Eligibility criteria for treatment with GnRH analogues [7].
\r\n\tThis book will aim to survey the most recent diagnostic techniques as well as the most promising therapeutic options we can count on to deal with optic nerve disorders. The audience of the book is quite wide and it aims at being the main entry to this fascinating topic for students, clinicians, and researchers.
",isbn:"978-1-80356-774-7",printIsbn:"978-1-80356-773-0",pdfIsbn:"978-1-80356-775-4",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"e3d02512ccae0638a73c5c2839e50015",bookSignature:"Prof. Felicia M. Ferreri",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11704.jpg",keywords:"Toxic Neuropathy, Ethambutol, Methanol, Leber Neuropathy, Congenital Anomalies, Coloboma, Optic Disc Excavation, Systemic Anomalies, Optic Disc Swelling, Anterior ION, Posterior ION, ION Variants",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 25th 2022",dateEndSecondStepPublish:"June 2nd 2022",dateEndThirdStepPublish:"August 1st 2022",dateEndFourthStepPublish:"October 20th 2022",dateEndFifthStepPublish:"December 19th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"24 days",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Prof. Felicia M. Ferreri graduated summa cum laude from the University of Messina, Italy in 1998. She served as co-investigator for many national and international clinical trials. Since 2002, she is an Assistant Professor in Ophthalmology at the University of Messina",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"32442",title:"Prof.",name:"Felicia M.",middleName:null,surname:"Ferreri",slug:"felicia-m.-ferreri",fullName:"Felicia M. Ferreri",profilePictureURL:"https://mts.intechopen.com/storage/users/32442/images/system/32442.png",biography:"Felicia M. Ferreri graduated summa cum laude from the University of Messina, Italy, in 1998 and completed her ophthalmology residency at the Policlinico Universitario, Messina, in 2002. She interned at the Corneal Section of San Raffaele Hospital in Milan and at the Pediatric Ophthalmology Diseases Section of Hospital Careggi in Florence. She spent research periods at Virginio del Rocio hospital in Seville, San Carlos hospital in Madrid, the Royal Bolton Hospital in Manchester, and Universidade Fluminense in Rio de Janeiro. She served as co-investigator of many national and international clinical trials. Since 2002, she is an Assistant Professor in Ophthalmology at the University of Messina. Her research interests are in the areas of glaucoma, neuro-ophthalmology, pediatric ophthalmology, and cataract. 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From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Blood transfusion has become more performable in small and large animal practice. By donor selection and the availability of blood component substitutes, usage of the blood products improved. The use of blood component therapy safely needed knowledge of blood groups, antibody prevalence and the impact of blood groups on veterinary transfusion medicine. Animal blood transfusions antibodies against blood group antigens also play a role. In addition knowledge of the means to decrease the risk of adverse reactions by using proper donors and screening assays that simplify detection of serological incompatibility is important. The clinical significance of blood group antigens in veterinary medicine is generally in the areas of transfusion reactions and neonatal isoerythrolysis (NI). This chapter includes an update on canine and feline, horse, donkey, cattle, sheep, gaot, pig, llama and alpaca blood groups and known blood incompatibilities, donor selection and blood collection, storage of blood components, available equine blood products and indications for transfusion, whole blood (WB) and blood product transfusion in ruminants and camelids, blood component and blood substitute therapy, administration, and adverse reactions in small and large animal blood transfusion.
Blood types are classified according to specific antigens on the surface of erythrocytes. Platelets, leukocytes, and body tissues and fluids may also consists of erytrocyte antigens. [1]. In immunogenicity and clinical significance these antigens can differ. They can serve as markers of disease in some cases and taking part in recognition of self. The clinical significance of blood group antigens is generally noted in transfusion reactions and neonatal isoerythrolysis (NI) in veterinary medicine [2]. These antigens can characteristically trigger a reaction caused by circulating anti-erythrocyte antibodies in the opposite host or donor. These antibodies can occur naturally. Also they can be induced by a previous transfusion. Interaction leads to the destruction by hemolysis of red blood cells (RBCs). This is one of the severe and potentially life-threatening situation. [3].
The dog erytrocyte antigen types or blood types are categorized by the DEA (Dog Erythrocyte Antigen) system. DEA 1.1, 1.2, and 1.3 are termed A system. There are also DEA 3, DEA 4, DEA 5, DEA 6, DEA 7 and DEA 8. [2]. In the United States the incidence of DEA 1.1 is approximately 45% and DEA 1.2 is 20% [4]. DEA 1.3 is common in German shepherd dogs and has been reported only in Australia [5]. Frequency of DEA 1.1 in Kangal Dog was found as 61.1% in Turkey [6]. In Croatia where the closest data studied the rate was 66.7% [7]. The rate was also 56.9% in Portugal [8] and 55% in Japan [9]. Approximately 60 % of the canine population is in DEAs 1.1 and 1.2 group. DEA 1.1 is the strongest antigen in the dog. Two membrane proteins of 50 and 200 kD has been identified by a monoclonal antibody to DEA 1.1 using immunoprecipitation techniques. [10]. Presenting in a single band DEA 1.2 has been found to be an 85-kD protein [11].
DEA 1.1 is the most antigenic group in respect to transfusion medicine. Little is investigated about DEA 3, 4, 5 and 7 in comparison to DEA 1.1. In literature, the frequency of DEA 3 is lower in comparison to DEA 1.1 blood type. In the United States it is determined that approximately 6% of the general dog population is DEA 3 positive [12]. This rate is reported as 13% in Brazil [13]. In Turkey, DEA 3 is most found blood type in the Kangal Dog [6]. In the canine blood groups DEA 4 is the most common type. In USA, it is indicated that overall 98% of the general dog population have DEA 4 blood [12]. In Brazil, all dogs blood type were positive for DEA 4 [13]. The molecular weight of DEA 4 present in a single band has been found to be 32 to 40 kD using immunoprecipitation techniques [11].
In the United States typing sera can be commercially obtained only for DEA 1.1, 1.2, 3, 4, 5, and 7 [4]. In Brazil a report studied on German shepherd dogs determined that 14% of the dogs were positive for DEA 5 and 8% were positive for DEA 7 [13]. The frequency of DEA 5 and 7 positive dogs was 55.5% and 71.7% respectively in Turkey [6]. Also, DEA 7 may cause an antibody response in dogs that lack it. A system of nomenclature about antigen Tr has described. The Tr antigen system is a 3-phenotype, 6-genotype system [14]. The molecular weight of DEA 7 present in 3 distinct bands has been found to be 53, 58, and 63 kD by using immunoprecipitation techniques [11].
An exact definition of a canine universal donor is not agreed among veterinary transfusion experts. Well excepted description of the universal donor is that a dog negative for DEA 1.1, 1.2, DEA 3, DEA 5, DEA 7, and positive for DEA 4. It is difficult to find DEA 4 negative dog because 98% of all dogs are positive for DEA 4. Thus there is a very little chance to influence donor selection. If the dog is DEA 7 positive, some other experts do not exclude it from the donor pool [15]. In most populations the incidence of DEA 4 blood type is more than 98% [16]. Because of this in transfusion medicine these dogs are the best candidate for being a donor. If other donors are known to be compatible with the recipient they can also be utilized [17]. DEA 3, 5 and 7 negative dogs have naturally occurring antibodies to DEA 3, 5 and 7 positive red cells. However during the first transfusion these blood groups do not possess a major transfusion reaction [4]. In Turkey, the most common blood types were DEA 1.1, 4 and 7. Because all Kangal dogs have DEA 4 positivity it does not seem to be important in respect to transfusion medicine. The prevalence and antigenic properties of DEA 1.1 and 7 are significantly important. If unmatched transfusion is performed in Turkish Kangal dogs they can constitute acute hemolytic transfusion reactions [6]. Dogs with DEA 1.1 or 1.2 are called group A positive. Adversely, dogs do not have DEA 1.1 or 1.2 are called group A negative [1].
A blood group system described as N-acetylneuraminic acid and N-glycolylneuraminic acid present on gangliosides (hematosides) of the RBC membrane in Japan [18]. It is referred as the D system. This system is consist of two antigens, D1 and D2, with phenotypes, D1, D2, and D1D2. The D1 and D2 antigens are codominanat factors. Anti-D1 is identical to anti-DEA3. The importance of this system in transfusion medicine pointed out by transfusion of D2 type blood into a D1 type patient, or of D1 type blood into a D2 type patient consistently cause severe acute transfusion reactions [19, 20]. RBCs of some dogs designated as type C at titre sup to 128 are aglutinated rather than lectin extracted from seeds of Clerodendron tricotomum. Type C is completely negative for other dogs. C system was compared to the DEA system and determined to be different [10, 19, 21]. Specific IgG alloantibodies in previously sensitized Dalmatian dog by blood transfusion is described as the Dal blood type. The frequency is not known. Typing sera for this antigen also is commercially not available [2, 22, 23].
Three blood types are described in the feline AB blood group system and mik group system. In cats a new blood group defined as Mik. It is named after the alloantibody identified in the first blood donor cat, Mike. In three cats that had not previously received transfusions Mik antibodies were detected. They are defined as a cause of incompatibilities between donor and recipient blood that are not related to the AB blood group system [24].
The phenotypes type A, type B, and type AB are occured. A null phenotype is not exist. The most common blood type is Type A. Type B is less common. Type AB is rare [2, 25]. Type B is indicated in Australia (26.3%), and Greece (20.3%) ([26], [27] ). In large studies of both pedigree and non-pedigree cats in the USA distribution of type AB cats is demonstrated to be rare (0.14%) ([28] ). Type AB were 0.4% in Australia (([26]). In Scotland the incidence of AB cats is 4.4% ([29] ).
Type B is indicated in Australia (26.3%), and Greece (20.3%) ([26, 27]. In large studies of both pedigree and non-pedigree cats in the USA distribution of type AB cats is demonstrated to be rare (0.14%) [28]. Type AB were 0.4% in Australia [26]. In Scotland the incidence of AB cats is 4.4% [29].
In Turkey, 60 % of Van cats and 46.4 % of Angora cats are type B [30]. And 220 (73.1%) nonpedigree domestic cats had type A blood, 74 (24.6%) had type B and seven (2.3%) had type AB [31] in Turkey. Except type AB group, cats have naturally occurring alloantibodies. It is known that cats have naturally occurring alloantibodies (isoantibodies) against the blood type they are lacking. Because of this to prevent blood incompatibility reactions in cats feline blood typing is important in clinical practice. Blood type incompatibility can especially result in two fatal reactions. The first is acute haemolytic transfusion reactions, occur particularly in cat transfused with type A blood [32]. Feline neonatal isoerythrolysis (NI) is the second incompatibility reaction. It occurs when type A or AB kittens born to type B queens are nursing. Naturally occurring anti-A alloantibodies result in blood incompatibility reaction in the type B queen’s colostrum and milk [25, 30].
Cats constitute non-self antibodies in contrast to dogs. As a result of this non-self antibodies potentially fatal antibody-mediated reactions can occur towards non-self red blood cells. Nearly 20% of type A cats have anti-B antibodies. These antibodies are usually weak. All type B cats have strong anti-A antibodies. In contrast AB cats do not have alloantibodies [32]. In previously unsensitized cats naturally occuring isoantibodies are responsible for transfusion reactions. Nearly all type B cats have highly titered anti-A agglutinins and hemolysins. RBCs can be destructed rapidly in type B cats taking type A blood. In type B cats the high titres of naturally occurring anti-A antibodies cause rapid intravascular destruction of transfused type A red blood cells [33]. This can be mediated by IgM, complement fixation and the release of potent vasoactive compounds. As a result of this shock can develop usually due to possessed antibodies towards the transfused RBCs [3, 34]. This can cause severe transfusion reaction and death even if as little as 1 ml of type A blood is administered to a type B-cat [2, 35]. Because of their endotheliochorial placenta newborn kittens have no alloantibodies. Nevertheless colostral transfer of immunoglobulin (Ig) G and a small amount of IgM occurs. Neonatal isoerythrolysis develops in cats. It is one of the cause of the fading kitten syndrome. Kittens that are type A or AB and those that are born to type B queens are at risk. In affected kittens Clinical sings can range from unapparent, to severe hemolytic anemia with hemoglobinuria, icterus, and death [1, 36, 37, 38].
Packed red blood cells (pRBCs) and fresh frozen plasma (FFP) are components generally provided for canine transfusions. If processed at once, 1-4 each unit (450 mL) of whole blood can be seperated into 1 unit of pRBCs and 1 unit of FFP. It is difficult to prepare components from a small volume of blood. Because of this cat blood transfusions are usually administered as fresh or stored whole blood. If patients requires specific components like pRBCs and FFP, in this case whole blood can be separated into them [39].
In veterinary medicine, red blood cell transfusions are used more frequent recently. They are the integral part of lifesaving. They are used in critically ill as advanced treatment. Situations required transfusions include life-threatening anemia from acute hemorrhage or surgical blood loss, hemolysis from drugs or toxins, immune-mediated diseases, severe nonregenerative conditions, and neonatal isoerythrolysis [40].
