Factors described as contributing to the risk of NSI and sharps injuries in veterinarians.
\r\n\t
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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"52841",title:"Epidemiology of Needlestick and Sharps Injuries in Veterinary Medicine",doi:"10.5772/66110",slug:"epidemiology-of-needlestick-and-sharps-injuries-in-veterinary-medicine",body:'\nOccupational health problems in veterinary medicine are very frequent, and veterinarians are considered to be members of a high-risk group for occupational hazards [1].
\nA needlestick injury (NSI) can be defined as an inadvertent (accidental) penetrating wound from a needle that may result in exposure to the blood or other body fluids. A sharps injury includes needles or other sharp objects, such as scalpels, lancets, razor blade, scissors, nose tongs for cattle, halters, calf pulling equipment and metal cattle chutes [2, 3]. These types of injuries are considered a major occupational health problem and of serious concern for veterinarians and other healthcare workers [4]. NSI injuries usually occur during activities such as taking blood and body fluid specimens and processing, needle disposal, waste collection and transferring blood from a syringe into another vessel [5].
\nAwareness of the transmissibility of bloodborne infectious agents in human medicine, including human immunodeficiency virus (HIV), hepatitis B virus and hepatitis C virus, has led to the identification of percutaneous sharps injury resulting in exposure to bloodborne pathogens as an important occupational health risk for people employed in the healthcare industry [6]. It is estimated that more than 2 million healthcare workers experience an NSI or sharps injury with a contaminated sharp instrument every year [7]. Injuries associated with NSI are associated with the potential exposure to infectious agents and syringe contents [8]. Injuries due to contact with contaminated needles may also have serious physical and psychological consequences [9].
\nThere has been less concern regarding NSI and sharps injuries in veterinary practice, and only a few epidemiological studies have been conducted in this area. On the other hand, methodological aspects are not comparable with different design approaches [8]. The analysis of NSI is essential to identifying areas of improvement.
\nIn order to understand the epidemiology of NSI in veterinarians over the last four decades, in this chapter we review the literature, focusing on the epidemiology of NSI and sharps injuries in veterinary practice.
\nEpidemiologic data on NSI and sharps injuries are essential for targeting and assessing interventions [10]. However, a few studies have looked at the epidemiology of NSI and sharps injuries in veterinary practice. Despite significant effort for reduction, NSI and sharps injuries continue to pose a significant risk in human medicine [11], and a similar risk occurs in veterinary medicine. Reports carried out in small and large-animal practice show a large variability in the prevalence and incidence.
\nBloodborne infections are recognized for a long time, and they are the main risk to the health of workers exposed to blood and other biological materials. However, it was only after the discovery of HIV that occupational injuries with potentially contaminated biological material were treated as a public health problem [12]. Infection control guidelines in human medicine put emphasis on protection against bloodborne pathogens. In veterinary medicine few serious zoonotic infections are currently considered to be bloodborne which reduces concern in the veterinary community [13]. HIV and hepatitis viruses are of potential concerns in human medicine but are absent in veterinary medicine [2]. However, veterinarians, by maintaining direct contact with animals, are often exposed to biological agents found in the blood and body fluids. In veterinary hospitals and clinics, occupational risk by biological agents is universally distributed; the risks are proportional to the amount of contacts with patients and blood, secretions and other body fluids [14, 15].
\nThe risk of transmission of infectious agents after the injury with biological material depends on several factors such as host susceptibility and resistance, virulence of the agent, the route of exposure and amount of the infectious agent. As such, the greater the manipulation of sharp objects, blood and other body fluids, the greater the exposure and risk of acquiring infectious diseases [16].
