University Denmark. Professor Akbar has a Master degree in Digital Electronics from Govt. College University, Lahore Pakistan and a P-hD degree in Control Engineering from the School of Engineering and Applied Sciences, University of Sussex United Kingdom. Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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In this chapter, it is defined as a possible ability of an individual or a group to face, manage, and anticipate a possible problem. This concept of vulnerability is associated with that of risk factor for social isolation, and therefore to situations that can also lead to illness and lack of mental and physical health. It can have its roots in poverty, in social exclusion, in ethnicity, in disability or simply in disease or specific developmental phases in life. All these aspects reflect very important vulnerability factors among biological, psychological, social, and behavioral variables. To date, no one has highlighted together two critical moments in life in which this brain area undergoes important variations: adolescence, in which its development occurs, and old age, in which this area goes into cognitive decline with the relative loss of many higher cognitive functions. This knowledge can help to better understand the forms of exclusion due to vulnerability in order to develop new forms of social inclusion.",book:{id:"8262",slug:"the-new-forms-of-social-exclusion",title:"The New Forms of Social Exclusion",fullTitle:"The New Forms of Social Exclusion"},signatures:"Rosalba Morese, Sara Palermo, Matteo Defedele, Juri Nervo and Alberto Borraccino",authors:[{id:"214435",title:"Dr.",name:"Rosalba",middleName:null,surname:"Morese",slug:"rosalba-morese",fullName:"Rosalba Morese"},{id:"218983",title:"BSc.",name:"Juri",middleName:null,surname:"Nervo",slug:"juri-nervo",fullName:"Juri Nervo"},{id:"218984",title:"MSc.",name:"Matteo",middleName:null,surname:"Defedele",slug:"matteo-defedele",fullName:"Matteo Defedele"},{id:"233998",title:"Ph.D.",name:"Sara",middleName:null,surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo"},{id:"266453",title:"Prof.",name:"Alberto",middleName:null,surname:"Borraccino",slug:"alberto-borraccino",fullName:"Alberto Borraccino"}]},{id:"74550",doi:"10.5772/intechopen.95395",title:"School Conflicts: Causes and Management Strategies in Classroom Relationships",slug:"school-conflicts-causes-and-management-strategies-in-classroom-relationships",totalDownloads:2342,totalCrossrefCites:1,totalDimensionsCites:10,abstract:"Conflicts cannot cease to exist, as they are intrinsic to human beings, forming an integral part of their moral and emotional growth. Likewise, they exist in all schools. The school is inserted in a space where the conflict manifests itself daily and assumes relevance, being the result of the multiple interpersonal relationships that occur in the school context. Thus, conflict is part of school life, which implies that teachers must have the skills to manage conflict constructively. Recognizing the diversity of school conflicts, this chapter aimed to present its causes, highlighting the main ones in the classroom, in the teacher-student relationship. It is important to conflict face and resolve it with skills to manage it properly and constructively, establishing cooperative relationships, and producing integrative solutions. Harmony and appreciation should coexist in a classroom environment and conflict should not interfere, negatively, in the teaching and learning process. This bibliography review underscore the need for during the teachers’ initial training the conflict management skills development.",book:{id:"7827",slug:"interpersonal-relationships",title:"Interpersonal Relationships",fullTitle:"Interpersonal Relationships"},signatures:"Sabina Valente, Abílio Afonso Lourenço and Zsolt Németh",authors:[{id:"324514",title:"Ph.D.",name:"Sabina",middleName:"N.",surname:"Valente",slug:"sabina-valente",fullName:"Sabina Valente"},{id:"326375",title:"Ph.D.",name:"Abílio",middleName:"Afonso",surname:"Lourenço",slug:"abilio-lourenco",fullName:"Abílio Lourenço"},{id:"329177",title:"Dr.",name:"Zsolt",middleName:null,surname:"Németh",slug:"zsolt-nemeth",fullName:"Zsolt Németh"}]},{id:"55323",doi:"10.5772/intechopen.68873",title:"Positive Psychology: The Use of the Framework of Achievement Bests to Facilitate Personal Flourishing",slug:"positive-psychology-the-use-of-the-framework-of-achievement-bests-to-facilitate-personal-flourishing",totalDownloads:1750,totalCrossrefCites:3,totalDimensionsCites:9,abstract:"The Framework of Achievement Bests, which was recently published in Educational Psychology Review, makes a theoretical contribution to the study of positive psychology. The Framework of Achievement Bests provides an explanatory account of a person’s optimal best practice from his/her actual best. Another aspect emphasizes on the saliency of the psychological process of optimization, which is central to our understanding of person’s optimal functioning in a subject matter. Achieving an exceptional level of best practice (e.g. achieving excellent grades in mathematics) does not exist in isolation, but rather depends on the potent impact of optimization. This chapter, theoretical in nature, focuses on an in‐depth examination of the expansion of the Framework of Achievement Bests. Our discussion of the Framework of Achievement Bests, reflecting a methodical conceptualization, is benchmarked against another notable theory for understanding, namely: Martin Seligman’s PERMA theory. For example, for consideration, one aspect that we examine entails the extent to which the Framework of Achievement Bests could explain the optimization of each of the five components of PERMA (e.g. how does the Framework of Achievement Bests explain