Indications of red blood cell transfusions are in the treatment of anemia caused by hemorrhage, hemolysis, or ineffective erythropoiesis. Oxygen is poorly soluble in plasma. Because of this oxygen in blood is mostly carried by hemoglobin (Hgb). In anemic patient, RBC transfusions increase the oxygen-carrying capacity. Therefore inadequate delivery of oxygen to tissues with consequent tissue hypoxia are prevented or treated [41].
The treatment of severe anemia caused by hemorrhage, hemolysis, ineffective erythropoiesis, auto-immune hemolytic anemia, or neoplasia is primary indication for blood transfusion. Lethargy and altered mentation, increased respiratory effort, pale mucous membranes and tachycardia are the clinical signs of anaemia. The body carry out a number of adaptive responses physiologically, to maintain carrying of oxygen to the tissues [42, 43]. The solution of oxygen in plasma is weak. Because of this hemoglobin (Hgb) carries approximately whole oxygen in blood [41]. The decision to conduct a RBC transfusion is generally based on a measurement of the patient\'s packed cell volume (PCV), hematocrit (Hct) or Hgb concentration (Hgb) and especially on clinical evaluation of the patient [41]. Clinically animals should be evaluated individually. Generally when the hematocrit is less than 10%, the treatment of anemia is transfusion. However, animals with acute-onset anemia usually require transfusion before their hematocrit decreases to 15%. This contrasts with the situation in animals with chronic anemia. Other indications for transfusion are hypovolemia, thrombocytopenia, clotting factor deficiency, and hypoproteinemia [1]. Electrocardiographic signs of myocardial ischaemia are similar to those identified in human patients with myocardial infarction. It can ocur with anemia [44].
The usage of administration of FFP are for the treatment of a single or multiple clotting factor deficiency, vitamin K deficiency or antagonism, surgical bleeding or where a massive transfusion is required [45]. Hypoalbuminaemia and coagulopathies especially due to liver disease are the main reported indications for FFP transfusions in cats [46].
Stored blood is more than 8 hours old. The length of storage depends on the anticoagulant/preservative solution used. It varies from 48 hours for 3.8% sodium citrate (no preservative) to 4 weeks for CPD-A1 (citrate, phosphate, dextrose, and adenine). Acid citrate dextrose (ACD), citrate phosphate dextrose (CPD and CP2D), and citrate phosphatedextrose-adenine (CPDA-1) are mostly used as preservatives. The viability of RBCs is provided by the added dextrose, phosphate, and adenine. Due to the preservative used, the storage can extend up to 3 to 5 week ([3, 41, 47].
In patients that are hypothermic or receiving large volumes of blood, refrigerated RBC products should be prewarmed to temperatures between 22 C and 37 C immediately before transfusion. In the routine practice of RBC products to normovolemic anemic patients, refrigerated blood components do not need warming before transfusion. Warming may accelerate the deterioration of stored RBCs and may cause rapid growth of contaminating microorganisms [48].
In clinical practice advances in safety of blood transfusion is important in preventing transfusion-transmitted infections (TTI). The most frequent severe infectious outcome of transfusion has been known as bacterial contamination of platelets, with resultant sepsis in the recipient recently. Using automated or semi-automated blood culture devices, apheresis platelets and prestorage pooled platelets are most often tested [49].
Generally, before a blood transfusion is given to animals, blood typing and/or cross-matching of the recipent and donor should be done to avoid the likelihood of a transfusion reaction. Also, ineffective therapy is caused by shortened survival of transfused mismatched red cells. In order to prevent primary sensitization and risk of developing hemolytic disease in breeding females, cross-matching and/or blood typing is important. In general veterinary practise, blood typing for canine DEA 1.1 and for feline types A and B is applied [1].
To decrease adverse reactions one sould pay attention to blood typing and crossmatching procedures as much as monitoring. There is always risk in blood transfusions. For this reason, they should be performed only when warranted. When taking history, previous transfusion therapy should be asked and in a history of previous transfusion therapy cross-matching is necessary [1, 50].
Depending on availability and indication for transfusion, whole-blood or blood-component therapy may be administered. RBCs, white blood cells (WBCs), platelets, all the coagulation factors, albumin and immunoglobulins constitute whole blood (WB) [51].
In cats, fresh whole blood is the most common product used recently. Stored whole blood, packed red blood cells and fresh frozen plasma (FFP) are also given as transfusions [45].
The heavier cellular elements from the supernatant plasma are sedimented by centrifugation of whole blood sediments. Due to separation of blood collection within 8 hours all protein activity and concentration are maintained in the plasma. The obtained supernatant usually frozen. For subsequent transfusion, it is stored as fresh frozen plasma (FFP). In addition it can also processed to provide cryoprecipitate and cryosupernatant. It can also be transfused immediately as fresh plasma [52, 53]. Fresh frozen plasma have to be stored frozen at -30 C before used. Also it should be identified with the donor blood type, name and collection date. Samples thawed and not used sould discarded or stored in a fridge and used within 12-24 h and should not be refrozen [43].
Recently an ultra-purified polymerised bovine haemoglobin solution is the only commercially available alternative to red cell transfusion (Oxyglobin). It is not licensed in cats but it has been used in treatment of anaemia in cats and also in therapy of carbon monoxide poisoning [54, 55].
Hemostatic protein deficiencies lead to hemorrhagic disorders and the treatment is done principally by plasma components [56]. In animals with von Willebrand disease (vWD) and hereditary coagulation factor deficiencies active hemorrhage is controlled by plasma components. Plasma components are also used for preoperative prophylaxis in these diseases [53].
For preparation of plasma components sterile plastic bags are used. After that they are stored and transferred as frozen in individual boxes. Products have to be stored at -20 C or lower. Just before transfusion they warmed to 37 C in a water bath or incubator. Preferred route of administration is the intravenous transfusion of plasma components. If attempts at vascular access have failed, intraosseous transfusion can be used in emergency situations. When acut allergic reactions occur transfusion is stopped and antihistamines and/or short-acting steroids are given [53, 57].
Cats have antibodies to non-self blood types within the plasma. Because of this only type-specific plasma should be administered to cats in contrast to dogs. Using one of the commercially available systems whole blood can be separated into FFP and packed red cells if it is taken aseptically. The blood spun at 3800 rpm at 10˚C in a refrigerated centrifuge for 12 mins. Using a plasma extractor the plasma is extracted and stored at –20 C [57].
In hypoalbuminemic dogs and cats, human serum albumin has been used for therapeutic use [58].
Correction of coagulation by fresh platelets are shown by in vitro coagulation studies. Freshly collected platelets correct thrombocytopenia, control associated hemorrhage, and prevent death from bleeding. Hemorrhagic diathesis are prevented by platelet replacement for thrombocytopenia [59].
Severe thrombocytopenia or thrombopathia result in bleeding. Platelet transfusion is used for the control of this bleeding. In veterinary medicine platelet transfusion has been used rarely compared to red blood cell (RBC) and plasma transfusion. In dogs, reports related to platelet transfusion are generally associated with experimental hematopoietic stem cell transplantation. Platelet-rich blood products consist of fresh whole blood (FWB), platelet-rich plasma (PRP) and platelet concentrate (PC). They are used for aggressive anticancer therapy and treating complex hematologic disorders. Centrifugation of whole blood constitute platelet-rich plasma (PRP) and centrifugation of platelet-rich plasma constitude platelet concentrates (PC). Platelet activation is induced by centrifugation so that the resuspension of the platelet pellet during PC preparation from dogs is difficult. The preparation efficiency of PC from dogs can be improved by addition of PGE1 in PRP before the centrifugation of PRP. Also therapeutic efficacy of the platelets are maintained. In 10-28 kg body weight dogs plateletpheresis has been used successfully. On the canine donor thrombocytopenia and hypocalcemia are the main adverse effects of plateletpheresis [60-62].
At room temperature (RT) (20-24 C), PRP and PC can be stored for 5-7 days with continuous or intermittent agitation. At RT FWB can be stored for up to 8 hours. The interest in freezed (4 C) storage of platelets is increasing because of the increased risk of bacterial proliferation at RT storage. Storage of human PRP and PC are limited to 5 days because of prevention of bacterial proliferation at room temperature [60- 63].
Platelet transfusions as with RBC and plasma components should be performed with 170 µm filters standard blood administration sets. Transfusion sets which can bind platelets should be exempt from latex [60].
The most common reaction to PC are febrile reactions. The frequency is decreased by pre-storage leukoreduction. In immunocompetent dogs receiving multiple transfusions, alloimmunization to platelet antigens occurs. Leukocyte reduction and ultraviolet B irradiation are recently accepted methods for preventing the development of platelet alloimmunization [64-66].
Recently platelet cryopreservation are used to provide long-term storage and immediate availability of platelet products for transfusion. When fresh platelets are unavailable cryopreserved platelets can be activated in vitro and provide therapeutic benefit [63].
Granulocyte transfusion can be used as supportive therapy. It is used in patients with life-threatening neutropenia caused by bone marrow failure or in patients with neutrophil dysfunction. Granulocyte transfusions is shown to be useful in treatment of infections in patients after treatment with high-dose chemotherapy. It is helpful especially in the chemotherapy associated with conditioning for hematopoietic stem cell transplant. By using granulocyte colony-stimulated factors higher doses of granulocytes for transfusion are produced. Thus recently the use of therapeutic granulocyte transfusion has been increased. The outcome of transfusion are effected by the type of infection being treated, the likelihood of recipient marrow recovery, and recipient alloimmunization [67].
In small animals therapeutic granulocyte transfusions have been used especially in experimental models of myelosuppression and neonatal sepsis. In clinical veterinary medicine they have been used rarely. Granulocytes can be used to identify the site of inflammation. Beside leukapheresis, centrifugation of FWB, with or without colloid-facilitated sedimentation, may be used to isolate canine and feline buffy coats. Only sedimentation may also be used in the cat. At RT granulocytes are stored immobil for 24 hours. The dose for beginning is 1 x 1011 granulocytes/kg in a volume of 15mL/kg. It is used once to twice in a day [68-70].
To select permanent blood donors, blood typing have to be performed. Donors should be healthy young adults. They undergo routine physical check up and hematology and clinical chemistry evaluations are done. They should never taken a blood transfusion and should be free of blood parasites and other infectious diseases [1].
Nulliparous and spayed female dog and cat donors have to be chosen. Blood have be collected via jugular venipuncture aseptically. Acepromazine interferes with platelet function. Because of this donors should not be sedated with it [1].
Every 3 to 4 weeks, dogs can donate between 13 and 17 ml of blood per kilogram of body weight. Features of donors sould include well nourished, supplemented with oral iron, bled less than once per month to prevent iron deficiency, greater than 25 kg, and negative for antigens for DEAs 1.1, 1.2, 3, 5, and 7. Donors should not have heartworm disease, babesiosis, brucellosis, ehrlichiosis, and Rocky Mountain spotted fever. Donors have appropriate neck skin that allows easy entrance to the jugular vein, have a packed cell volume that is at least 0.40 L/L, have demonstrated a good temperament and be in good physical condition, have no past time history of transfusion or pregnancy, and have got sufficient levels of von Willebrand factor (vWF) [1, 3].
The ideal feline blood donors should be healthy, indoor-only cats with an agreeable temperament for easy handling and restraint. Owned pet cats should be donate maximum once every 2 months [43]. The features of feline donor sould be as follows; weigh more than 4.5 kg, have a packed cell volume that is at least 0.35 L/L, have demonstrated a good temperament, and be in good physical condition [3]. Donor cats can donate between 10 and 12 ml/kg. Adult healthy cats can donate 50 ml every weeks. Donors have to be type A. Type B donors may be demanded depending on breed prevalence and geography. Feline leukemia virus, feline immunodeficiency virus (FIV), feline infectious peritonitis, heartworm disease, and Hemobartonella sp have to be excluded in donor cats [1].
For appropriate care of donors some processes needed. These are current vaccinations, if there is contact with new animals every 6 mo fecal floatation, monitorization of hemogram every year, analysing clinical chemistry, screening for infectious diseases and in the dog preventative heartworm therapy in areas where it is necessary. When blood collection is taken the donor\'s weight, temperature, and packed cell volume have to be analysed [3, 71]. PCV or Hb are measured by taking a blood sample. Preferentially cats with a PCV of 30–35% are used but cats with low–normal PCVs should not be used [43].
In the cat, blood can be taken by using a 19- to 20 gauge needle or butterfly into a syringe via jugular vein venipuncture. The region over the jugular vein is clipped and prepared aseptically and sedation is administered. It is prefered to use a 1:1 combination of ketamine 100 mg/ml and midazolam 5 mg/ml. It is made up in a small syringe and given intravenously up to a maximum dose of 5 mg/kg ketamine (0.1 ml/kg of combination). Syringe consists of either ACD, CPD, or CPDA- 1 (1 mL/9 mL of blood), or heparin (5 units/mL of blood). Before a preservative solution is used it can be placed in a small blood bag. To access the jugular vein a 19-21G butterfly needle is used. The blood is collected over a total of 10 15 mins. At once a maximum of 10-12 ml/kg blood can be donated. Isotonic crystalloid fluid therapy post-donation at a rate of 60 ml/h for 3 h is given to the cat [3, 43].