\nThe few recognized bloodborne pathogens that can be transmitted between animals and humans probably are the reason for the less concern regarding NSI and sharps in veterinary practice [17]. The most important bloodborne pathogens in veterinary work are Staphylococcus spp.; Pseudomonas spp. (inoculated from the animal skin); pathogens from fine-needle aspirates Blastomyces, Pasteurella spp., Staphylococcus spp. and Streptococcus spp. (from fine-needle aspirates); certain arboviruses or modified live vaccines [2]. Bartonella spp. appear to be a zoonotic pathogen [18]. There are two reports in the literature about accidental needlestick transmission of Bartonella to veterinarians. One study reported a suspected needlestick transmission of Bartonella vinsonii subspecies berkhofii to a veterinarian [19], and another reports a veterinarian with Bartonella henselae after a needle puncture [20]. Disease associated with NSI occurrence was addressed in one study [21] where injury during Brucella vaccine administration was found to be a risk factor for occupational brucellosis. More reports in veterinary practice that NSI and sharps injuries resulted in a zoonotic disease are of a 26-year-old veterinary technician who became infected with B virus following a needlestick injury [22] and blastomycosis developed in a veterinarian after an NSI following a fine-needle aspiration [23]. No cases of other biological agents have been reported after NSI in small or large-animal practice in the literature review. Exotic zoonotic pathogens are hypothetically transmitted through contact with the blood, and the risk of emerging bloodborne pathogens should be seriously considered by all veterinary practitioners [13, 24, 25].
\nApproximately 1.2 million occupational NSI and sharps injuries occur in the European Union (EU) each year [26]. It is very difficult to conduct studies in prevalence or incidence (per time per person) or exposure rate of NSI and sharps injuries in veterinary medicine, but these studies are important to determine the risk factors associated with occurrence of injuries [1]. Another problem is that the rate of underreporting of NSI and sharps events is very high [27], and the quality of available data is variable [2].
\nThe studies available about NSI and sharps injuries in veterinary medicine reported different prevalence, ranging from 1% to 86.7%. However, their comparison is difficult since prevalence is calculated from different data sources. In one study conducted in veterinarians in Wisconsin, the incidence of NSI and sharps exposures to Johne’s bacterin during vaccination against paratuberculosis was 5.5/100 person-years [28]. A survey conducted in female veterinarians reported 63.9% of one or more needlesticks after graduation from veterinary college. The incidence of NSI was 9.3/100 person-years [27]. The prevalence of NSI and sharps injuries in American zoo veterinarians was 86.7% [29]. The overall exposure rate reported by Australian veterinarians was 75.3%, but those reported suffering from at least one contaminated NSI in the previous year were 58.9% [30]. A survey of veterinary technicians reported that 93% had at least one NSI over the course of their career and 74% had experienced a needlestick injury during the previous 12 months of the study [8]. In another study, veterinarians that reported at least one unintentional NSI were 74.2 in the previous year of the study [31]. A survey of veterinarians from Uganda reported a NSI prevalence of 15.0% [32]. In a study performed in Portugal, 78.5% of veterinarians enrolled in the study reported having had at least one NSI during their careers [33]. The prevalence of NSI in Japanese veterinarians during containment measures of foot-and-mouth diseases was 1%, and NSI accounted for 18% of all reported injuries in all veterinarians [34].
\nRates observed in veterinary medicine are variable, but in some epidemiological studies, values are much higher than the prevalence rates described for human medicine [35, 36].
\nAccurate reporting of NSI and sharps injuries is essential, to ensure that incidents are appropriately managed [37]. An accident with a needlestick or a sharp should be reported immediately to the supervisor, which supports the workers in administrative and legal terms if they develop a disease resulting from an accident [38]. Surveillance in NSI and sharps injuries should be activated in every healthcare setting to monitor injuries and contaminations and identify the need for corrective interventions [39]. It is difficult to provide accurate statistics on the incidence of NSI or sharps injuries because even in developed countries in human medicine, all cases are not reported [40]. Reasons for underreporting in human medicine include the lack of necessity of reporting with a presumption that the risk of bloodborne pathogens transmission is low and lack of knowledge of systems [37]. There is no single reporting system for injuries or disease in veterinarians, and reported cases of NSI and sharps may greatly underestimate the real number of occurrences [1]. Recall bias and deterioration of memory with the passage of time are other problems associated with the rates of prevalence reported. The true incidence may be underreported owing to the incapacity of busy professionals to remember and write down the details [27].