the optimization of engagement?).",book:{id:"5761",slug:"quality-of-life-and-quality-of-working-life",title:"Quality of Life and Quality of Working Life",fullTitle:"Quality of Life and Quality of Working Life"},signatures:"Huy P. Phan and Bing H. Ngu",authors:[{id:"196435",title:"Prof.",name:"Huy",middleName:"P",surname:"Phan",slug:"huy-phan",fullName:"Huy Phan"}]},{id:"55349",doi:"10.5772/intechopen.68596",title:"The Development of a Human Well-Being Index for the United States",slug:"the-development-of-a-human-well-being-index-for-the-united-states",totalDownloads:2055,totalCrossrefCites:3,totalDimensionsCites:9,abstract:"The US Environmental Protection Agency (EPA) has developed a human well-being index (HWBI) that assesses the over-all well-being of its population at the county level. The HWBI contains eight domains representing social, economic and environmental well-being. These domains include 25 indicators comprised of 80 metrics and 22 social, economic and environmental services. The application of the HWBI has been made for the nation as a whole at the county level and two alternative applications have been made to represent key populations within the overall US population—Native Americans and children. A number of advances have been made to estimate the values of metrics for counties where no data is available and one such estimator—MERLIN—is discussed. Finally, efforts to make the index into an interactive web site are described.",book:{id:"5761",slug:"quality-of-life-and-quality-of-working-life",title:"Quality of Life and Quality of Working Life",fullTitle:"Quality of Life and Quality of Working Life"},signatures:"J. Kevin Summers, Lisa M. Smith, Linda C. Harwell and Kyle D. Buck",authors:[{id:"197485",title:"Dr.",name:"J. Kevin",middleName:null,surname:"Summers",slug:"j.-kevin-summers",fullName:"J. Kevin Summers"},{id:"197486",title:"Ms.",name:"Lisa",middleName:null,surname:"Smith",slug:"lisa-smith",fullName:"Lisa Smith"},{id:"197487",title:"Ms.",name:"Linda",middleName:null,surname:"Harwell",slug:"linda-harwell",fullName:"Linda Harwell"},{id:"197488",title:"Dr.",name:"Kyle",middleName:null,surname:"Buck",slug:"kyle-buck",fullName:"Kyle Buck"}]},{id:"56529",doi:"10.5772/intechopen.70237",title:"Well-being and Quality of Working Life of University Professors in Brazil",slug:"well-being-and-quality-of-working-life-of-university-professors-in-brazil",totalDownloads:1685,totalCrossrefCites:2,totalDimensionsCites:6,abstract:"This chapter presents a study about the perceptions on quality of working life (QWL) regarding factors and indicator in two public universities in Brazil. It aimed also to analyze their perceptions about university working conditions. This exploratory study is based on quantitative and qualitative analyses. A sample of 715 university professors participated on the research. Data collection was carried out in two steps: online survey and focus groups. There is a moderate negative correlation between psychological well-being and work-related stress. Emotional charge also presents a moderate positive correlation with work-related stress, as well as physical charge and psychological distress. Work-life balance is negatively correlated with physical charge, emotional charge, work-related stress, psychological distress, and burnout. We observed also that 43.6% of the professors reported high levels of work-related stress in their everyday work. The precariousness of university teaching is associated with three main elements, which we defined as the tripod of the precarization of university teaching work. It consists of academic productivism, excess of administrative work and bureaucratic activities, and inadequate working conditions. The operating dynamics of this tripod effect professors’ well-being, their QWL, and even the quality of the work they develop in public universities.",book:{id:"5761",slug:"quality-of-life-and-quality-of-working-life",title:"Quality of Life and Quality of Working Life",fullTitle:"Quality of Life and Quality of Working Life"},signatures:"Alessandro Vinicius de Paula and Ana Alice Vilas Boas",authors:[{id:"175373",title:"Dr.",name:"Ana Alice",middleName:null,surname:"Vilas Boas",slug:"ana-alice-vilas-boas",fullName:"Ana Alice Vilas Boas"},{id:"196534",title:"Dr.",name:"Alessandro Vinicius",middleName:null,surname:"De Paula",slug:"alessandro-vinicius-de-paula",fullName:"Alessandro Vinicius De Paula"}]}],mostDownloadedChaptersLast30Days:[{id:"74550",title:"School Conflicts: Causes and Management Strategies in Classroom Relationships",slug:"school-conflicts-causes-and-management-strategies-in-classroom-relationships",totalDownloads:2339,totalCrossrefCites:1,totalDimensionsCites:10,abstract:"Conflicts cannot cease to exist, as they are intrinsic to human beings, forming an integral part of their moral and emotional growth. Likewise, they exist in all schools. The school is inserted in a space where the conflict manifests itself daily and assumes relevance, being the result of the multiple interpersonal relationships that occur in the school context. Thus, conflict is part of school life, which implies that teachers must have the skills to manage conflict constructively. Recognizing the diversity of school conflicts, this chapter aimed to present its causes, highlighting the main ones in the classroom, in the teacher-student relationship. It is important to conflict face and resolve it with skills to manage it properly and constructively, establishing cooperative relationships, and producing integrative solutions. Harmony and appreciation should coexist in a classroom environment and conflict should not interfere, negatively, in the teaching and learning process. This bibliography review underscore the need for during the teachers’ initial training the conflict