Precaution is necessary to prevent damage of the blood product and harm to recipient. Blood typing or crossmatching have to be carried out to provide compatibility before RBC transfusion [41].
Transfusions of red blood cell should be administered through a filter. The filter is arranged to remove clots and particles which are potentially harmful to the patient. Blood infusion sets have in-line filters. These filters trap large cells, cellular debris, and coagulated proteins. The pore size range from 170µm to 260µm. A filter may be used to administer 2-4 units of blood to a patient or for a maximum time limit of 4 hours according to human blood banking standards. High protein concentration at the filter surface and room temperature conditions promote proliferation of any contaminating microorganisms. The rate of flow slowed down by accumulated material. After 5 days or more of refrigerated storage constituted microaggregates composed of degenerating platelets, white blood cells (WBCs), and fibrin strands in blood. They are removed by other blood filters with a pore size of 20-40 Jim. For transfusions of RBCs primarily microaggregate filters are designed. In administering small volumes of blood (<50 mL WB or <25mL pRBCs) to cats and small dogs a pediatric micro-aggregate blood filter (18 um pore size, priming space <lmL) is especially helpful. Because of a progressive decrease in pore size due to increased blood filtered larger volumes of blood administration can result in hemolysis [41].
If plasma is taken from blood preservative solutions can be put in. Blood preservative solutions are dextrose, adenine, mannitol, and the sodium chloride. They are necessary for RBCs to carry on their energy metabolism and viability during storage [3]. Canine pRBCs stored in a RBC preservative can be applied directly. Other pRBC products have to be diluted by putting 10mL of saline feline pRBCs or 100mL of saline to the blood bag so that the viscosity of the donor blood decreased [41].
In the dog, if sedation is needed, butorphanol (0.1 mg/kg BW, IV) is generally used for sedation. But acepromazine should not be used because it may cause platelet function disturbance [72]. In the cat, ketamin may be used 2 to 4 mg/kg BW, IV for sedation. In addition to ketamin is very successful when it is used together with 0.1 to 0.2 mg/kg BW diazepam [3]. Also combinations of ketamine hydrochloride, midazolam and butorphanol tartrate, or mask administration of sevoflurane can be used [73, 74].
Generally, intravenous administration is used for RBC transfusions. In addition intraosseous administration is a perfect alternative. Peripheral veins may be preferred to central veins because of an increased bleeding predisposition [41].
Blood is administered through administration sets containing 0.9% saline intravenously. Contraindications include hypotonic saline, 5% dextrose in water and lactated Ringer\'s solution. Cardiac arrest may be caused by injection of undiluted citrate containing anticoagulants [1].
Using a syringe driver or by hand the transfusion should begin slowly at 0.25 ml/kg/h. If no adverse affects are encountered after the first 30–60 mins of administration the rate can be increased. Due to the urgency of the requirement for whole blood and any underlying concurrent disease the rate of administration can vary [75].
With a PCV of 20%, dogs and cats with chronic anemia can be cardiovascularly stable [76]. Conversely in patients with an acute onset of anemia and continuing blood loss or hemolysis, transfusion to a higher PCV is necessary for stabilization. Generally administration of 2mL/kg of WB or lmL/ kg of pRBCs will increase the patient\'s PCV by 1% if there is no continuing hemorrhage or hemolysis [41].
Patient\'s overall condition determine the rate of blood administration. The maximum rate of transfusion is 10-20mL/ kg/h in normovolemic anemic patients, to avoid circulatory overload [41].
To provide blood volume again fluid therapy with crystalloids or colloids is necessary. If the patient\'s total blood volume do not decrease under 20% this is usually enough for losses. If losses are more than 20% whole blood or packed red cell transfusion is used. Between 20% and 50% of blood volume losses are treated by crystalloids and packed RBCs [3, 77].
Blood components like cryoprecipitate and platelet-rich plasma are used infrequently. Cryoprecipitate contains vWF, factors VIII, XIII, fibrinogen, and fibronectin. In vWF-deficient patients cryoprecipitate is recommended particularly when surgery is planned or patient affected by blood loss. Bleeding hemophilia A patients, or patients having hypo or dysfibrinogenemia are the other indications for choosing it [3, 78].
Sometimes platelet-rich plasma is used in veterinary practice. In small-sized animals it is more useful because in larger dogs it is difficult to gain enough volume and management of platelet count. An alternative to platelet-rich plasma are frozen platelet concentrates [79].
For expansion of plasma volume, different types of colloids as dextrans and hetastarch are used as alternatives to blood products. Altering hemostasis is one of the problems of dextrans and hetastarch. Oxyglobin is a hemoglobin-based oxygen carrier. It is approved for use in the dog in 1998. In emergency situations it is used instead of blood products when there is limited time for preparing it or performing compatibility testing [3, 80].
In clinical signs of anaemia and as a therapy for carbon monoxide poisoning oxyglobin is used in cats. Because it is a potent colloid (colloid osmotic pressure 43 mmHg), the main risk associated with administration is volume overload. In patients with normovolaemic anaemia conservative administration rates are needed such as as low as 0.2-0.4 ml/kg/h and to a maximum of 1 ml/kg/h. Careful monitorization of patients with paying particular attention to their heart and respiratory rate is recommended [81, 82].
A recent study described the clinical outcome in dogs experiencing massive transfusion. Also this study documented predictable changes in electrolytes and coagulation status. Massive transfusion is different from usual transfusions in terms of volume and rate of blood transfusion and blood components administered. Transfusion of a volume of whole blood or blood components has been described as massive transfusion. The administrated blood is greater than the patient\'s predicted blood volume within a 24-hour period or arranged as replacement of half the patient\'s predicted blood volume in 3 hours. In a study, massive transfusion receiving dogs were investigated and in this study the mean volumes of pRBCs was 66.5mL/kg and FFP was 22.2mL/kg. As a result of this mean plasma, RBC ratio was 1:3. After transfusion clinicopathologic changes consists of electrolytes disturbances, dilutional coagulopathy, ionized hypocalcemia and hypomagnesemia and progressive thrombocytopenia and prolongation of prothrombin and activated partial thromboplastin times [41, 83].
The gold standard approach is that the donor and recipient are cross-matched before administration. Administration is maintained mainly intravascular with the use of peripheral or centrally placed catheter. Also intraosseous catheters can be used to administer all blood products. It is useful in collapsed neonatal patients where vascular access is difficult [43, 75, 84].
In acute hemorrhage, anemia, decreased red cell mass, severe methaemoglobinaemia, paracetamol toxicity, chronic non-regenerative anaemia, coagulation disorders, and thrombocytopenia fresh whole blood is used [1, 45].
The reason of anaemia in cats requiring transfusion are haemorrhage and primary immune-mediated haemolytic anaemia. Hemorrhage is caused as a result of peri- or postoperative bleeding, trauma, gastrointestinal bleeding, abdominal neoplasia, primary immune-mediated thrombocytopenia and coagulopathies [85, 86, 87]. Also in a number of infectious diseases anaemia is reported such as especially feline immuno-deficiency virus (FIV) and feline leukaemia virus (FeLV) infections, and feline infectious peritonitis [88, 89]. Other infectious diseases which cause anemia are Ehrlichia species, Bartonella species, Haemoplasmas (Mycoplasma haemofelis, ‘Candidatus Mycoplasma haemominutum’ and ‘Candidatus Mycoplasma turicensis’), Anaplasma phagocytophilum, Neorickettsia risticii, Cytauxzoon felis and Rickettsia felis have additionally been associated with anaemia [43, 90].
The indication of whole blood is in a patient whom needed several blood components or has acutely lost more than 50% of its total blood volume. When 50% of total blood volume is lost oxygen carrying capacity and oncotic activity should be recovered. In anemia, stored whole blood is used. For anemic animals packed erythrocytes especially those with volume overload are prefered. For tissue reoxygenation the transfusion of packed RBCs are used. They are also useful for normovolemic, anemic patient. Before administration, to dilute any potentially damaging antibodies these erythrocytes can be washed with saline. Refrigerated whole blood should be warmed to room temperature. Before administration it sould be gently agitated to resuspend the red blood cells. Infusion rate is limited by colder blood which has a higher viscosity [3, 41, 91].
The usage of transfusion of fresh-frozen or stored-frozen plasma (FFP) are as follows; lack of coagulation factors associated with hepatic insufficiency, disseminated intravascular coagulation (DIC), vitamin K deficiency, rodenticide toxicosis, liver insufficiency, biliary tract obstruction, sepsis/multiple organ dysfunction syndrome, pancreatitis, hypoalbuminemia, and DIC without associated laboratoryproven coagulopathy, malassimilation syndrome, chronic antibiotic use, a need for plasma volume expansion, or a massive blood loss within a few hours. Other It is also used in congenital or a hereditary deficiency in coagulation factors (i.e hemophilia A, B, or von Willebrand\'s disease and hypoproteinemia), [1, 3, 39]. Plasma (FP or FFP) is used especially in the emergency conditions like excessive protein loss such as enteropathy, nephropathy, exudative dermatitis or inadequate intake. It is not appropriate for using as long-term source of protein in these patients [3, 92]. In cats, reactions have not been reported following transfusions of FFP [46].
The collection and re-transfusion of the cat’s own blood is called autotransfusion. It is a useful technique in an emergency situation. It can be obtained when animals bleed into body cavities. It should not be used if the blood is contaminated with urine, bacteria or bile. Blood is collected from the body cavity in a sterile manner. After that it re-transfused into the patient through an appropriate fitler. To prevent clotting anticoagulant like acid citrate dextrose should be included at a ratio of 1:7 [39, 43].
The indication of transfusion reactions can be immunologic or nonimmunologic. They can be immediate or delayed. Antibodies to surface antigens of transfused erythrocytes cause immune-mediated hemolytic reactions. According to surface antigens canine blood is grouped. For six of these antigens typing is available. Except DEA 4, canine universal donor is negative for all dog erythrocyte antigens (DEAs). Universal donors should be examined. If other donors are known to be compatible with the recipient they can be also used. Acute hypersensitivities mediated by IgE antibodies are one of the possible immunologic reaction. The other can be leukocyte or platelet sensitivity caused by recipient antibodies to the donor\'s white cells or platelets. The mechanisms of nonimmunologic reactions are various. According to the specific reaction the type and severity of clinical signs vary [17] Adverse reaction occurs in 2 types. First one is immediate reaction and following transfusion it occurs within 1 to 2 h. Second is delayed reaction and it may begin within days, months, or years later [17]. Adverse reaction varies from mild (fever) to severe (death). Transfusion reactions can be acute or delayed. In animals receiving incompatible transfusions, acute intravascular hemolysis with hemoglobinemia and hemoglobinuria may be seen. Acute hemolytic reaction is the most serious transfusion reaction that can be prevented. It is an immunological reaction and it happens when circulating natural or acquired antibodies towards donor erythrocytic antigens are given. Hemoglobinuria, vasoconstriction, renal ischemia occur due to intravascular hemolysis. Intravascular hemolysis determine clinical signs. Disseminated intravascular coagulopathy (DIC) can be caused by release of thromboplastic substances. Secondary to the release of vasoactive substances, hypotension and shock can ocur. Also acute renal failure and death can develop. After transfusion a decrease in hematocrit between 2 days and 2 weeks resulted in suspicion of delayed hemolysis. As a result of extravascular hemolysis, hyperbilirubinemia and bilirubinuria may occur. In dogs clinical signs are as follows: fever, tachycardia or bradycardia, hypotension, dyspnea, cyanosis, excessive salivation, tearing, urination, defecation, vomiting, collapse, opisthotonos, cardiac arrest, hemoglobinemia, and hemoglobinuria. When an acute hemolytic reaction occured transfusion sould be interrupted at once and shock should be treated. Also blood product being used sould be checked out and the steps that led to the transfusion sould be examined [1, 3, 17, 93].
To detect transfusion reactions earlier requires careful evaluation of patient\'s behavior, vital signs, and perfusion before, during, and after a RBC transfusion. Pre- and post-transfusion measurement of PCV and total solids for example instantly and at 24 hours are needed. Also evaluation of the plasma and urine for the presence of Hgb is done [41].
In the dog the acute hemolytic reaction is rare because in this species naturally occurring anti-erythrocytic antibodies prevalence is low [3]. Alloantibodies against the common canine erythrocyte antigens 1.1 and 1.2 do not exist in dogs. As a result of this generally first transfusion can be safely given without regard for donor blood type. Thus the recipient can be sensitized to immunogenic antigens (i.e 1.1, 1.2, 7, and others). On first transfusion it can cause shortened survival times of the transfused cells. Subsequent predisposition to severe transfusion reaction can develop. DEA 1.1 which is the strongest antigen in dogs, leads to the most severe transfusion reaction [1]. In the second transfusion especially when DEA-1 type blood is applied twice to a DEA- 1-negative dog there is more risk [3].