\nIdentification of risk factors of NSI and sharps has been reported in few epidemiological studies involving veterinarians. As a consequence, little information is available concerning the risk factors for NSI and sharps injuries. Some risk factors associated with NSI and sharps have been referred to in the literature as presented in Table 1.
\nFactors described | \nReference | \n
---|---|
Poor quality of restraint | \n[30] | \n
Inadequate access to sharps containers | \n[49] | \n
Poor needle handling practices by veterinarians | \n[13, 29, 52] | \n
Female gender | \n[30] | \n
Working in small-animal practice | \n[30] | \n
Working with large animals | \n[46, 47] | \n
Veterinarians working with dogs | \n[33] | \n
Less experienced veterinarians (years as veterinarian) | \n[30, 41] | \n
Veterinarians with more than 10 years of practice | \n[33] | \n
Seeing excessive numbers of patients per week | \n[30] | \n
Working longer than normal hours per week | \n[30] | \n
Number of patients treated per week | \n[30] | \n
Household bovines and sheep during childhood | \n[33] | \n
Factors described as contributing to the risk of NSI and sharps injuries in veterinarians.
The influence of sex in the prevalence of NSI and sharps injuries has been studied. Female veterinarians presented higher odds of injury than male veterinarians [30].
\nYears as veterinarians have been described as risk factors. Less experienced veterinarians [30, 41] were more likely to report injuries, which is consistent with that observed in human medicine where the probability of injuries by sharp devices among new personnel or healthcare students is superior when compared to healthcare workers with more years of experience [42]. Clinical experience may have provided expertise and techniques for handling needles and sharp devices, reducing the risk of occupational injuries [43]. However, other studies of veterinarians are contradictory and showed that the proportion of veterinarians who experienced NSI increases with years of practice [33]. This is probably because younger veterinarians may apply the knowledge in infection control acquired in the university and put safety procedures into practice, while practitioners with experience have familiarity with needles and sharp instruments and pay less attention to risks and have lower compliance with biosafety measures [44].
\nIn human medicine, increased risk of injury incidents is positively associated with time constraints and rushing to complete procedures, nervousness, tiredness and loss of concentration. The predisposition to increased risk was also noted to be associated with high workload, working hastily, a crowded work environment, times when personnel are fatigued, do not have a patient’s collaboration or when the medical team was not fully present [12, 45]. In veterinary medicine there are no studies that associate time constraints with NSI and sharps injuries, but these injuries were directly connected with working longer hours per week and number of patients treated per week [30].
\nHousehold association with cattle during childhood has previously been identified as a risk factor. Interaction with animals in infancy could lead to a sense of security in the handling of animals. This can give rise to overconfidence and generate negligent safety behaviours [33].
\nThere is no consensus about the link between the type of practice and the occurrence of accidents that cause injuries. Working in small or mixed animal practice was associated with a significantly higher exposure rate for contaminated NSI in one study [30]. In another study, working with dogs was a risk factor for NSI occurrence, probably, because these animals are extremely mobile animals that are seldom fully restrained during the course of veterinary care and they are often treated with parenteral drugs [33]. According to another study, people working with large animals were more likely to report injuries [46] suggesting that the treating of large animals is more hazardous than the treating of small animals [47]. Animal handling and environmental problems probably influence the occurrence, such as working in semi-dark settings, confinement in closed spaces and high animal densities. However, in a Minnesota and Wisconsin survey, the type of practice did not affect the exposure rate to NSI and sharps injuries, although large animals caused more severe injuries—which is not surprising [48].
\nVeterinary occupational injury can increase with prior injuries, participation in sports, current smoking and six or fewer hours of sleep [49]. Neglected management of occupational health and a failure to comply with simple proactive measures are risk factors for NSI events [38].
\nPoor quality of restraint caused by lack of adequate personnel or inadequate assistance with restraint of animals is considered as a risk factor for an NSI event. Animals are far less obedient than human patients, and movement of the animal at the time of needle puncture is more common if the animal patient is not well restrained [30]. It is probable that the large-animal veterinarians may experience a lower rate of needlestick puncture wounds because they are more likely to restrain their large-animal patients compared to the small-animal clinicians [27, 50]. Poor restraint can compromise not only the person inoculating but also other healthcare workers and animal owners who may be helping [2].