management skills development.",book:{id:"7827",slug:"interpersonal-relationships",title:"Interpersonal Relationships",fullTitle:"Interpersonal Relationships"},signatures:"Sabina Valente, Abílio Afonso Lourenço and Zsolt Németh",authors:[{id:"324514",title:"Ph.D.",name:"Sabina",middleName:"N.",surname:"Valente",slug:"sabina-valente",fullName:"Sabina Valente"},{id:"326375",title:"Ph.D.",name:"Abílio",middleName:"Afonso",surname:"Lourenço",slug:"abilio-lourenco",fullName:"Abílio Lourenço"},{id:"329177",title:"Dr.",name:"Zsolt",middleName:null,surname:"Németh",slug:"zsolt-nemeth",fullName:"Zsolt Németh"}]},{id:"76968",title:"In the Darkness of This Time: Wittgenstein and Freud on Uncertainty",slug:"in-the-darkness-of-this-time-wittgenstein-and-freud-on-uncertainty",totalDownloads:466,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Both Wittgenstein and Freud experienced the crisis of humanism resulting from the first and second world wars. Although they were both considered to be influential figures, they hardly investigated the ways in which people could cope with the consequences of these crises. However, Wittgenstein and Freud did suggest ways of understanding uncertainties caused by real life events, as well as by the nature of human thought processes. This article will explore the therapeutic ways of dealing with uncertainties common to both thinkers and the different concepts facilitating their methodologies. The central contention of this article is that both Wittgenstein and Freud developed a complex methodology, acknowledging the constant and unexpected changes humans have deal with, whilst also offering the possibility of defining “hinge propositions” and “language-games” which can stabilize our consciousness.",book:{id:"10814",slug:"anxiety-uncertainty-and-resilience-during-the-pandemic-period-anthropological-and-psychological-perspectives",title:"Anxiety, Uncertainty, and Resilience During the Pandemic Period",fullTitle:"Anxiety, Uncertainty, and Resilience During the Pandemic Period - Anthropological and Psychological Perspectives"},signatures:"Dorit Lemberger",authors:[{id:"325725",title:"Dr.",name:"Dorit",middleName:null,surname:"Lemberger",slug:"dorit-lemberger",fullName:"Dorit Lemberger"}]},{id:"76565",title:"Introductory Chapter: The Transition from Distress to Acceptance of Human Frailty - Anthropology and Psychology of the Pandemic Era",slug:"introductory-chapter-the-transition-from-distress-to-acceptance-of-human-frailty-anthropology-and-ps",totalDownloads:398,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"10814",slug:"anxiety-uncertainty-and-resilience-during-the-pandemic-period-anthropological-and-psychological-perspectives",title:"Anxiety, Uncertainty, and Resilience During the Pandemic Period",fullTitle:"Anxiety, Uncertainty, and Resilience During the Pandemic Period - Anthropological and Psychological Perspectives"},signatures:"Fabio Gabrielli and Floriana Irtelli",authors:[{id:"174641",title:"Dr.",name:"Floriana",middleName:null,surname:"Irtelli",slug:"floriana-irtelli",fullName:"Floriana Irtelli"},{id:"259407",title:"Prof.",name:"Fabio",middleName:null,surname:"Gabrielli",slug:"fabio-gabrielli",fullName:"Fabio Gabrielli"}]},{id:"77214",title:"The Impact of the COVID-19 Pandemic on the Mental Health of Dentists",slug:"the-impact-of-the-covid-19-pandemic-on-the-mental-health-of-dentists",totalDownloads:394,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Since March 2020, the COVID-19 disease has declared a pandemic producing a worldwide containment. For months, many people were subjected to strict social isolation away from family and loved ones to prevent disease transmission, leading to anxiety, fear, and depression. On the other hand, many had to close down their businesses and stop working, resulting in financial issues. Previous studies have reported that pandemics, epidemics, and some diseases can lead to mental disorders such as fear, anxiety, stress, and depression. Among those most affected, healthcare workers (HCWs), especially those on the front line, often develop mental health problems. Although there is data available on the management and care of HCWs, little attention has been paid to the mental health and well-being of dentists during the COVID-19 pandemic. Therefore, this chapter aims to review the impact of the COVID-19 pandemic on dentists’ mental health and mental health-related symptoms. Finally, to recommend specific measures to avoid consequent potential implications for dentists, dental students, and dental patients.",book:{id:"10814",slug:"anxiety-uncertainty-and-resilience-during-the-pandemic-period-anthropological-and-psychological-perspectives",title:"Anxiety, Uncertainty, and Resilience During the Pandemic Period",fullTitle:"Anxiety, Uncertainty, and Resilience During the Pandemic Period - Anthropological and Psychological Perspectives"},signatures:"Andrea Vergara-Buenaventura and Carmen Castro-Ruiz",authors:[{id:"346660",title:"M.Sc.",name:"Andrea",middleName:null,surname:"Vergara-Buenaventura",slug:"andrea-vergara-buenaventura",fullName:"Andrea Vergara-Buenaventura"},{id:"419814",title:"MSc.",name:"Carmen",middleName:null,surname:"Castro-Ruiz",slug:"carmen-castro-ruiz",fullName:"Carmen Castro-Ruiz"}]},{id:"55323",title:"Positive Psychology: The Use of the Framework of Achievement Bests to Facilitate Personal Flourishing",slug:"positive-psychology-the-use-of-the-framework-of-achievement-bests-to-facilitate-personal-flourishing",totalDownloads:1750,totalCrossrefCites:3,totalDimensionsCites:9,abstract:"The Framework of Achievement Bests, which was recently published in Educational Psychology Review, makes a theoretical contribution to the study of positive psychology. The Framework of Achievement Bests provides an explanatory account of a