In cats receiving typed or crossmatched transfusions low rates of transfusion reactions have been indicated. Transfusions with whole blood or packed red blood cells transfusion reactions were reported [45]. But transfusions with FFP no reactions have been reported in cats [46].
Initial or subsequent AB-mismatched transfusions in cats can cause acute hemolytic incompatibility reactions. Erythrocytes are destroyed immediately in cats because of alloantibodies. On the contrary in dogs, delayed transfusion reactions are more often occur. A type B transfusion to type A cat causes mild signs. In this situation shortened erythrocyte survival can occur. This causes ineffective therapy. Acute hemolytic transfusion reaction with massive intravascular hemolysis with serious clinical signs occurs in type A transfusion to a type B cat. These symptoms may occur even if it is the first transfusion. Type AB or A blood can be received by type AB cats safely [1, 94].
The transfusion should be stopped immediately if a transfusion reaction is suspected. The recipient sould be monitored continually for follow up. The most severe is acute haemolytic transfusion reactions developing as a result of naturally occurring alloantibodies [32].
Clinical signs are restlessness, vocalisation, tachypnoea, bradycardia, tachycardia, hypotension and hypertension. Pyrexia is seen frequently as a result of reactions to donor leukocytes, platelets and plasma proteins. As a result of binding by citrate, there is potential for hypocalcaemia when administering large volumes of blood products. Thus, if the patient is showing clinical signs of hypocalcaemia calcium should be measured [38, 43].
The next hour after transfusion nonhemolytic fever can ocur as adverse reactions. If contaminated blood products applied by mistake, fever may occur in an acute hemolytic reaction in association with septicemia. Vomiting or diarrhea can be seen after plasma administration. Rarely urticaria may cause trouble to patient. It can be treated with antihistamines, with or without glucocorticosteroids. If whole blood is administered with rapid administration of a large volume of blood component to normovolemic cats or small-sized dogs hypervolemia can be observed. Hypervolemia can result in pulmonary edema. Cough, tachypnea, dyspnea, or cyanosis can occur due to hypervolemia. Treatment can be done by stopping the transfusion, administering diuretics (furosemide) to reduce pulmonary edema, and providing oxygen support [3,72, 93].
The recipient should be carefully examined before the procedure. Its heart rate, respiratory rate, mucous membrane colour, capillary refill time and temperature sould be recorded. Also the PCV and total plasma protein should be recorded [43, 51].
Delayed adverse transfusion reactions are consist of delayed hemolytic reaction, transmission of infectious disease, and posttransfusion purpura. Posttransfusion purpura has been reported in the dog. It is characterized by the appearance of severe thrombocytopenia in the week following a second transfusion. [3, 95, 96].
Anemia, regardless of underlying cause, is troublesome for clinicians in respect to stabilising and supporting the patient. The survival rate of all reasons for a transfusion is 84% in the first 24 h. It is 75% for blood loss anaemia and 49.6% for ineffective erythropoeisis at 10 days [43, 97].
The incompatibilities between the donor’s red blood cells and recipient’s plasma are identified by major cross-match. The incompatibilities between the donor’s plasma and recipient’s red blood cells is identified by a minor cross-match [43].
Cross-Matching usually is identified as either ‘‘major’’ or ‘‘minor’’ cross-matches. A major cross-match include putting patient serum into donor cells and determine the presence of agglutinating and/or hemolytic antibodies in the patient aganist the donor antigens. The principle of this test is hemolytic or agglutinating reaction. In this test the reagent or antibody reacts with the RBCs. Serological discordance between a candidate donor and the patient is identified by the crossmatching. It does not determine the blood group [3]. A positive in vitro reaction is caused by the presence of antibodies. In patients that had no antibodies at the time of transfusion, a mild reaction can be seen in 4 to 14 days after mismatched transfusions. When blood is transfused to a patient in which antibodies are already present, a severe reaction occurs. This antibody can be developed by either naturally occurring or as a result of a previous mismatched transfusion. Furthermore, high concentrations of antibodies can be caused by isosensitization from transplacental immunization. In dogs that have received transfusions before, a crossmatch should always be performed. A minor cross-match include putting donor serum into patient erythrocytes. This step is not necessary for the donor whom previously tested negative for antibodies. Transfusing packed or washed erythrocytes rather than whole blood can prevent administration of antibodies in donor blood against patient erythrocytes [1].
Before transfusion the reason of analysis with these methods are to prevent acute hemolytic reaction due to transfusion, to provide optimal lifetime of the transfused RBCs, to prevent next discordant blood transfusions and to prevent neonatal isoerythrolysis [3].
Because there are blood types that have not been described and it is not possible to type for Mik it is recommended that cross-matching is performed before any transfusion. If the recipient has received a transfusion before more than 4 days cross-matching should be performed [98].
Horses have eight RBC groups or systems: A, C, D, K, P, Q, U, and T. The first seven systems are recognized by the International Society of Animal Blood Grouping Research. Blood-typing antiserum is not readily available for horses. Because of this to identify suitable donors equine blood-group testing can be performed by only few diagnostic laboratories. Over 30 different factors have been identified within these seven equine systems. Experimentally many more systems have been identified [99, 100]. Red cell antigens Ca, Aa, and Qa are play an important role in transfusion reactions and neonatal isoerythrolysis. There is no universal equine blood donor. Because of this to prevent inadvertent sensitization of brood mares against the two most common alloantigens (Aa and Qa) involved in neonatal isoerythrolysis, the preferred donor should be negative for factors Aa, Qa, and Ca [100, 101]. Aa and Qa alloantigens are most immunogenic, and most neonatal isoerythrolysis cases are associated with anti-Aa or Qa antibodies. The horse is clinically relevant for blood group incompatibilities. It is the only livestock species for this situation. Blood group antibodies can laed to transfusion reactions or NI and can be found in horses either ‘‘naturally’’ or as a result of a blood group incompatible pregnancy [2]. A donkey RBC antigen that has not been found in the horse has been identified, it is unique to the donkey and the mule [1].
In horses, requirement of blood transfusion include correction of anemia arising from acute blood loss secondary to trauma, surgical complications, ruptured uterine artery, guttural pouch mycosis, and neonatal isoerythrolysis [99, 102].
Generally, whole blood transfusions are applied to horses that have acute blood loss caused by trauma, surgery, or some other conditions like splenic rupture or uterine artery hemorrhage. The transfusion recovers blood volume and oxygen-carrying capacity in cases of blood loss. There is no certain indicative variables for the beginning of transfusion so that physical examination and clinicopathologic parameters should be used to make the transfusion decision. In cases of acute hemorrhage one sould remember that the packed cell volume (PCV) may be normal for up to 12 hours because of the time required for fluid redistribution and the effects of splenic contraction. As the horse is rehydrated with intravenous fluids, serial monitoring of PCV and total protein (TP) can estimate the amount of blood loss. The transfusion decision is made by suspection of large volume blood loss, together with tachycardia, tachypnea, pale mucous membranes, lethargy, and decreasing TP. During an acute bleeding episode when the PCV fall under 20%, blood transfusion is probably required. In acute severe cases, transfusion may be required before there is a significant fall in PCV. PVC shows the need for beginning of transfusion in chronic anemia better whereas in acute hemorrhage, with transfusions proposed for horses with demonstration of tissue hypoxia and a PCV less than 10-12% [103, 104].
Blood is collected and stored in glass bottles containing acid–citrate–dextrose (ACD). The method traditionally used for collecting blood from donor horses. Glass bottles containing ACD are easy and suitable for rapid vacuum blood draw. Because of this they are recommended for equine whole-blood collection. For equine whole blood the optimal storage method is commercial citrate–phosphate–dextrose with adenine (CPDA-1) bags [105, 106].
Packed RBCs (pRBCs) are specified for normovolemic anemia (i.e neonatal isoerythrolysis, erythropoietic failure, and chronic blood loss). Markers of tissue oxygenation, for example lactate and oxygen extraction are useful in chronic or hemolytic anemia cases. In horses, disseminated intravascular coagulation, clotting factor deficiency, hypoalbuminemia, decreased colloid oncotic pressure, and failure of transfer of passive immunity (FPT) are treated by plasma [104].
Colloid is usually used in patients with a total protein less than 4.0g/dL or serum albumin concentration less than 2.0g/dL. When there is oncotic pressure less than 14 mmHg, clinical symptoms like ventral edema, and conditions which increase microvascular permeability like sepsis are other indications for colloid usage [104].
According to plasma obtained by plasmapheresis and centrifugation preparations, plasma prepared by gravity sedimentation contains greater numbers of erythrocytes and leucocytes. The risk of a transfusion reaction can be increased by these cells. During storage leukocytes can degranulate and fragment and release pyrogens and proinflammatory substances [107, 108, 112].
Multiple hyperimmune plasma products are avaible with bacterial or viral specific antibodies. For the treatment of equine endotoxemia, the efficacy of E. coli (J5) and Salmonella tiyphiimiriuni hyperimmune plasma has proved to be useful in some reports; in contrast, there are some reports which disapprove the utility of such products. For the protection of R. equi, the use of Rhodococcus equi hyperimmune plasma has also been controversial. For treatment of specific disease additional plasma products like botulism antitoxin, West Nile virus antibody, and Streptococcus equi antibody are usable. In general equine practice plasma is administered to neonates to provide protective immunoglobulins. Protective immunoglobulins are used for treatment of failure of transfer of passive immunity or prophylaxis against Rhodococcus equi. Also, the albumin content of the plasma used as a colloid for circulatory volume support and in the treatment of protein-losing enteropathies. In horses heritable and acquired coagulopathies can occur. Specific coagulation factors are not available for supplementation. Also indications include coagulopathies, protein-losing nephropathy and protein loss through third spacing into a body cavity (occurring with peritonitis or pleuritis) [104, 109-113].
Fresh frozen plasma must be separated and frozen within 8 hours of blood collection. Then it can be colder at -18 C and stored for up to 1 year. Frozen plasma is considered as plasma separated any time after 8 hours of blood storage [112, 114, 115].
Healthy, young gelding weighing at least 500 kg is the ideal equine blood donor. Donor horses should be performed current vaccinations. To prevent from equine infectious anemia donors should be tested each year. RBC antigens Aa and Qa are the most immunogenic antigens. Because of this in the ideal donor, the Aa and Qa alloantigens should be absent. There are breed-specific blood factor frequencies. Thus a donor of the same breed as the recipient, particularly when blood typing is absent may be preferable. Horses that have taken blood or plasma transfusions and mares that have had foals are not appropriate as donors. Because they have a higher risk of carrying RBC alloantibodies. Donkeys have a RBC antigen known as "donkey factor". Horses do not have this antigen. Thus donkeys or mules should not be used as donors for horses because horses can develop anti-donkey factor antibodies if transfusion takes place [1, 104, 116].
An immediate blood transfusion can be applied for the first time in an emergency situation with a very minor risk of serious transfusion reaction. Horses can develop alloantibodies within 1 week of transfusion. Thus blood typing and crossmatching are recommended before a second transfusion is given. A second blood transfusion may be given confidently without a blood crossmatch within 2-3 days of the first transfusion. Blood typing and alloantibody screening can be used for the transfusion needed patient to find the most suitable donor horse. Blood typing and antibody screening before initial transfusion are more important for horses. Because subsequent blood transfusions are anticipated and if sensitized to other blood group factors broodmares may produce foals with neonatal isoerythrolysis (NI). For detection of equine RBC antigens Ca and Aa, a rapid agglutination method has been developed. It can be more suitable for pretransfusion testing [99, 103, 104].
Blood is collected from the jugular vein of the donor horse. For this purpose two way used; direct needle cannulation or catheteri-zation. When a large volume of blood is required, a 10 or 12 gauge catheter is recommended. A 14 gauge catheter is also sufficient. Plastic bags and vacum-collection glass bottles in sizes ranging from 450 mL to 2 L are suitable for blood accumulation. Anticoagulation with 3.2% sodium citrate is enough when blood is received for immediate transfusion. In saline-adenine-glucose-mannitol solution red blood cell concentrates stored and they can be used for transfusion for up to 35 days after blood accumulation. Equine blood storage condition resemble to canine and human blood storage condition. According to both in vitro tests and human parameters after 35 days of storage equine erythrocytes remain appropriate for transfusion. Fresh frozen plasma is obtained by separation of erythrocytes and plasma. Both of them can be used alone. RBC survival evaluation sould be doen in vivo [104, 117].
To allow separation of red blood cells by gravity sedimentation the blood is stored in a refrigerator at 5 C for 48 hours in an upright position. Then the plasma is decanted into a sterile 3-L bag with sterile plastic connecting tubing using gravity. 3-L bags containes a constant weight of plasma (3.4 kg). The red cell fraction is thrown out. The plasma bags are sealed, labeled with the horse’s name and the date of decantation. They are stored at -20 C until needed for plasma transfusion [112, 118].