\nNo sharps boxes present increased rates to injuries [49]. Sharps should be disposed of immediately after use directly into a container (i.e. not left bare on any surface) [17]. These sharps containers need to be in close proximity so that the staff can place the sharps into the appropriate containers immediately after use [51]. Pocketing of needles poses a risk for NSI to other staff whilst doing unrelated tasks such as in the laundry [2, 8]. Poor needle handling practices, such as not firmly recapping needles or not bothering to recap them at all, is an important risk factor [13, 29, 52]. But it is likely that this behaviour is improving. In a study performed in small-animal veterinary practices, 89% of practices dispose of sharps directly, rather than recapping them, though a few even indicated a preference for careful recapping [53]. If an appropriate disposal container is not in proximity and available, recapping should be done using some procedures and techniques such as the one-handed ‘scoop’ or using a device to handle the needle cap [54, 55].
\nNeedlestick and sharps injuries most often occur before disposal of a needle or sharp device, during the use of a sharp device, after a procedure and after improper disposal (leaving needles in a laboratory coat with subsequent needlestick injury to laundry personnel) [2]. There are many possible mechanisms of injury. Some circumstances associated with NSI and sharps have been referred to in the literature.
\nRegarding the circumstances in which incidents of NSI and injuries by sharp instruments occurred, it is possible to observe that injury can occur during vaccination and other procedures, in which veterinarians are frequently accidentally ‘self-inoculated’ or suffer other self-inflicted wounds [20, 31, 32, 56, 57]!
\nConcerning veterinary activity at time of injury, it has been demonstrated that vaccine administration is an activity that accounts for a lot of accidents. Within the studies reviewed which evaluated substances involved, two studies refer to injury during Brucella vaccine administration, RB51 [58] and S19 strain [21]. Vaccine administration in chickens against infectious bursal disease (Gumboro) and Newcastle disease was the single most important cause of self-inoculations in practitioners from Uganda [32]. A study of 1347 NSI involving vaccines demonstrated that one-third of the vaccine-related sticks involved rabies and about 11% involved distemper vaccines [27]. Self-inoculation with the vaccine against Leptospira was reported by 7.5% of US veterinarians [31]. Accidental injection of an inoculation against (Mycobacterium avium subspecies paratuberculosis) (bovine Johne’s disease) was reported in two studies [28, 56]. Accidental exposures (due to NSI) to vaccines against diseases such as West Nile virus, Giardia and Leptospira spp. [46] and to live equine vaccination against Equilis StrepE [57] have also been reported in the literature. Erysipelas vaccine and other vaccines was the most commonly cited agent exposure reported by US swine veterinarians in a study of occupational hazards [52].
\nProcedures involving large animals were reported in more studies [27, 29, 30, 32, 34, 46, 47, 52, 58, 59] of epidemiology occurrence than small animals. Zoo animals were also involved in accidents [29].
\nRecapping needles is another activity that increased the risk of percutaneous injury. There was an association between recapping needles in small-animal practice and in large-animal practice and NSI and sharps injuries [13, 52]. A study of zoo veterinarians reported that 86.0 % of NSIs involved recapping needles [29]. Uncapping of needles by the mouth can be a relatively common but risky form of behaviour [17]. Another practice of risk for parenteral exposures, especially in large-animal medicine, is the reuse of needles and syringes [13]. Standard precautions for human medicine guidelines recommend never recapping needles [51].
\nThere was little information about the most affected anatomical parts of the body injured. There was no agreement between studies with respect to the most frequent site of the involvement. In one study, a veterinarian experienced an NSI in the right index finger [19]; in other two studies, veterinarians experienced an NSI into the right thumb [20, 56]; and in another study, seven veterinarians were said to have experienced an NSI in the upper limb [32].