person’s optimal best practice from his/her actual best. Another aspect emphasizes on the saliency of the psychological process of optimization, which is central to our understanding of person’s optimal functioning in a subject matter. Achieving an exceptional level of best practice (e.g. achieving excellent grades in mathematics) does not exist in isolation, but rather depends on the potent impact of optimization. This chapter, theoretical in nature, focuses on an in‐depth examination of the expansion of the Framework of Achievement Bests. Our discussion of the Framework of Achievement Bests, reflecting a methodical conceptualization, is benchmarked against another notable theory for understanding, namely: Martin Seligman’s PERMA theory. For example, for consideration, one aspect that we examine entails the extent to which the Framework of Achievement Bests could explain the optimization of each of the five components of PERMA (e.g. how does the Framework of Achievement Bests explain the optimization of engagement?).",book:{id:"5761",slug:"quality-of-life-and-quality-of-working-life",title:"Quality of Life and Quality of Working Life",fullTitle:"Quality of Life and Quality of Working Life"},signatures:"Huy P. Phan and Bing H. 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The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983",scope:"Biochemistry, the study of chemical transformations occurring within living organisms, impacts all areas of life sciences, from molecular crystallography and genetics to ecology, medicine, and population biology. Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. 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Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:6,paginationItems:[{id:"22",title:"Applied Intelligence",coverUrl:"https://cdn.intechopen.com/series_topics/covers/22.jpg",isOpenForSubmission:!0,editor:{id:"27170",title:"Prof.",name:"Carlos",middleName:"M.",surname:"Travieso-Gonzalez",slug:"carlos-travieso-gonzalez",fullName:"Carlos Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Carlos M. Travieso-González received his MSc degree in Telecommunication Engineering at Polytechnic University of Catalonia (UPC), Spain in 1997, and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. He won the “Catedra Telefonica” Awards in Modality of Knowledge Transfer, 2017, 2018, and 2019 editions, and awards in Modality of COVID Research in 2020.\n\nPublic References:\nResearcher ID http://www.researcherid.com/rid/N-5967-2014\nORCID https://orcid.org/0000-0002-4621-2768 \nScopus Author ID https://www.scopus.com/authid/detail.uri?authorId=6602376272\nScholar Google https://scholar.google.es/citations?user=G1ks9nIAAAAJ&hl=en \nResearchGate https://www.researchgate.net/profile/Carlos_Travieso",institutionString:null,institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"23",title:"Computational Neuroscience",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",isOpenForSubmission:!0,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null},{id:"24",title:"Computer Vision",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",isOpenForSubmission:!0,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. Papakostas has received a diploma in Electrical and Computer Engineering in 1999 and the M.Sc. and Ph.D. degrees in Electrical and Computer Engineering in 2002 and 2007, respectively, from the Democritus University of Thrace (DUTH), Greece. Dr. Papakostas serves as a Tenured Full Professor at the Department of Computer Science, International Hellenic University, Greece. Dr. Papakostas has 10 years of experience in large-scale systems design as a senior software engineer and technical manager, and 20 years of research experience in the field of Artificial Intelligence. Currently, he is the Head of the “Visual Computing” division of HUman-MAchines INteraction Laboratory (HUMAIN-Lab) and the Director of the MPhil program “Advanced Technologies in Informatics and Computers” hosted by the Department of Computer Science, International Hellenic University. He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. Dr Ventura also holds the positions of Affiliated Professor at Virginia Commonwealth University (Richmond, USA) and Distinguished Adjunct Professor at King Abdulaziz University (Jeddah, Saudi Arabia). Additionally, he is deputy director of the Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI) and heads the Knowledge Discovery and Intelligent Systems Research Laboratory. He has published more than ten books and over 300 articles in journals and scientific conferences. Currently, his work has received over 18,000 citations according to Google Scholar, including more than 2200 citations in 2020. In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. He is a Senior Member of the IEEE Computer, the IEEE Computational Intelligence, and the IEEE Systems, Man, and Cybernetics Societies, and the Association of Computing Machinery (ACM). Finally, his main research interests include data science, computational intelligence, and their applications.",institutionString:null,institution:{name:"University of Córdoba",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"26",title:"Machine Learning and Data Mining",coverUrl:"https://cdn.intechopen.com/series_topics/covers/26.jpg",isOpenForSubmission:!0,editor:{id:"24555",title:"Dr.",name:"Marco Antonio",middleName:null,surname:"Aceves Fernandez",slug:"marco-antonio-aceves-fernandez",fullName:"Marco Antonio Aceves Fernandez",profilePictureURL:"https://mts.intechopen.com/storage/users/24555/images/system/24555.jpg",biography:"Dr. Marco Antonio Aceves Fernandez obtained his B.Sc. (Eng.) in Telematics from the Universidad de Colima, Mexico. He obtained both his M.Sc. and Ph.D. from the University of Liverpool, England, in