In acute blood loss cases, PCV is usually impractical for estimation of volume to be transfused because it does not exactly indicate blood loss. Instead of this the volume of blood needed are predicted by estimation of blood loss and evaluation of clinical parameters. Fluid shifts will replace much of the circulating volume so between 25% and 50% of the total blood lost should be replaced by transfusion. Pay attention sould be give to that up to 75% of RBCs lost into a body cavity like hemoperitoneum are within 24-72 hours autotransfused back into circulation. Thus in cases of intracavitary hemorrhage lower percentages of blood volume replacement can be needed. To remove small clots and fibrin blood and plasma products should be given with an in-line filter [104, 119].
Blood should be given at a rate of approximately 0.3mL/ kg over the first 10-20 minutes for monitoring the transfusion reactions. Heart rate, body temperature, and respiratory rate sould be monitored. Additionally horses have to be monitored for signs of muscle fasciculation, piloerection, and urticaria. Urticaria, hemolysis, pruritis, edema, tachycardia, tachypnea, pyrexia, colic, changes in mentation and acute anaphylactic reactions are adverse reactions indicated in horses taking blood transfusions. The rate of adverse reaction to WB transfusion has been reported as 16% which are mild urticarial reactions and worsening hemolysis. Also 1 of 44 horses (2%) exhibit a fatal anaphylactic reaction [103, 113].
Transfusion reactions may vary from mild urticarial reactions to anaphylaxis. They are divided into immunogenic and nonimmunogenic reactions. Immunogenic reactions include anaphylaxis, hemolysis, fever, hives, acute lung injury, posttransfusion purpura, immunosuppression, and neonatal isoerythrolysis. Nonimmunogenic reactions include circulatory overload, bacterial contamination, citrate toxicity, coagulopathy, hyperammonemia, and transmission of disease. In horses that have received fresh frozen plasma serum hepatitis has been observed [52, 93, 112, 120].
In a second plasma or blood transfusion there exists risk for severe adverse reactions in dogs. Also there is a risk of development of neonatal isoerythrolysis in gravid mares. The risk is much more in whole blood transfusions [26, 33, 112].
In horses suffered from normovolemic anemia polymerized ultrapurified bovine hemoglobin (PUBH) improves hemodynamics and oxygen transport parameters. During infusion to be informed about any adverse reactions patients should be monitored closely. Intense pruritus, tachycardia, and tachypnea can be resolved shortly after stopping the infusion [121].
Eleven blood groups have been classified in cattle. The greatest clinical relevance is in groups B and J. The B group is extremely complex, thus closely matched transfusions are very difficult. Newborn calves do not have the J antigen. During the first six months of life they generally acquire it. Cows can be sensitized to erythrocyte antigens by vaccinations of blood origin like some anaplasmosis and babesiosis vaccines. As a result of this neonatal isoerythrolysis in subsequent calves occur. [1].
Seven blood groups have been classified in sheep. The B group in these animals is resemble to the B group in cattle, and the R group is resemble to the J group in cattle. For example, antigens are soluble and soluble antigens passively absorbed to erythrocytes. In the goat, five blood groups are identified which resemble to those of sheep [1].
Blood group A–O expression is affected by 16 porcine blood groups and the S gene. Carbohydrate antigens like AO blood group antigens and minor histocompatibility antigens can be important targets for the immune response to transplanted organs or tissues. These antigens remain an unknown and untested variable in many transplant studies using pigs. Depending, on work performed in some Europian country pig blood groups developed and expanded largely. The source of blood typing reagents is especially from isoimmune sera. Most antibodies behave as agglutinins and a few as hemolysins. Internationally sixteen genetic systems are recognized [2, 122-124].
In two domestic South American camelids, Ilama and alpaca, our knowledge is little about group variation. Six blood groups factors were identified (e.g A, B, C, D, E and F). from iso- and heteroimmune sera constituted for these animals [2].
In ruminants and camelids indications for WB and plasma transfusion are similar to horses. Chronic anemia may be a more common problem in ruminants. Gastrointestinal parasites, particularly Haemonchus contains, and ectoparasites (e.g. Haematopinus spp. and Linognathus spp.) are causes of chronic blood loss anemia, and iron-deficiency anemia. These can affect neonatal calves [104, 121, 125].
Studies with camelids and bovines has showed that the neonatal intestine can only successfully absorb colostral immunoglobulins for 12–24 hours postpartum. Passive transfer (FPT) is failed in 19% to 24% of neonatal camelids. A common indication for plasma transfusion in neonatal calves and crias is failure of transfer of passive immunity. Hyperimmune serum products are existing for subcutaneous and intramuscular dosing in ruminants. These are products with antibodies against E. coli, Pasturella, Aercanobacter pyogenes, Salmonella typhimurium and Clostridium [104, 126-129].
An integral component of neonatal camelid care is IV plasma transfusion. It is used for the purpose of antibody supplementation and fluid resuscitation in critical illness. Neonates are immunocompetent at birth but due to initial postpartum absorption of colostrum for passive acquisition of immunoglobulins (especially IgG) they are severely hypogammaglobulinemic [130, 131].
In cattle, the first blood transfusion should usually be safe, regardless of the donor. J-negative donor is ideal. Because agglutination reactions do not develop, routine crossmatching is not useful in ruminants. First transfusions are usually safe to apply without a blood cross-match but crossmatching is recommended when more than 48-72 hours have passed away since the first blood transfusion. Blood donors should not have disease like bovine leukosis virus, anaplasmosis, and bovine viral diarrhea virus [104].
Total blood volume estimated in cattle is 80 mL/kg. From the donor animal up to 20-25% of total blood volume can be removed. Usually needle cannulation or jugular catheterization used in this situation. Blood can be collected into bottles or bags using citrate anticoagulant (e.g CPDA-1) in equine transfusions [104].
Blood samples can be taken from the jugular vein in sheep. A 500 ml transfer bag system including a needle can use for the storage. These bags include 70 ml of CPDA-1-stabiliser. Then the blood should be put into four 150 ml transfer bags. These bags can be stored on a horizontal shaker. It shows the best preservation of platelet function. Also it can be used for the storage experiment consecutively [132].
Platelet count and aggregability of CPDA-1-stabilised ovine blood is kept most covenient at room temperature. It provides adequate haemostatic function for ex vivo experiments for one working day. In ovine blood functional loss and high percentage of platelets within aggregates can be observed at refrigerator temperature. This should be considered in blood transfusion in sheep [132].
In order to monitor transfusion reactions blood should first be transported slowly. Ruminant blood type discordance result in primarily complement-mediated hemolysis. Volume overload should not be given. Also in neonates and small ruminants volume should carefully be given [104].
Intestinal absorption of antibodies declines sharply within the first 24 hours postpartum. For treatment of crias with failure of passive transfer (FPT) IV or intraperitoneal administration of 20–40 mL/kg of camelid plasma is recommended. In compromised neonates requiring fluid resuscitation IV administration of plasma is generally preferred. It is used for the correction of FPT and colloid support. In foals during extensive plasma volume expansion careful monitoring is needed to prevent cardiopulmonary complications. Following IV plasma administration the cardiovascular and pulmonary effects of plasma volume expansion have not been specifically worked out in camelids. But in several species (i.e sheep and cat) plasma volume overexpansion depending on excessive IV fluid administration has been associated with reduced lung function and pulmonary edema formation in clinical and experimental settings. In addition according to measures in presumed hypovolemic human patients administration of colloids can induce a greater reduction in lung function than crystalloids [130, 133-137].
Measurable plasma volume expansion and a concurrent reduction in pulmonary functional residual capacity (FRC) is caused by IV administration of 30 mL/kg camelid plasma to neonatal crias. In healthy neonatal crias administration of this quantity of plasma seems to be safe. But with underlying cardiopulmonary or systemic disease changes in lung volume associated with plasma administration could create risks for crias (131).
Adverse effects of transfusing blood stored for prolonged periods in lamps is encountered more often in patients with reduced vascular nitric oxide levels because of endothelial dysfunction. These patients can benefit from transfusion of fresh PRBC if available. Also inhaled nitric oxide supplementation can prevent pulmonary hypertension associated with transfusion of stored PRBC [138].
In previously untransfused pigs, hemolytic transfusion reactions do not appear to develop. But there have been two reports about adverse reactions in pigs undergoing liver transplants by the use of A–O incompatible transfusions. Pulmonary hypertension and decreased fibrinogen with an associated increase in fibrin degradation products occured in pigs that received A–O incompatible transfusions [139]. In a study, two pigs that administered A–O incompatible blood transfusions during liver transplants died because of disseminated intravascular coagulation (DIC), bleeding and progressive hypotension [140].
Vital part of veterinary emergency and critical care medicine is transfusion medicine. It is also therapy of some disease of patient. Blood and blood products can be obtained through the purchase of blood products or donors. Potentially fatal adverse transfusion reactions risk is higher in cats than in dogs. Also, adverse transfusion reactions are very important for large animals. By using known donors and screening assays that permit detection of incompatibility of blood typing or crossmatching, the risk can be decreased in both species.
Gender identity was first defined by Stoller as “a complex system of beliefs that everyone has about himself, that is, his own sense of masculinity or femininity” [1]. According to the current binary system, which rigidly distinguishes male and female, the common expectation is that gender identity in children and adolescents develops in line with biological sex [2]. However, the developmental trajectories of gender identity are manifold. Only recently has a theorization of gender identity begun as a fluid dimension of the self, in which the boundaries between masculine and feminine are blurred, and of which diversified manifestations are possible [2]. In the case of young gender variants, interests and attitudes do not conform to the social stereotypes of masculinity and femininity [3]. If the gender variance is associated with clinically significant suffering, for which the young person shows a rejection of their sexual attributes and the desire to belong to the other gender, then it is gender dysphoria [4]. Gender dysphoria is a clinical condition and requires specialist intervention, which includes psychological care of the young person and the family, associated with targeted medical and pharmacological treatment [5]. Biological puberty generates severe suffering for adolescents with gender dysphoria who do not recognize themselves in their bodies and can interfere with psychological functioning and individual well-being. Drug therapies are currently available to alleviate the psychological distress associated with gender dysphoria. Suppression of biological puberty involves the administration of gonadotropin-releasing hormone (GnRH) analogues that disrupt the endogenous production of gametes and sex hormones, arresting the development of secondary sexual attributes [5, 6, 7]. However, the question of early pharmacological intervention with adolescents with gender dysphoria is still the subject of debate among professionals in the field, and further investigations are needed to better understand the benefits and risks associated with the therapy.
Hypothalamic blockers have been used in the treatment of children and adolescents with central precocious puberty since 1981. Empirical studies demonstrate the efficacy and long-term safety of similar drugs, such as gonadotropin-releasing hormone (GnRH) [8]. In 2009, the Endocrine Society published guidelines for the treatment of adolescents with gender dysphoria, recommending suppression of puberty with hypothalamic blocking drugs for patients who have reached Tanner stages 2–3 (Table 6 and Table 7 in the appendix) and who meet the eligibility criteria (further detailed below), assigning pediatricians to care for children with gender dysphoria [6]. The World Professional Association for Transgender Health also follows the Endocrine Society guidelines for the treatment of children and adolescents, and published the seventh edition of the Standards of Care [7]. Adolescents with gender dysphoria often consider the physical changes associated with puberty to be unsustainable [6, 9]. Girls experience breast appearance, followed by an increase in breast volume and fat mass. Breast growth is also associated with accelerated height development, with menarche usually occurring 2 years later. In boys, the first physical change is the growth of the testicles that reach a volume of at least 4 ml. Starting from a testicular volume of 10 ml, daily testosterone levels increase, resulting in virilization of the physical appearance. Physical changes in pubertal development are the consequence of the maturation of the hypothalamus-pituitary-gonadal axis and the development of secondary sexual characteristics [10]. According to clinical practice guidelines, transgender and gender non-conforming (TGNC) young people can undergo puberty suspension procedures, with the administration of the synthetic hormones GnRH analogues that have the effect of suppressing the endogenous production of sex hormones [6, 7, 11, 12]. The suppression of the functioning of the gonads can be effectively achieved with the inhibition of gonadotropic secretion with GnRH analogues and antagonists [6]. While similar drugs achieve this effect after a short period of administration, the antagonists immediately block pituitary secretions. Since long-acting antagonists are not available for use in pharmacotherapy, long-acting agonist analogues are the best treatment option.
According to the indications provided in the Standards of Care, withdrawal therapy can only be started at the beginning of puberty, which coincides with Tanner stages 2–3 [7], and a detectable presence of steroid sex hormones in the blood [5]. The treatment eligibility criteria proposed in the Standards of Care are shown in Table 1 [7].
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Eligibility criteria for treatment with GnRH analogues [7].