\nThe consequences of occupational exposure to the blood and other body fluids are not only related to infections but also the psychological trauma, anxiety, relationships and prophylactic drugs [60]. NSI and sharps injuries can produce physical trauma, but it is unlikely that they cause severe injuries alone. Physical trauma such as severe laceration can be significant, especially from large-bore needles, and can result from animal movement during injection or blood collection [2]. Every needlestick and sharps injury carries a risk of trauma or inoculation of harmful substances. While the physical trauma caused by needle or a sharp in the body may often be minor, introduction of hazardous compounds such as chemical or biological contaminants has been associated with severe sequelae, including serious infections and damage to tissue [27]. Side effects of NSI and sharps injuries following accidental exposures were normally characterized as mild or severe and local or systemic. Serious adverse effects, while uncommon, do occur [2]. Local adverse events are characterized by one or more of the following symptoms: pain, erythema, local swelling and superficial abscess [27, 52, 58]. These were frequently reported after an injury. Systemic adverse effects experienced after NSI or sharps injuries included myalgia, fever, arthralgia, headaches, fatigue, sweats, severe allergic reaction, chills, lacerations, psychedelic experience, diarrhoea, vomiting or granuloma [27, 56, 58, 59]. Severe reactions included severe local inflammation, abscess formation, localized necrosis, local nerve damage, disease, severe allergic reaction and miscarriage [2, 23].
\nVeterinarians experiencing adverse reactions are more likely to report having had a NSI than others [2].
\nPsychological and psychiatric consequences of NSIs are not yet quantified in veterinary medicine. In human medicine occupational blood exposure can lead to posttraumatic stress, anxiety and depression and is a major contributing factor of time loss from work [60–62].
\nAlthough many types of sharps injure veterinarians, the most common causative devices associated with a higher rate of injury were syringes and needles [19, 30, 47], needle biopsy [56], scalpel blades [63] and ampoule/vial [30]. Although some accidents occurred with empty or clear needles [27, 52], NSI injuries may involve the risk of self-injecting drugs or other hazardous substances, which can result in mild or severe allergic reactions or other more severe consequences [2, 27].
\nAgents producing a side effect most often include anthelmintics [27, 52], euthanasia agents and anaesthetics and steroids [27], immobilizing agents [29], hormones, vaccines [20, 21, 28, 29, 31, 32, 46, 56] and antibiotics [29, 30, 32]. Mineral oil adjuvants of veterinary vaccines can produce a chronic granulomatous reaction with sterile abscess formation [64]. Accidental needlestick injuries and conjunctival or open wound exposures of humans involving the RB51 vaccine were associated with both local and systemic adverse events in the United States [58].
\nOccupational NSI and sharps injuries may also represent a serious human reproductive health hazard, notably the unintentional injection of dinoprost tromethamine, a prostaglandin compound leading to miscarriage in a previous study [27].
\nIn some cases NSI and sharps injuries require medical treatment with hospital admission, in which case medical attention [20, 29, 34, 56, 57] and sometimes surgical intervention are needed [56, 58]. In a study examining zoo veterinarians, 6.5% of veterinarians required medical care after a NSI event [29]. The demand for medical treatment occurs in cases of adverse reactions to injected harmful substances and severe trauma. Self-treatment of injuries was common [48].
\nNeedlestick and sharps injuries are a serious problem in veterinary medicine, but it is often preventable. In human medicine almost 83% of needlestick injuries can be prevented [65]. However, preventive efforts can reduce the risk of exposures, but not eliminate them [66].
\nIn human medicine, time and considerable economic resources have been expended to reduce the incidence of NSI associated with bloodborne agents. Some countries and governments have invested in the need to introduce safety devices, educating healthcare workers on the safe handling and disposal of sharp devices and developing strategies to prevent them [67, 68]. Aggressive educational campaigns concerning NSI prevention are lacking in veterinary medicine. Probably, the factor associated with the lack of this approach is a poorly developed culture of concern about biosafety in veterinary medicine, and only a few bloodborne zoonotic pathogens are recognized in clinically normal animals [2, 8].