the field of Intelligent Systems. He is a full professor at the Universidad Autonoma de Queretaro, Mexico, and a member of the National System of Researchers (SNI) since 2009. Dr. Aceves Fernandez has published more than 80 research papers as well as a number of book chapters and congress papers. He has contributed in more than 20 funded research projects, both academic and industrial, in the area of artificial intelligence, ranging from environmental, biomedical, automotive, aviation, consumer, and robotics to other applications. He is also a honorary president at the National Association of Embedded Systems (AMESE), a senior member of the IEEE, and a board member of many institutions. His research interests include intelligent and embedded systems.",institutionString:"Universidad Autonoma de Queretaro",institution:{name:"Autonomous University of Queretaro",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null},{id:"27",title:"Multi-Agent Systems",coverUrl:"https://cdn.intechopen.com/series_topics/covers/27.jpg",isOpenForSubmission:!0,editor:{id:"148497",title:"Dr.",name:"Mehmet",middleName:"Emin",surname:"Aydin",slug:"mehmet-aydin",fullName:"Mehmet Aydin",profilePictureURL:"https://mts.intechopen.com/storage/users/148497/images/system/148497.jpg",biography:"Dr. Mehmet Emin Aydin is a Senior Lecturer with the Department of Computer Science and Creative Technology, the University of the West of England, Bristol, UK. His research interests include swarm intelligence, parallel and distributed metaheuristics, machine learning, intelligent agents and multi-agent systems, resource planning, scheduling and optimization, combinatorial optimization. Dr. Aydin is currently a Fellow of Higher Education Academy, UK, a member of EPSRC College, a senior member of IEEE and a senior member of ACM. In addition to being a member of advisory committees of many international conferences, he is an Editorial Board Member of various peer-reviewed international journals. He has served as guest editor for a number of special issues of peer-reviewed international journals.",institutionString:null,institution:{name:"University of the West of England",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:6,paginationItems:[{id:"82526",title:"Deep Multiagent Reinforcement Learning Methods Addressing the Scalability Challenge",doi:"10.5772/intechopen.105627",signatures:"Theocharis Kravaris and George A. Vouros",slug:"deep-multiagent-reinforcement-learning-methods-addressing-the-scalability-challenge",totalDownloads:19,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Multi-Agent Technologies and Machine Learning",coverURL:"https://cdn.intechopen.com/books/images_new/11445.jpg",subseries:{id:"27",title:"Multi-Agent Systems"}}},{id:"82196",title:"Multi-Features Assisted Age Invariant Face Recognition and Retrieval Using CNN with Scale Invariant Heat Kernel Signature",doi:"10.5772/intechopen.104944",signatures:"Kamarajugadda Kishore Kumar and Movva Pavani",slug:"multi-features-assisted-age-invariant-face-recognition-and-retrieval-using-cnn-with-scale-invariant-",totalDownloads:14,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Pattern Recognition - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11442.jpg",subseries:{id:"26",title:"Machine Learning and Data Mining"}}},{id:"82063",title:"Evaluating Similarities and Differences between Machine Learning and Traditional Statistical Modeling in Healthcare Analytics",doi:"10.5772/intechopen.105116",signatures:"Michele Bennett, Ewa J. Kleczyk, Karin Hayes and Rajesh Mehta",slug:"evaluating-similarities-and-differences-between-machine-learning-and-traditional-statistical-modelin",totalDownloads:7,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Machine Learning and Data Mining - Annual Volume 2022",coverURL:"https://cdn.intechopen.com/books/images_new/11422.jpg",subseries:{id:"26",title:"Machine Learning and Data Mining"}}},{id:"81791",title:"Self-Supervised Contrastive Representation Learning in Computer Vision",doi:"10.5772/intechopen.104785",signatures:"Yalin Bastanlar and Semih Orhan",slug:"self-supervised-contrastive-representation-learning-in-computer-vision",totalDownloads:61,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Pattern Recognition - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11442.jpg",subseries:{id:"26",title:"Machine Learning and Data Mining"}}}]},overviewPagePublishedBooks:{paginationCount:11,paginationItems:[{type:"book",id:"7723",title:"Artificial Intelligence",subtitle:"Applications in Medicine and Biology",coverURL:"https://cdn.intechopen.com/books/images_new/7723.jpg",slug:"artificial-intelligence-applications-in-medicine-and-biology",publishedDate:"July 31st 2019",editedByType:"Edited by",bookSignature:"Marco Antonio Aceves-Fernandez",hash:"a3852659e727f95c98c740ed98146011",volumeInSeries:1,fullTitle:"Artificial Intelligence - Applications in Medicine and Biology",editors:[{id:"24555",title:"Dr.",name:"Marco Antonio",middleName:null,surname:"Aceves Fernandez",slug:"marco-antonio-aceves-fernandez",fullName:"Marco Antonio Aceves Fernandez",profilePictureURL:"https://mts.intechopen.com/storage/users/24555/images/system/24555.jpg",biography:"Dr. Marco Antonio Aceves Fernandez obtained his B.Sc. 