GnRH is a decapeptide produced by the GnRH-secreting neuronal system, located in the preoptic area of the anterior hypothalamus and the mid-basal hypothalamus [13]. The axons of GnRH secreting neurons send projections to different areas of the nervous system. Some of these terminate in a ganglion of vascular buttons in the median eminence of the primary portal vessel, which releases GnRH into gonadotropic cells. GnRH reaches the anterior pituitary via the portal system and activates specific receptors, stimulating the production of gonadotropins, such as luteinizing hormone (LH) and follicle-stimulating hormone (FSH). The gonadotropins thus synthesized regulate the activity of the gonads (reproductive organs), responsible for the production of gametes and female and male steroids. If GnRH is administered it results in rapid production of LH and less secretion of FSH. Since GnRH is a decapeptide, it is made up of a chain of 10 amino acids, joined together by a peptide bond. The amino acids of GnRH with crucial functions are found at positions 1, 2, 3, 6, and 10. A large number of analogues with agonistic or antagonistic properties have been synthesized, obtained by modifications of the amino acid chain. Triptorelin in GnRH analogue is mostly used to treat adolescents with gender dysphoria.
The single administration of GnRH agonists causes the secretion of LH and FSH in the pituitary cells, with the consequent regulation of the activity of the gonads (stimulating or flare-up effect), [13]. Repeated administrations, on the other hand, result in the desensitization of gonadotropic cells and a reduction in the number of GnRH receptors on the membranes (down-regulation), with the effect of inhibiting the production of the hormones LH and FSH. The result is the blocking of the synthesis of androgens, estrogens, and male and female gametes. The mechanism of action of the antagonists is different since they act by blocking the pituitary receptors for endogenous GnRH and exogenous agonists, blocking access. Levels of LH and FSH decrease rapidly a few hours after administration. The drugs are effective in suppressing gonadotropic production, however, long-acting formulations have not yet been synthesized.
There are potential risks concerning the use of similar GnRH drugs, in relation to the effects that they can generate in the critical time interval for the development of the adolescent brain and bone mass. Although the therapy is safe in patients with central precocious puberty, these data are not generalizable to transsexual adolescents. For them, the treatment, in addition to starting later in development and continuing until the age of 15–16, is not followed by a process of inducing puberty of the biological sex, but of the opposite sex to that of birth [11]. These practices may also expose individuals to greater psychosocial difficulties as they remain physically prepubertal as peers reach puberty [5]. Therapy can thus contribute to more and more socially isolating transsexual adolescents, further increasing the risk of being victims of discrimination and bullying. Furthermore, adolescents could interpret the administration of hypothalamic blockers as a guarantee for future surgical sex reassignment, without engaging in other reflections on the matter [14]. They may risk feeling trapped in a certain life trajectory once puberty suppression therapy has begun, because family members and healthcare professionals, albeit in a benevolent way, may inadvertently reinforce a specific gender identity [12]. Furthermore, GnRH analogues are very expensive and not always reimbursed by health insurers [6, 9]. Progestins represent a less effective but more affordable alternative: they suppress gonadotropic secretion and exert a mild peripheral anti-androgen effect in boys; in girls, they suppress ovulation and progesterone production for long periods of time, with variable estrogen residues [15]. However, side effects such as disruption of adrenal functioning and bone growth are frequent at these doses of administration [6]. Therefore, when the patient can bear the costs of the therapy, the guidelines recommend proceeding with the administration of GnRH analogues, as they are safer and more effective [7].
Empirical studies demonstrate the efficacy of GnRH analogue therapy in suppressing puberty in transgender adolescents. Schagen and colleagues found the efficacy of GnRH analogue therapy in suppressing puberty in trans adolescents: after 12 months of therapy, in 49 trans assigned female at birth (AFAB, mean age 13.6 years) adolescents, testicular development was halted with a reduction in volume, in 67 trans assigned male at birth (AMAB) adolescents, (mean age 14.2 years), menstruation was blocked and breast development regressed [16]. They share the belief that therapy is a way to allow patients to buy time in which they can mature cognitively and emotionally, in order to better manage gender variance [17]. In addition, the timeliness of the intervention is fundamental: hypothalamic blockers are less effective in reducing secondary sexual attributes when taken when puberty is already advanced (Tanner stage 4 or 5), [18]. If administered in prepuberty, drugs reduce the number of operations required in the future for gender reassignment, including breast removal in MtoF transsexual individuals, facial and voice feminization procedures in FtoM individuals [9, 19]. The cartilage of the nose, jaw, and larynx (Adam’s apple) is also less developed after treatment [9, 20]. Those who are in favor of early treatment emphasize the suffering of patients who have been treated as adults, the advantage of buying time in the diagnostic phase, and having a physical appearance more conforming to that of the desired gender [11]. Also in Italy, a group of psychologists and endocrinologists expert in gender identity issues has begun to question the use of analogous GnRH drugs, coming to the conclusion that they do not cause any sex change, which temporarily suspends the formation of secondary sexual characteristics and have reversible effects [21]. Early therapy does not initiate the transition phase, but allows the adolescent to explore their gender identity, preventing, in the case of “desistant” young people in whom gender dysphoria would tend to regress naturally, the possibility of undergoing treatments more irreversible such as therapies with gender-affirming hormones (GAH) [9, 18, 19]. Adolescents have the opportunity to explore their gender identity in greater tranquility, without having to worry about the development of secondary sexual attributes [22]. Therapy with hypothalamic blockers can be considered a diagnostic tool since it allows a greater understanding of the degree and persistence of adolescent distress [23] and improves the accuracy of the diagnosis itself [20].
Another advantage of the use of GnRH analogues is the reversibility of the treatment: when the patient, after having explored the role consistent with gender identity, no longer wishes to undergo sex reassignment therapies, therapy with GnRH analogues can be interrupted and normal pubertal physiological development resumes [6, 19]. Furthermore, in adolescents who are already biologically mature but are undecided about cross-sex hormone therapy, hypothalamic blockers can inhibit those physiological functions that are perceived as unpleasant, such as menstruation in girls and erections in boys, in the intervening period, until the actual decision [11]. Regarding the efficacy of the drugs, the suppression of the activation of the hypothalamic–pituitary-gonadal axis has been demonstrated, with a reduction in testicular volume, in the levels of gonadotropins and prepubertal steroid sex hormones [23].
Some international scientific societies, such as the World Professional Association for Transgender Health-WPATH; the European Society of Endocrinology-ESE; the European Society for Pediatric Endocrinology-ESPE; and the Lawson Wilkins Pediatric Endocrine Society-LWPES, recommend treatment with blockers that can improve children’s quality of life and social relationships since gender-variant adolescents can experience severe distress that can lead to suicide [21]. Studies showing an association between the suspension of puberty and a reduction in depression and anxiety are encouraging in this regard [11, 12]. A better psychosocial adaptation seems to be related to early intervention, as the physical aspect more conforming to that of the experienced gender, allows one to be better accepted as a member of the other sex than those who start treatment in adulthood [20, 24]. Two longitudinal studies conducted by researchers from the medical centre of VU University in Amsterdam investigated the effectiveness of drug therapy with similar GnRH, in terms of psychological effects and drug tolerance. The first survey involved 70 transsexual adolescents [25]. The initiation of treatment was associated with reduced emotional and behavioral problems and an improvement in general functioning. However, the feelings of anger and anxiety remained stable even in a second measurement time before the start of cross-sex hormone therapy. The second research with 55 young transsexuals evaluated the long-term efficacy of the treatment protocol in subsequent times: before the start of therapy with GnRH analogues, at the time of induction of puberty with cross-sex hormones, 1 year after gender reassignment surgery [26]. By investigating psychological functioning and general well-being in areas such as social interactions and education or quality of life, the researchers showed that among young adults, gender dysphoria was attenuated, with improved psychological functioning following the beginning of gender-affirming medical interventions. Greater satisfaction with one’s physical appearance was noted: the therapy had allowed an anatomical development that conformed to and not in contrast with one’s gender identity. Furthermore, the psychological well-being level of the population was equal to or greater than that of the general population [26]. The results suggest that the origin of psychiatric symptoms may not be primarily psychiatric, but secondary to gender dysphoria, in particular, due to the development of secondary sexual attributes in the pubertal phase [26]. These results were replicated by a study conducted with young patients with gender dysphoria at Boston hospital [18]. Costa and colleagues [27] have evaluated the psychological functioning, measured with CGAS, in a sample of adolescents with gender dysphoria at different stages of care: after 6 months of psychological support; after 12 months of psychological support and six of treatment with similar GnRH; after 18 months of psychological support and 12 months of treatment with GnRH analogues using the Children’s Global Assessment Scale (CGAS). The sample was divided into a group immediately eligible for treatment, and a group not immediately eligible for treatment. Young people immediately eligible for treatment had higher psychological functioning scores at the start of management and showed no significant improvement after 6 months of psychological support. Psychological functioning improved significantly after 12 months of treatment with GnRH analogues in young people immediately eligible for treatment, with results similar to those found in a sample of adolescents without psychological or psychiatric symptoms. On the other hand, in the group not immediately eligible for treatment, there was an improvement in functioning already after 6 months of psychological support. A 2011 study by the Dutch group evaluated psychological functioning by administering the Minnesota Multiphasic Inventory-2 (MMPI-2) and Minnesota Multiphasic Inventory-Adolescent (MMPI-A) in a group of adults and adolescents requiring reassignment of type. Compared to adolescents, a higher percentage of adults were in the clinically significant range of scores on the Paranoia scale (49.8% vs. 18. 1%, χ2 (1) = 26.641, pb0.001) and the Psychasthenia scale (36.9% vs. 13.3%, χ2 (1) = 16.662, pb0.001), [28].
When adolescents and adults were compared for the number of total MMPI scales for which they achieved scores in the range of clinical significance, most adults (62.8%) had clinical relevance scores for two or more scales. Instead, most adolescents (67.5%) had clinical relevance scores for none or only one of the subscales (χ2 (2) = 24.198, pb0.001). The authors speculate that the better functioning observed in adolescents compared to adults may also be associated with the timing of the assessment since they had not yet developed secondary sexual characteristics.
Brain development patterns during puberty increase the likelihood of adopting risky behaviors, a typical characteristic of adolescents [29]. However, the decision to undertake a reassignment process is not immediate and usually derives from a deep-rooted desire already present years before the young person turns to specialized centres. Furthermore, given the presence of this variable of impulsivity, adolescents with gender dysphoria could react to the omission of care by adopting risky behaviors, such as prostitution [30] and self-harming behaviors, even going so far as to attempt suicide [31].
The Harm Reduction Model is configured as an alternative to the moral model and the disease model, focusing on the consequences of deviant behavior [30]. When it is no longer possible to work preventively and the young transsexual has already adopted risky behaviors, he is encouraged to reduce them by the mental health professional who provides him with information on the pros and cons of each type of conduct, in order to protect his health [30, 32].
For many professionals who treat developmental gender dysphoria, the decision to administer GnRH analogues is based on the fear of a possible increased risk of suicide in untreated adolescents. In the literature, there is a greater risk of suicidal ideation and attempts among young transsexuals [31, 33, 34, 35]. Studies investigating suicidal risk factors in transgender and gender non-conforming youth (TGNC) have identified gender dysphoria, parental physical and verbal abuse, and body image concerns as predictors [36]. Research conducted in Europe and America shows that young people with gender dysphoria are more likely to have other coexisting mental health problems, resulting in anxiety, depression, and suicidal tendencies [12]. GnRH analogue therapy has been shown to reduce psychological distress in transsexual adolescents [25, 26], so it could be hypothesized that the administration of hypothalamic blockers can actually prevent the adoption of suicidal behaviors in the adolescent with gender dysphoria. Spack and colleagues (2012) examined a sample of 97 adolescents with gender dysphoria from the Gender Management Service (GeMS) between January 1998 and February 2010 [18]. The data collected indicate that among young people: 44.3% had a history of psychiatric diagnoses; 37.1% took psychiatric drugs; 21.6% had a history of self-injurious behavior. Specifically, 20 patients reported self-mutilation episodes, and nine had attempted suicide at least once. The authors found an improvement in psychological functioning after medical intervention, suggesting that the patient’s psychiatric symptoms may be secondary to gender dysphoria. Grossman and D’Augelli investigated the ideas and suicide attempts in a group of 55 adolescents with gender dysphoria [31]. The results obtained indicate an association between suicidal risk and two aspects related to self-esteem: body weight and the perception of one’s physical appearance by others. Transsexual people strive to change their bodies in order to be perceived externally in a way that is congruent with their gender identity [37]. The use of hypothalamic blockers to nullify the inconsistency between perceived gender and the development of secondary sexual attributes reduces the stress associated with gender role transition and provides the opportunity to socially present oneself as a member of the opposite sex [38]. However, most adolescents with gender dysphoria do not have access to the care and resources to be able to achieve this state of self-congruence and satisfaction for their own bodies [31]. Therefore, age-appropriate medical treatment with GnRH analogues and hormones could prevent self-harming behaviors, ideas, and suicide attempts in young transsexuals. Indeed, when adequate treatment cannot be offered, some adolescents may react by making suicide attempts [30].