\nAdherence and compliance with the universal precaution recommendations proposed by the Centers for Disease Control and Prevention (CDC) are important factors for the prevention of NSI [69]. Recommended prevention strategies include educational programmes, avoidance of recapping, better needle disposal systems and careful handling and disposal of sharp devices [12]. Infection control and workplace safety include safe handling of sharps [17]. Avoid recapping needles or use a ‘one-handed scooping technique’ to recap is a simple infection control procedure which may substantially reduce this form of occupational injury [46]. The CDC recommended the use of gloves and gowns during patient contact that requires handling of blood [69]. Although this equipment does provide a physical barrier to shield the skin and mucous membranes from contact with blood, most protective equipment is easily penetrated by needles [10]. Universal precautions recommended that persons that manipulate needles and other sharps wear gloves and have eye protection and reduce the risk of exposure to needlestick [58]. In previous studies, wearing two pairs of gloves seems to protect because when the outer glove is perforated, the inner glove can protect the hand [70, 71]. Previous studies suggest a low compliance with personal protective equipment in healthcare workers [39]. Discomfort, reduction of agility and decreased sensation of touch were reported to outweigh the benefits afforded by double gloving [72]. The use of personal protective equipment could be affected by availability [51].
\nThe risk of NSI can also be reduced by the use of safety medical devices, which are becoming more commonly used in human healthcare [73] incorporating safety-engineered protection mechanisms (safety-engineered devices, e.g. retractable needles, fixed-needle safety syringes). These modern safety devices minimize the risk and impact of NSI injuries [39, 45]. However some healthcare workers refuse to use such devices [4]. Cost is an obvious concern with needle safety devices, particularly when the benefits are difficult to quantify [2]. And in veterinary medicine, the cost of using the safety-engineered devices can be unaffordable, and cost may be a limiting factor for the use of this kind of device [52].
\nRisk management prevention is necessary to reduce the likelihood of NSI and sharps injuries [2]. The implementation of legislation into the field can help identify and reduce future risk of these injuries [67, 74]. In Europe, legislation to improve the safety and health of personnel has been in place since 1989 and was published to protect healthcare workers and requires an integrated approach [74]. However, in some countries, this legislation is not adapted to veterinary medicine. Current guidelines to reduce NSI and sharps injuries in veterinary practice are not based on veterinary data, but are modified from studies in human medicine [30]. On the other hand, it is very important that veterinarians understand the reasons to comply with safe procedures, which include good needle and sharp handling practices and correct disposal by veterinarians [39]. Veterinarians should be familiar with the recommendations of the CDC guidelines on universal precautions [51]. Work-practice controls are important in preventing exposures to blood and hazardous substances and include verbal statements when passing sharps, avoiding hand-to-hand passage of sharp instruments [75].
\nCosts are harder to quantify. They include the direct costs associated with the initial and follow-up treatment when necessary [76], the emotional cost associated with fear and anxiety associated with the possible consequences of the injury, direct and indirect costs related with lost productivity and cost of any associated legal action [10, 11]. Occupational hazards in the work of American veterinarians resulted in an estimated US$ 4 million in losses [77], and the costs of injuries related to sharp contaminated instruments in the USA have been estimated to be around 118–591 million dollars in 2010 [78]. These costs associated with NSI can be reduced and healthcare protected with investment in safety-engineered sharp devices [79].
\nEducation plays an important role in decreasing NSI rates as it decreased recapping, unnecessary needle manipulation and improper disposal of used devices [39]. Training should always be provided for new employees and periodically for veterinary clinical personnel, as well as for supporting staff [7]. Educational interventions including videotaping and performance feedback proved effective in the short term; however, long-term adherence was not observed [80]. To encourage constant compliance with good safety standards, educational sessions incorporating regular teaching, practical classes and reminders in the form of posters could be used [51]. Education and training need to be encouraged in older workers who receive less training and have more limited access to new technologies than younger workers [39, 81]. Adequate staffing and personnel training in proper animal restraint are also important, as poor restraint is an important risk factor [50]. To prevent injuries with aggressive animals, it is important to handle those animals with care and to make proper use of restraining devices and protective equipment [47].