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Dr. Adimule has attended, chaired, and presented papers at national and international conferences. He is a guest editor for Topics in Catalysis and other journals. He is also an editorial board member, life member, and associate member for many international societies and research institutions. His research interests include nanoelectronics, material chemistry, artificial intelligence, sensors and actuators, bio-nanomaterials, and medicinal chemistry.",institutionString:"Angadi Institute of Technology and Management",institution:null},{id:"284317",title:"Prof.",name:"Kantharaju",middleName:null,surname:"Kamanna",slug:"kantharaju-kamanna",fullName:"Kantharaju Kamanna",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284317/images/21050_n.jpg",biography:"Prof. K. Kantharaju has received Bachelor of science (PCM), master of science (Organic Chemistry) and Doctor of Philosophy in Chemistry from Bangalore University. He worked as a Executive Research & Development @ Cadila Pharmaceuticals Ltd, Ahmedabad. He received DBT-postdoc fellow @ Molecular Biophysics Unit, Indian Institute of Science, Bangalore under the supervision of Prof. P. Balaram, later he moved to NIH-postdoc researcher at Drexel University College of Medicine, Philadelphia, USA, after his return from postdoc joined NITK-Surthakal as a Adhoc faculty at department of chemistry. Since from August 2013 working as a Associate Professor, and in 2016 promoted to Profeesor in the School of Basic Sciences: Department of Chemistry and having 20 years of teaching and research experiences.",institutionString:null,institution:{name:"Rani Channamma University, Belagavi",country:{name:"India"}}},{id:"158492",title:"Prof.",name:"Yusuf",middleName:null,surname:"Tutar",slug:"yusuf-tutar",fullName:"Yusuf Tutar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/158492/images/system/158492.jpeg",biography:"Prof. Dr. Yusuf Tutar conducts his research at the Hamidiye Faculty of Pharmacy, Department of Basic Pharmaceutical Sciences, Division of Biochemistry, University of Health Sciences, Turkey. He is also a faculty member in the Molecular Oncology Program. He obtained his MSc and Ph.D. at Oregon State University and Texas Tech University, respectively. He pursued his postdoctoral studies at Rutgers University Medical School and the National Institutes of Health (NIH/NIDDK), USA. His research focuses on biochemistry, biophysics, genetics, molecular biology, and molecular medicine with specialization in the fields of drug design, protein structure-function, protein folding, prions, microRNA, pseudogenes, molecular cancer, epigenetics, metabolites, proteomics, genomics, protein expression, and characterization by spectroscopic and calorimetric methods.",institutionString:"University of Health Sciences",institution:null},{id:"180528",title:"Dr.",name:"Hiroyuki",middleName:null,surname:"Kagechika",slug:"hiroyuki-kagechika",fullName:"Hiroyuki Kagechika",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180528/images/system/180528.jpg",biography:"Hiroyuki Kagechika received his bachelor’s degree and Ph.D. in Pharmaceutical Sciences from the University of Tokyo, Japan, where he served as an associate professor until 2004. He is currently a professor at the Institute of Biomaterials and Bioengineering (IBB), Tokyo Medical and Dental University (TMDU). From 2010 to 2012, he was the dean of the Graduate School of Biomedical Science. Since 2012, he has served as the vice dean of the Graduate School of Medical and Dental Sciences. He has been the director of the IBB since 2020. Dr. Kagechika’s major research interests are the medicinal chemistry of retinoids, vitamins D/K, and nuclear receptors. He has developed various compounds including a drug for acute promyelocytic leukemia.",institutionString:"Tokyo Medical and Dental University",institution:{name:"Tokyo Medical and Dental University",country:{name:"Japan"}}},{id:"94311",title:"Prof.",name:"Martins",middleName:"Ochubiojo",surname:"Ochubiojo Emeje",slug:"martins-ochubiojo-emeje",fullName:"Martins Ochubiojo Emeje",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94311/images/system/94311.jpeg",biography:"Martins Emeje obtained a BPharm with distinction from Ahmadu Bello University, Nigeria, and an MPharm and Ph.D. from the University of Nigeria (UNN), where he received the best Ph.D. award and was enlisted as UNN’s “Face of Research.” He established the first nanomedicine center in Nigeria and was the pioneer head of the intellectual property and technology transfer as well as the technology innovation and support center. Prof. Emeje’s several international fellowships include the prestigious Raman fellowship. He has published more than 150 articles and patents. He is also the head of R&D at NIPRD and holds a visiting professor position at Nnamdi Azikiwe University, Nigeria. He has a postgraduate certificate in Project Management from Walden University, Minnesota, as well as a professional teaching certificate and a World Bank certification in Public Procurement. Prof. Emeje was a national chairman of academic pharmacists in Nigeria and the 2021 winner of the May & Baker Nigeria Plc–sponsored prize for professional service in research and innovation.",institutionString:"National Institute for Pharmaceutical Research and Development",institution:{name:"National Institute for Pharmaceutical Research and Development",country:{name:"Nigeria"}}},{id:"436430",title:"Associate Prof.",name:"Mesut",middleName:null,surname:"Işık",slug:"mesut-isik",fullName:"Mesut Işık",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/436430/images/19686_n.jpg",biography:null,institutionString:null,institution:{name:"Bilecik University",country:{name:"Turkey"}}},{id:"268659",title:"Ms.