Adolescents often prefer to buy hormones and blockers illegally rather than go to a specialized clinic, especially if the professional requires the fulfillment of many criteria to be able to administer the therapy [30]. If the doctor refuses to prescribe the therapy or to correct the dosage and way of taking it, young transsexuals will probably continue to obtain the drugs in unconventional ways. The risk of psychological, social, and behavioral complications is greater if the administration is not guided by a specialist [30]. The injection of potentially toxic, low-quality drugs without medical supervision could expose the adolescent to unsatisfactory physical outcomes and health-threatening medical conditions, such as HIV, AIDS, and hepatitis. Teens may also be given silicone injections, increasing the risk of infections or other complications (discolouration of surrounding tissues, inflammation and silicone-induced pulmonary embolism). Furthermore, involvement in illegal buying practices can have judicial consequences for young people, with repercussions in terms of social stigma and further involvement in the criminal justice system in adulthood [12, 39]. Those who come from geographic areas where gender adjustment treatments are not available often need to emigrate in order to receive appropriate medical treatment [39]. Often these are young illegal immigrants for whom prostitution remains the only option available to earn the money needed to pay for healthcare [40]. Baltieri and colleagues report two case reports of adolescents with gender dysphoria in Brazil who engaged in prostitution to obtain enough money to illegally buy cross-sex hormones, after being denied treatment because they were not reaching age, minimum sufficient [30]. Hormonal drugs were not given as there are no laws in Brazil regulating the medical treatment of young trans people.
Denial of treatment has irreversible psychological effects on the psychosexual development of the adolescent since he will never be able to experience puberty in line with his own gender identity. Transsexual adolescents often suffer more from not being able to experience puberty of the desired sex than from the inability to experience puberty of the sex assigned at birth in case of treatment with similar GnRH [24]. Retrospective studies conducted with transsexual adults indicate that psychological problems, such as anxiety and depression, often emerge during puberty as a consequence of the distress associated with the development of secondary sexual attributes [24]. Psychopathologies secondary to gender dysphoria can, therefore, be prevented if we intervene in time [28]. Unfavorable outcomes of surgical gender reassignment in adults appear to be associated with late treatment rather than early intervention [41, 42]. Studies evaluating the psychological functioning of adults and transsexual adolescents from the same clinic also found improved functioning among adolescents who had been treated early with hormone therapy [28, 38, 43]. The poorer psychological functioning in adults may result in part from the constant and lasting distress they have experienced throughout their lives. In fact, the omission of treatment can result in long-term psychosocial outcomes such as stigmatization and social isolation [24].
Given the effects of drugs on the body during treatment, the guidelines recommend monitoring the adolescent with auxological clinical evaluations (weight, height, body mass index, blood pressure, and Tanner stage) every 3–6 months, and evaluation hormones (LH, FSH, estradiol, testosterone, prolactin, and 25-OH vitamin D) to be repeated every 6–12 months for the first year of therapy [5].
Hypothalamic blockers are generally well tolerated, with the exception of possible hot flashes [23], fatigue, migraine, mood changes, injection pain, and abscesses [5]. Some cases of arterial hypertension following the administration of Triptorelin were observed in three male transsexual adolescents in a sample of 138 subjects [5, 44]; and in two treated patients, with complications in one out of two patients related to increased intracranial pressure, which resulted in a temporary interruption of treatment [45]. The increase in intracranial pressure is a very rare side effect, usually associated only with the analogue GnRH drug Leuprolide [46]. The consequences that the use of similar GnRH drugs can have on blood pressure require further investigation [11].
From the available literature, it is noted that treatment with analogous GnRH has no negative effects on the fertility of younger patients who are treated before the age of 7 [47], indeed it seems to have a protective effect in patients with central precocious puberty [48]. In young male (biological sex) adolescents with gender dysphoria undergoing GnRH analogue therapy, sperm production and development of the reproductive system is insufficient for sperm cryopreservation [6]. However, sperm production can be induced by a spontaneous recovery in gonadotropin production after cessation of GnRH analogues, or by gonadotropin-stimulating treatment (associated with physical manifestations of testosterone production), [6].
The physiological reorganization of the central nervous system occurs during puberty, in particular the executive functions located in the prefrontal cortex develop [49]. What emerges from the studies conducted so far is that there are no undesirable effects on brain development for adolescents undergoing therapy with GnRH analogues and GAF: the brain functioning of young patients seems to replicate that of the general population [24]. No negative effects on executive function emerged in research [50]. However, further long-term investigations are needed to arrive at more conclusive data [11].
During puberty, bone mass increases, reaching its maximum density around 20–30 years of age [11]. Suspension of puberty in adolescence is associated with reduced bone mineral density (BMD) in adult men [6]. Some studies do not detect changes in BMD values during the period of administration of GnRH analogues [6]. Other data report stable values of bone mineral density during therapy, but with a decrease in zeta scores, and a resumption of bone mass accumulation at the start of cross-sex hormone therapy [23]. When BMD was assessed in the same adult sample, a delay in reaching peak bone mass was detected, since the loss of zeta scores was still partially present at the age of 22. William Malone, an American endocrinologist interested in puberty blockers, affirms that the drugs seem to halt the rapid increase in bone density, the expected rise that takes place typically in adolescence is delayed [51]. Van Coverden and colleagues observed an increase in bone mass in the long-term treatment of adolescents with gender dysphoria: during the administration of gender-affirming hormones (GAF) there is a recovery in bone mass accumulation following normal physiological development [52]. Therapy with GnRH analogues appears to initially reduce BMD, with a future normalization after the induction of puberty with cross-sex hormones. Dutch studies report a reduction of BMD during puberty suppression, with a subsequent increase at the start of GAH therapy and achieving a final BMD no different than that observed before initiating analogue [44, 53].
The first data on early hormone therapy in adolescents with gender dysphoria revealed an increase in fat mass and a decrease in lean mass, only during the first year of treatment with Triptorelin, followed by a restoration of normal values with the administration of GAF [23]. Effects on lipid and carbohydrate metabolism were absent in the sample examined. Evidence shows an increase in body mass index (BMI) [54], an increase in fat mass, and a reduction in lean mass [16] in trans adolescents taking GnRH analogues.
Suppression of puberty can impair growth in trans adolescents AFAB and AMAB [6, 55]. Schagen and colleagues found a reduction in the rate of growth rate in the sample of trans adolescents analyzed [16]. This can be an advantage for trans AMAB adolescents, who are more likely to reach a height similar to the average female population. Growth reduction can also have side effects on bone development and metabolism [56]. Subsequent therapy with cross-sex hormones allows for manipulation of growth and the achievement of an almost normal height [23]. Since the expected height for trans AMAB adolescents is greater than the female average, it is possible to increase the dose of estrogen administered during therapy with GAF, to reduce the final height. On the contrary, for trans AFAB adolescents, treatment with GnRH analogues must be longer, before being able to administer androgens at the age of 16 [55]. To achieve maximum height, a slow introduction of androgens mimics an acceleration of growth typical of puberty, or one can proceed with the administration of oxandrolone, a growth-stimulating anabolic steroid [6].
Despite the lack of clear results, venous thromboembolism can be a complication of drugs, so early screening for thrombophilia is appropriate for those with a personal or family history of venous thromboembolism [6].
The biomedical ethics model, theorized by Beauchamp and Childress, is the main point of reference for the management of ethical problems in the clinical setting [57]. According to the authors, there are four prerequisites that healthcare and health professionals must abide by in clinical practice, which are autonomy, non-maleficence, beneficence, and justice.
Hormonal treatment in puberty is justified as it aims to satisfy the desire of adolescents who want to align biological sex with their gender identity. Respect for the autonomy of the young person and the decision to undergo therapy should be emphasized, as the same results are not achievable if the drugs are administered in adulthood, except with invasive operations [20]. Furthermore, to fully respect the autonomy of the child, it is essential to educate him to know the different treatment options for gender dysphoria, in order to allow an informed decision, regardless of geographic location or socioeconomic status. The exercise of autonomy in the decision-making process is based on the recognition of children’s rights and the informed consent expressed by the adolescent and the family [58].
The principle of non-maleficence imposes the obligation not to inflict harm on the patient. Hypothalamic blockers are classified as a reversible treatment since they appear to be free of long-term side effects. The doctor who respects the principle of non-maleficence adopts a more holistic approach and considers not only the possible damage to the body but also any negative consequences on the emotional, social, and spiritual values. For many adolescents, the ability to reduce the distress associated with developing secondary sexual attributes is far more important than drug-induced fertility deprivation. In general, the arguments against the use of blockers are based on the concern that gender dysphoria in childhood may go into remission in adolescence [59, 60]; on the impossibility of making a certain diagnosis of gender dysphoria in developmental age given the variability of gender identity in childhood and adolescence [17, 33]; and on the lack of knowledge of the long-term effects on the organism and psychological functioning [60, 61]. Furthermore, therapy can inhibit the spontaneous formation of a compliant gender identity, which sometimes develops through the “gender crisis” [62], and reduce libido, negatively affecting the adolescent’s sexual experiences and limiting exploration of one’s sexual orientation [17, 33]. Finally, for trans adolescents AMAB, the arrest of the development of the penis and testicles reduces the amount of skin tissue needed to perform a better vaginoplasty [63]. According to Giordano, the ethics of puberty suppression therapy depend not only on the balance of risks and benefits of the treatment but also on the evaluation of the consequences of the omission of treatment [39]. Health professionals must consider the long-term implications on the body (invasiveness of surgery), and the psychological and social/relational risks (self-loathing, social integration, and suicide risk).
Given the variability in the persistence of gender dysphoria from childhood to adulthood, it is not easy to establish how the specialist can operate in such a way as to respect the principle of beneficence The health professional makes some choices also influenced by personal belief systems and theoretical orientation that can influence the future of the adolescent, in both cases of treatment with similar GnRH and abstention from therapy [64]. The Standards of Care authorizes specialists to adapt the guidelines according to the needs and wishes of the individual patient [7]. The choice of prescribing blockers is ethical when the doctor believes that the patient will benefit from the treatment. If, after conducting the appropriate assessments, the physician concludes that refusal of treatment is the riskiest option because gender dysphoria is likely to persist into adolescence and adulthood, then early treatment is found to be in the best interests of the patient. Child [19]. The doctor’s responsibility is to help the child or adolescent consider the possible consequences of each choice.
According to the principle of justice of Beauchamp and Childress, health services must be equally distributed among the population. Gender-dysphoric young people seeking assistance face a variety of barriers due to socioeconomic status and geographic location. There are disparities in access to care between gender-variant adolescents and cisgender peers, due to the stigma that prevents them from seeking and obtaining adequate treatments [12]. The social and structural stigma experienced by gender non-conforming young people reduces accessibility to care from a structural, interpersonal, and individual point of view [65]. The structural stigma implies a reduction in available resources and health coverage; the medicalization of atypical expressions of gender identity; electronic registers with only two options for gender identification; the lack of knowledge and research on the health of trans people [65]. Stigma in social relationships at school and in the family also represents a barrier to access to specialized medical services for atypical gender identity [66]. Young people, inserted in a stigmatizing social context, are increasingly reluctant to reveal their atypical gender identity. The tendency to hide associated with the fear of being judged as different reduces the likelihood for young gender-variant people to seek and receive assistance [67]. Furthermore, the services are not equally distributed throughout the territory, so there are few clinics with specialized professionals who are used to treat problems related to gender identity, generating inequalities in access to care due to geographic location. The shortage of adequately trained and competent personnel can lead to inappropriate or even harmful medical care for patients [68]. Gender-variant young people often have difficulty accessing other forms of assistance [69].
The experience of biological puberty is an undesirable condition for adolescents with gender dysphoria who find themselves living in a body they do not recognize as their own. Actionable interventions for gender dysphoria are classified in the Standards of Care as fully reversible, partially reversible, and irreversible interventions [7]. Suppression of puberty is a reversible treatment that involves the administration of similar drugs of gonadotropin-releasing hormone (GnRH). The analogue agonist most frequently used with adolescents with gender dysphoria is Triptorelin, administered by the intramuscular or subcutaneous route. This intervenes to arrest the development of secondary sexual attributes and associated physiological functions in adolescents with gender dysphoria. After the suppression of puberty, if gender dysphoria persists, the induction of puberty of gender identification can be carried out by administering GAF [11]. Regarding drug safety, GnRH analogues appear to be well tolerated in the short term, with the exception of hot flashes [23], fatigue, migraine, mood swings, pain from injection, and abscesses [5]. Even in the long term, there do not seem to be any significant side effects on the body, but the knowledge is still uncertain [11]. The issue of fertility is particularly delicate, since, if the gender adjustment process is continued, it remains irremediably compromised for adolescents who have not resorted to the preservation of sexual gametes. This aspect represents an element to be evaluated when defining the decision-making capacity of the minor who chooses to undergo medical treatment for gender dysphoria [24]. When the young person has not yet reached the age of majority, the request for the gender adjustment process should be accompanied by parental approval. However, there is no agreement on the minimum age for adolescents to express consent. Furthermore, it seems useless to establish an age threshold: the International Covenant on the Rights of the Child focuses on the capacity for judgment, whereby the adolescent can express consent when he has reached sufficient emotional and cognitive maturity to understand the implications of therapy, including possible side effects and risks that may occur [12]. Since puberty suppression therapy is partly experimental, consent cannot be fully informed, because the professionals themselves are not aware of all the long-term outcomes of drugs on the body [19]. The candidate can undertake treatment if he meets the eligibility criteria for treatment, whereby the professional assesses whether the adolescent is able to understand and provide consent; and was informed of the expected outcomes, possible disadvantages, potential loss of fertility, and opportunities for preserving fertility [5].