\nThis chapter describes the epidemiology of NSI and sharps injuries in veterinary medicine and emphasizes the importance of compliance with international standards of infection control practices, of training and of the education of veterinarians. It emphasizes the need for reporting and prevention of NSI and sharps injuries. Increasing awareness of hazards and how to avoid them and establishing better work environments are also crucial. Education regarding the use of personal protective equipment and the importance of reporting accidents should be promoted. There is a need to assess accurately the risk of NSI and sharps hazards in veterinary practice in order to develop effective measures for reducing related incidents. More epidemiological studies in this field are needed to study risk factors, to determine knowledge, attitudes and practices. It is also essential to put a cost-effective and efficient injury and control programme into place.
\nThe work was supported by the strategic research project PEst-OE/AGR/UI0772/2014 financed by the Foundation for Science and Technology [FCT] and to Prof. D.A. Davis that fully revised English text.
\nThis chapter will try and help general practitioners master minor surgical procedures.
General practitioners require these procedures for diagnostic or therapeutical reasons, in the outpatient setting as well in the emergency (excision of skin lesions or wound suturing for example). For that reason, the training of the general doctors in minor surgery is an additional tool for good medical practice and acquiring skills in minor surgical procedures has become a critical part of medical training.
Minor surgical procedures do not involve very sophisticated devices. However, some basic requirements in terms of infrastructure and equipment must be met [1, 2].
It is recommended that each facility has a specific room for these procedures. This room (Figure 1) must include:
Well-equipped room of minor surgery.
Surgical room: a well-ventilated room, with a suitable temperature, it is imperative that is clean, but it does not require sterile isolation. The surgical room should be cleaned properly at the end of the surgical session, particularly after contaminated procedures (e.g. abscesses).
Operating table: It should be easily accessible from all sides, Height-adjustable and articulated tables. It is essential that allows the doctor to work in comfort, both standing and sitting.
Doctor’s stool: A height-adjustable stool on wheels.
Side table: it is used to place the surgical instruments and material used during the surgery.
Lamp: It is necessary to have a directional light source, and it must provide adequate lighting with, at least, 45,000 lux of illuminance. It is advisable to have another auxiliary lamp with a magnifying glass.
Showcase and containers: For storing consumables and surgical instruments. There should also be properly marked containers for bio contaminated material, and a disposal system in accordance with current health legislation.
Resuscitation equipment: Including material for vascular access, airway intubation, saline, drugs for resuscitation (e.g. epinephrine, atropine, bicarbonate) and a defibrillator.
Performing minor surgical procedures carries some risk of transmission of infectious diseases (such as HCV and HIV), both from patient to doctor and vice versa. To minimize this risk, all physicians performing invasive procedures should adopt and apply universal precautions, which include:
Surgical attire: surgical shirts and trousers (“scrubs”) or gowns and sterile gloves. Surgical masks and eye goggles is considered highly desirable but not essential. Disposable gowns are very useful.
Hand washing: Hygienic scrubbing is suitable for minor surgery and involves using a normal soap solution (no brush) and washing thoroughly all skin folds for at least 20 seconds. Time span from scrubbing to glove placement should never exceed 10 minutes.
Sterile glove placement: Outer surface of the glove should be sterile, therefore they cannot be touched with the hands, only with the other glove; nonetheless, the inner or powdered part of the glove can be touched.
The quality, condition and type of instruments used in any procedure can affect its outcome. Choosing the right instruments for each surgical intervention is, therefore, an important issue [1].
Scalpel: A number 3 handle with leaves number 15 for dissection and 11 for incisions and withdrawal of points. The scalpel blade is installed on the handle in a unique position, matching the blade guide with the handle guide. The scalpel is handled with the dominant hand like a pencil (Figure 2), allowing small and precise incisions. To increase precision, hand should be partially supported on the working surface. Skin should be tightened perpendicularly to the direction of the incision using the contralateral hand, cutting the skin perpendicularly. In hairy areas (eyebrows or scalp), to avoid damaging the follicles, the incision should be parallel to the hairshafts.
Correct way of managing of the scalpel.
Scissors: The scissors allows us both the cutting dissection of the tissues and the blunt dissection.