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/268659/images/8143_n.jpg",biography:"Dr. Zhan received his undergraduate and graduate training in the fields of preventive medicine and epidemiology and statistics at the West China University of Medical Sciences in China during 1989 to 1999. He received his post-doctoral training in oncology and cancer proteomics for two years at the Cancer Research Institute of Human Medical University in China. In 2001, he went to the University of Tennessee Health Science Center (UTHSC) in USA, where he was a post-doctoral researcher and focused on mass spectrometry and cancer proteomics. Then, he was appointed as an Assistant Professor of Neurology, UTHSC in 2005. He moved to the Cleveland Clinic in USA as a Project Scientist/Staff in 2006 where he focused on the studies of eye disease proteomics and biomarkers. He returned to UTHSC as an Assistant Professor of Neurology in the end of 2007, engaging in proteomics and biomarker studies of lung diseases and brain tumors, and initiating the studies of predictive, preventive, and personalized medicine (PPPM) in cancer. In 2010, he was promoted to Associate Professor of Neurology, UTHSC. Currently, he is a Professor at Xiangya Hospital of Central South University in China, Fellow of Royal Society of Medicine (FRSM), the European EPMA National Representative in China, Regular Member of American Association for the Advancement of Science (AAAS), European Cooperation of Science and Technology (e-COST) grant evaluator, Associate Editors of BMC Genomics, BMC Medical Genomics, EPMA Journal, and Frontiers in Endocrinology, Executive Editor-in-Chief of Med One. He has\npublished 116 peer-reviewed research articles, 16 book chapters, 2 books, and 2 US patents. His current main research interest focuses on the studies of cancer proteomics and biomarkers, and the use of modern omics techniques and systems biology for PPPM in cancer, and on the development and use of 2DE-LC/MS for the large-scale study of human proteoforms.",institutionString:null,institution:{name:"Xiangya Hospital Central South University",country:{name:"China"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"418340",title:"Dr.",name:"Jyotirmoi",middleName:null,surname:"Aich",slug:"jyotirmoi-aich",fullName:"Jyotirmoi Aich",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038Ugi5QAC/Profile_Picture_2022-04-15T07:48:28.png",biography:"Biotechnologist with 15 years of research including 6 years of teaching experience. Demonstrated record of scientific achievements through consistent publication record (H index = 13, with 874 citations) in high impact journals such as Nature Communications, Oncotarget, Annals of Oncology, PNAS, and AJRCCM, etc. Strong research professional with a post-doctorate from ACTREC where I gained experimental oncology experience in clinical settings and a doctorate from IGIB where I gained expertise in asthma pathophysiology. A well-trained biotechnologist with diverse experience on the bench across different research themes ranging from asthma to cancer and other infectious diseases. An individual with a strong commitment and innovative mindset. Have the ability to work on diverse projects such as regenerative and molecular medicine with an overall mindset of improving healthcare.",institutionString:"DY Patil Deemed to Be University",institution:null},{id:"349288",title:"Prof.",name:"Soumya",middleName:null,surname:"Basu",slug:"soumya-basu",fullName:"Soumya Basu",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035QxIDQA0/Profile_Picture_2022-04-15T07:47:01.jpg",biography:"Soumya Basu, Ph.D., is currently working as an Associate Professor at Dr. D. Y. Patil Biotechnology and Bioinformatics Institute, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India. With 16+ years of trans-disciplinary research experience in Drug Design, development, and pre-clinical validation; 20+ research article publications in journals of repute, 9+ years of teaching experience, trained with cross-disciplinary education, Dr. Basu is a life-long learner and always thrives for new challenges.\r\nHer research area is the design and synthesis of small molecule partial agonists of PPAR-γ in lung cancer. She is also using artificial intelligence and deep learning methods to understand the exosomal miRNA’s role in cancer metastasis. Dr. Basu is the recipient of many awards including the Early Career Research Award from the Department of Science and Technology, Govt. of India. She is a reviewer of many journals like Molecular Biology Reports, Frontiers in Oncology, RSC Advances, PLOS ONE, Journal of Biomolecular Structure & Dynamics, Journal of Molecular Graphics and Modelling, etc. She has edited and authored/co-authored 21 journal papers, 3 book chapters, and 15 abstracts. She is a Board of Studies member at her university. She is a life member of 'The Cytometry Society”-in India and 'All India Cell Biology Society”- in India.",institutionString:"Dr. D.Y. Patil Vidyapeeth, Pune",institution:{name:"Dr. D.Y. Patil Vidyapeeth, Pune",country:{name:"India"}}},{id:"354817",title:"Dr.",name:"Anubhab",middleName:null,surname:"Mukherjee",slug:"anubhab-mukherjee",fullName:"Anubhab Mukherjee",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y0000365PbRQAU/ProfilePicture%202022-04-15%2005%3A11%3A18.480",biography:"A former member of Laboratory of Nanomedicine, Brigham and Women’s Hospital, Harvard University, Boston, USA, Dr. Anubhab Mukherjee is an ardent votary of science who strives to make an impact in the lives of those afflicted with cancer and other chronic/acute ailments. He completed his Ph.D. from CSIR-Indian Institute of Chemical Technology, Hyderabad, India, having been skilled with RNAi, liposomal drug delivery, preclinical cell and animal studies. He pursued post-doctoral research at College of Pharmacy, Health Science Center, Texas A & M University and was involved in another postdoctoral research at Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Santa Monica, California. In 2015, he worked in Harvard-MIT Health Sciences & Technology as a visiting scientist. He has substantial experience in nanotechnology-based formulation development and successfully served various Indian organizations to develop pharmaceuticals and nutraceutical products. He is an inventor in many US patents and an author in many peer-reviewed articles, book chapters and books published in various media of international repute. Dr. Mukherjee is currently serving as Principal Scientist, R&D at Esperer Onco Nutrition (EON) Pvt. Ltd. and heads the Hyderabad R&D center of the organization.",institutionString:"Esperer Onco Nutrition Pvt Ltd.",institution:null},{id:"319365",title:"Assistant Prof.",name:"Manash K.",middleName:null,surname:"Paul",slug:"manash-k.