Parents have the right to make decisions for their children only when they do not hinder the “best interests” of young people [12]. The choice of the clinician should not be based only on parental opinion, because parents do not always know what their children’s wishes are, and there is a risk of limiting the child’s right to autonomy [17]. Gender dysphoria implies a strong inconsistency between assigned sex and experienced gender, with a rejection of one’s sexual attributes leading to clinically significant suffering and impaired individual functioning in daily life [4]. This condition is also associated with problems of a psychological and psychiatric nature, such as depression and anxiety [70]; suicide ideas and attempts [18, 31, 35]; an intense dissatisfaction with one’s body image [71, 72].
The negative psychosocial consequences of untreated gender dysphoria in adolescence are now well known. First of all, the young person can experience the omission of treatment as psychological torture and interpret it as a denial of the possibility of experiencing puberty of the kind of identification. Faced with this suffering, the adolescent who reacts with impulsiveness can adopt behaviors that are risky to health [30]. The anguish can be so intense that it leads to suicidal ideas and attempts. Suicidal behaviors are more frequent in the transgender population than in the rest of the population [31, 33, 34, 35]. Unfavorable outcomes of surgical gender reassignment in adults appear to be associated with late treatment rather than early intervention [41]. Poorer psychological functioning in adults could be due to the distress experienced due to a prolonged inconsistency between gender identity and physical appearance that exposes to stigmatization and social isolation [24]. On the other hand, timely treatment with similar GnRH not only allows to prevent negative outcomes but also bring benefits to the young person. The same effects cannot be obtained if therapy is started later in puberty, as blockers are less effective in reducing secondary sexual attributes when they are already formed [18, 20], for which it will be necessary to expose themselves to invasive surgical removal operations in the future. Suppression of puberty can be considered a diagnostic tool, as it saves time for both the adolescent, who can explore their gender identity without worrying about the development of secondary sexual attributes [22], and to the clinician, who can better understand the nature and intensity of adolescent distress [23] to arrive at a more precise diagnosis [20]. Many studies have found an improvement in functioning and psychological well-being after treatment with GnRH analogues [25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38]. When, on the other hand, therapy is denied, and the adolescent resorts to self-medication, he is no longer followed by professionals in the sector, with the foreseeable physical and psychological repercussions that follow (wrong methods and dosages of administration, possible infections due to injections that do not comply with appropriate hygiene standards), [12, 39]. Involvement in prostitution exposes adolescents to situations that are risky for their life and sexual health since they could be victims of abuse or contract infections and diseases if they do not use the appropriate precautions [71]. The advantages that can be brought by GnRH analogue therapy cannot be underestimated, which are arresting in the development of secondary sexual attributes and greater satisfaction with body image; preventing a series of risky behaviors for health, in particular suicidal ideations and attempts. The right of the adolescent emerges to a future in which life opportunities are maximized, whereby the possibility of living the puberty experience of gender identification is offered, preventing the need to undergo invasive gender affirmation surgeries in future [73, 74, 75]. The importance of respecting the right of the child to exercise personal autonomy in the decision-making process is noted, so his/her opinion must be considered by the professional when making a therapeutic choice [17, 76, 77]. Whether parents not only deny consent but adopt abusive attitudes towards the gender-variant child, then the possibility of intervention to protect the minor is evaluated [78]. Since the prevalence of gender in adolescence is progressively increasing in the population [24], this issue cannot be underestimated, and it is important to convey the right therapeutic tools for young people afferent to health services [79]. It is clear that denial of therapy is not a neutral option, and the health professional cannot omit the intervention, thus thinking of not harming the patient. This type of action can harm young people in two ways: it does not respect the principle of non-maleficence as they can adopt risk behaviors that compromise their health; does not respect the principle of beneficence as it does not bring benefit. The studies cited highlight the importance of evaluating for each case which therapeutic option is that can improve the well-being and quality of life of the minor, without focusing on rigid and a priori beliefs, but keeping the multiple possibilities of treatment open.
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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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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:null},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"423519",title:"Dr.",name:"Sizakele",middleName:null,surname:"Ngwenya",slug:"sizakele-ngwenya",fullName:"Sizakele Ngwenya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419270",title:"Dr.",name:"Ann",middleName:null,surname:"Chianchitlert",slug:"ann-chianchitlert",fullName:"Ann Chianchitlert",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419271",title:"Dr.",name:"Diane",middleName:null,surname:"Selvido",slug:"diane-selvido",fullName:"Diane Selvido",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419272",title:"Dr.",name:"Irin",middleName:null,surname:"Sirisoontorn",slug:"irin-sirisoontorn",fullName:"Irin Sirisoontorn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"355660",title:"Dr.",name:"Anitha",middleName:null,surname:"Mani",slug:"anitha-mani",fullName:"Anitha Mani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"355612",title:"Dr.",name:"Janani",middleName:null,surname:"Karthikeyan",slug:"janani-karthikeyan",fullName:"Janani Karthikeyan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334400",title:"Dr.",name:"Suvetha",middleName:null,surname:"Siva",slug:"suvetha-siva",fullName:"Suvetha Siva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334239",title:"Prof.",name:"Leung",middleName:null,surname:"Wai Keung",slug:"leung-wai-keung",fullName:"Leung Wai Keung",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Hong Kong",country:{name:"China"}}}]}},subseries:{item:{id:"20",type:"subseries",title:"Animal Nutrition",keywords:"Sustainable Animal Diets, Carbon Footprint, Meta Analyses",scope:"An essential part of animal production is nutrition. Animals need to receive a properly balanced diet. One of the new challenges we are now faced with is sustainable animal diets (STAND) that involve the 3 P’s (People, Planet, and Profitability). We must develop animal feed that does not compete with human food, use antibiotics, and explore new growth promoters options, such as plant extracts or compounds that promote feed efficiency (e.g., monensin, oils, enzymes, probiotics). These new feed options must also be environmentally friendly, reducing the Carbon footprint, CH4, N, and P emissions to the environment, with an adequate formulation of nutrients.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/20.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11416,editor:{id:"175967",title:"Dr.",name:"Manuel",middleName:null,surname:"Gonzalez Ronquillo",slug:"manuel-gonzalez-ronquillo",fullName:"Manuel Gonzalez Ronquillo",profilePictureURL:"https://mts.intechopen.com/storage/users/175967/images/system/175967.png",biography:"Dr. Manuel González Ronquillo obtained his doctorate degree from the University of Zaragoza, Spain, in 2001. He is a research professor at the Faculty of Veterinary Medicine and Animal Husbandry, Autonomous University of the State of Mexico. He is also a level-2 researcher. He received a Fulbright-Garcia Robles fellowship for a postdoctoral stay at the US Dairy Forage Research Center, Madison, Wisconsin, USA in 2008–2009. He received grants from Alianza del Pacifico for a stay at the University of Magallanes, Chile, in 2014, and from Consejo Nacional de Ciencia y Tecnología (CONACyT) to work in the Food and Agriculture Organization’s Animal Production and Health Division (AGA), Rome, Italy, in 2014–2015. He has collaborated with researchers from different countries and published ninety-eight journal articles. He teaches various degree courses in zootechnics, sheep production, and agricultural sciences and natural resources.\n\nDr. Ronquillo’s research focuses on the evaluation of sustainable animal diets (StAnD), using native resources of the region, decreasing carbon footprint, and applying meta-analysis and mathematical models for a better understanding of animal production.",institutionString:null,institution:{name:"Universidad Autónoma del Estado de México",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,series:{id:"13",title:"Veterinary Medicine and Science",doi:"10.5772/intechopen.73681",issn:"2632-0517"},editorialBoard:[{id:"175762",title:"Dr.",name:"Alfredo J.",middleName:null,surname:"Escribano",slug:"alfredo-j.-escribano",fullName:"Alfredo J. 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The considerable development of technology, including the computing power of computers, is also conducive to the development of bioinformatics, including personalized medicine. In an era of rapidly growing data volumes and ever lower costs of generating, storing and computing data, personalized medicine holds great promises. Modern computational methods used as bioinformatics tools can integrate multi-scale, multi-modal and longitudinal patient data to create even more effective and safer therapy and disease prevention methods. Main aspects of the topic are: Applying bioinformatics in drug discovery and development; Bioinformatics in clinical diagnostics (genetic variants that act as markers for a condition or a disease); Blockchain and Artificial Intelligence/Machine Learning in personalized medicine; Customize disease-prevention strategies in personalized medicine; Big data analysis in personalized medicine; Translating stratification algorithms into clinical practice of personalized medicine.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",keywords:"Biomedical Data, Drug Discovery, Clinical Diagnostics, Decoding Human Genome, AI in Personalized Medicine, Disease-prevention Strategies, Big Data Analysis in Medicine"},{id:"8",title:"Bioinspired Technology and Biomechanics",scope:'Bioinspired technologies take advantage of understanding the actual biological system to provide solutions to problems in several areas. Recently, bioinspired systems have been successfully employing biomechanics to develop and improve assistive technology and rehabilitation devices. The research topic "Bioinspired Technology and Biomechanics" welcomes studies reporting recent advances in bioinspired technologies that contribute to individuals\' health, inclusion, and rehabilitation. 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Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering"}],annualVolumeBook:{},thematicCollection:[],selectedSeries:null,selectedSubseries:null},seriesLanding:{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. 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Topics include, but are not limited to: Advanced techniques of cellular and molecular biology (Molecular methodologies, imaging techniques, and bioinformatics); Biological activities at the molecular level; Biological processes of cell functions, cell division, senescence, maintenance, and cell death; Biomolecules interactions; Cancer; Cell biology; Chemical biology; Computational biology; Cytochemistry; Developmental biology; Disease mechanisms and therapeutics; DNA, and RNA metabolism; Gene functions, genetics, and genomics; Genetics; Immunology; Medical microbiology; Molecular biology; Molecular genetics; Molecular processes of cell and organelle dynamics; Neuroscience; Protein biosynthesis, degradation, and functions; Regulation of molecular interactions in a cell; Signalling networks and system biology; Structural biology; Virology and microbiology.",annualVolume:11410,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"79367",title:"Dr.",name:"Ana Isabel",middleName:null,surname:"Flores",fullName:"Ana Isabel Flores",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRpIOQA0/Profile_Picture_1632418099564",institutionString:null,institution:{name:"Hospital Universitario 12 De Octubre",institutionURL:null,country:{name:"Spain"}}},{id:"328234",title:"Ph.D.",name:"Christian",middleName:null,surname:"Palavecino",fullName:"Christian Palavecino",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000030DhEhQAK/Profile_Picture_1628835318625",institutionString:null,institution:{name:"Central University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"186585",title:"Dr.",name:"Francisco Javier",middleName:null,surname:"Martin-Romero",fullName:"Francisco Javier Martin-Romero",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSB3HQAW/Profile_Picture_1631258137641",institutionString:null,institution:{name:"University of Extremadura",institutionURL:null,country:{name:"Spain"}}}]},{id:"15",title:"Chemical Biology",keywords:"Phenolic Compounds, Essential Oils, Modification of Biomolecules, Glycobiology, Combinatorial Chemistry, Therapeutic peptides, Enzyme Inhibitors",scope:"Chemical biology spans the fields of chemistry and biology involving the application of biological and chemical molecules and techniques. 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Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. 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Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. The Proteomics topic aims to attract contributions on all aspects of MS-based proteomics that, by pushing the boundaries of MS capabilities, may address biological problems that have not been resolved yet.",annualVolume:11414,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null,editorialBoard:[{id:"72288",title:"Dr.",name:"Arli Aditya",middleName:null,surname:"Parikesit",fullName:"Arli Aditya Parikesit",profilePictureURL:"https://mts.intechopen.com/storage/users/72288/images/system/72288.jpg",institutionString:null,institution:{name:"Indonesia International Institute for Life Sciences",institutionURL:null,country:{name:"Indonesia"}}},{id:"40928",title:"Dr.",name:"Cesar",middleName:null,surname:"Lopez-Camarillo",fullName:"Cesar Lopez-Camarillo",profilePictureURL:"https://mts.intechopen.com/storage/users/40928/images/3884_n.png",institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",institutionURL:null,country:{name:"Mexico"}}},{id:"81926",title:"Dr.",name:"Shymaa",middleName:null,surname:"Enany",fullName:"Shymaa Enany",profilePictureURL:"https://mts.intechopen.com/storage/users/81926/images/system/81926.png",institutionString:"Suez Canal University",institution:{name:"Suez Canal University",institutionURL:null,country:{name:"Egypt"}}}]}]}},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/195210",hash:"",query:{},params:{id:"195210"},fullPath:"/profiles/195210",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()