-paul",fullName:"Manash K. Paul",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/319365/images/system/319365.png",biography:"Manash K. Paul is a scientist and Principal Investigator at the University of California Los Angeles. He has contributed significantly to the fields of stem cell biology, regenerative medicine, and lung cancer. His research focuses on various signaling processes involved in maintaining stem cell homeostasis during the injury-repair process, deciphering the lung stem cell niche, pulmonary disease modeling, immuno-oncology, and drug discovery. He is currently investigating the role of extracellular vesicles in premalignant lung cell migration and detecting the metastatic phenotype of lung cancer via artificial intelligence-based analyses of exosomal Raman signatures. Dr. Paul also works on spatial multiplex immunofluorescence-based tissue mapping to understand the immune repertoire in lung cancer. Dr. Paul has published in more than sixty-five peer-reviewed international journals and is highly cited. He is the recipient of many awards, including the UCLA Vice Chancellor’s award and the 2022 AAISCR-R Vijayalaxmi Award for Innovative Cancer Research. He is a senior member of the Institute of Electrical and Electronics Engineers (IEEE) and an editorial board member for several international journals.",institutionString:"University of California Los Angeles",institution:{name:"University of California Los Angeles",country:{name:"United States of America"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/219081/images/system/219081.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals. He is currently working on the protective activity of phenolic compounds in disorders associated with oxidative stress and inflammation.",institutionString:null,institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Dr.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. She has been a Professor since 1996. Currently, she is the Head of the Laboratory of Metabolism, a division of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation. N.V. Beloborodova has many years of clinical experience in the field of intensive care and surgery. She studies infectious complications and sepsis. She initiated a series of interdisciplinary clinical and experimental studies based on the concept of integrating human metabolism and its microbiota. Her scientific achievements are widely known: she is the recipient of the Marie E. Coates Award \\"Best lecturer-scientist\\" Gustafsson Fund, Karolinska Institutes, Stockholm, Sweden, and the International Sepsis Forum Award, Pasteur Institute, Paris, France (2014), etc. Professor N.V. Beloborodova wrote 210 papers, five books, 10 chapters and has edited four books.',institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"354260",title:"Ph.D.",name:"Tércio Elyan",middleName:"Azevedo",surname:"Azevedo Martins",slug:"tercio-elyan-azevedo-martins",fullName:"Tércio Elyan Azevedo Martins",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/354260/images/16241_n.jpg",biography:"Graduated in Pharmacy from the Federal University of Ceará with the modality in Industrial Pharmacy, Specialist in Production and Control of Medicines from the University of São Paulo (USP), Master in Pharmaceuticals and Medicines from the University of São Paulo (USP) and Doctor of Science in the program of Pharmaceuticals and Medicines by the University of São Paulo. Professor at Universidade Paulista (UNIP) in the areas of chemistry, cosmetology and trichology. Assistant Coordinator of the Higher Course in Aesthetic and Cosmetic Technology at Universidade Paulista Campus Chácara Santo Antônio. Experience in the Pharmacy area, with emphasis on Pharmacotechnics, Pharmaceutical Technology, Research and Development of Cosmetics, acting mainly on topics such as cosmetology, antioxidant activity, aesthetics, photoprotection, cyclodextrin and thermal analysis.",institutionString:null,institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"334285",title:"Ph.D. Student",name:"Sameer",middleName:"Kumar",surname:"Jagirdar",slug:"sameer-jagirdar",fullName:"Sameer Jagirdar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334285/images/14691_n.jpg",biography:"I\\'m a graduate student at the center for biosystems science and engineering at the Indian Institute of Science, Bangalore, India. I am interested in studying host-pathogen interactions at the biomaterial interface.",institutionString:null,institution:{name:"Indian Institute of Science Bangalore",country:{name:"India"}}},{id:"329248",title:"Dr.",name:"Md. Faheem",middleName:null,surname:"Haider",slug:"md.-faheem-haider",fullName:"Md. Faheem Haider",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329248/images/system/329248.jpg",biography:"Dr. Md. Faheem Haider completed his BPharm in 2012 at Integral University, Lucknow, India. In 2014, he completed his MPharm with specialization in Pharmaceutics at Babasaheb Bhimrao Ambedkar University, Lucknow, India. He received his Ph.D. degree from Jamia Hamdard University, New Delhi, India, in 2018. He was selected for the GPAT six times and his best All India Rank was 34. Currently, he is an assistant professor at Integral University. Previously he was an assistant professor at IIMT University, Meerut, India. 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