A 14 cm long curved blunt May scissors (cutting scissors) and an 11.5 cm curved blunt Metzenbaum scissors (dissecting scissors) should be available.
Scissors are handled by inserting the distal phalange of the thumb and fourth finger into the rings, then supporting the second finger on the branches of the scissors. Usually scissors are inserted with the tip closed and are then opened, separating the tissues in the anatomical layers, except for sharp dissection they are inserted with the tip open, then cutting the tissue.
Needle-holder: needle-holders are meant to hold curved needles while stitching. The needle is held 2/3 of the way back from its point. A small or medium (12–15 cm). Long needle holders are not recommended.
Like other instruments with rings, the needle support is handled equally. To facilitate the passage of the needle through the tissues, the needle holder should describe a prono-supination movement, and for a proper edge eversion of the wound the angle of entry of the needle should be 90°. The non-dominant hand holds the skin with a retractor or dissecting forceps, opposing the pressure of the needle.
Dissecting forceps: Use of a 12 cm-long Adson forceps with teeth to handle the skin, plus a toothless Adson forceps for suture removal or two standard forceps, one with and one without teeth. It is important not to manipulate the skin using non-toothed forceps.
They used with the non dominant hand, between the first, second and third fingers.
They allow the surgeon to expose the tissues to manipulate them.
Homeostats: homeostats are used to pull tissue, for homeostasis and, in some cases, for blunt dissection in absence of small scissors. Usually with 12 cm curved non-toothed Mosquito forceps.
For most minor surgical interventions, a basic set of surgical instruments is enough (Figure 3). But some surgical procedures require the use of special instruments or equipment, such as:
Basic set of instruments of minor surgery: Scalpel (handle of the number 3 for scalpel number 15), scissors of May, Adson forceps with teeth, needle-holders and mosquito forceps.
Biopsy punch: it is an instrument consisting of a handle and a cylindrical cutting edge (trephine) for obtaining tissue biopsies. It allows the surgeon to obtain full- thickness samples of the skin.
The most useful in minor surgery is the 4 mm punch but they are manufactured in different diameters. They are handled with the dominant hand, performing rotational movements of the instrument to cut the skin and obtain the sample [3].
Curette: it allows scraping of lesions on the skin Surface with a simple surgical technique that involves “scraping” or enucleating different types of superficial, hyperkeratotic or raised partial-thickness skin lesions.
Cryosurgical equipment: these are devices that spray a cryogen, which is usually liquid nitrogen that uses extremely cold temperatures to treat benign and malignant skin lesions (solar lentigines, common warts, myxoid cysts, actinic keratosis, etc.).
It is available, cost-effective, and rapid treatment that rarely requires anesthesia [4].
Electrocautery: it applies an electric current with ability to coagulate and cut through different tissues. There are different terminals depending on the type of procedure that is to be performed [5].
Different types of suture materials are available: threads, staples, adhesive sutures and tissue adhesives.
Depending on the material used for the suture, the operation time will be modified and will require anesthesia or not.
Conventional sutures require the use of anesthesia, operating time is increased, and tissue is traumatized, but provide a secure wound closure and minimal wound- dehiscence rate compared to other types of closure [6].
They are classified according to their origin (natural, such as silk, or synthetic polymers that produce less tissue reaction), their configuration (monofilament or multifilament), and their size (the thickness of the suture is measured using a zero-scale [USP system] (Figure 4). The most commonly used in minor surgery range from 2/0 to 4/0 or 5/0.
Information on suture: (1) caliber of the thread (system USP and metric), (2) trade name of the suture, (3) composition and physical structure of the thread, (4) length of the thread, (5) color of the thread, (6) model of needle (every manufacturer uses different references), (7) I draw from the needle to scale 1:1, (8) circumference of the needle (expressed in parts of circle), (9) section of the needle, (10) length of the needle, (11) expiry date, (12) indexes of the manufacturer, (13) indicator of sterile packing.
The size and type of suture will be selected depending on the anatomical site, the type of wound and on the patient’s features.
Nonabsorbable sutures: They are not degraded by the body and they are used for skin wounds in which stitches that are to be removed or for internal structures that must maintain a constant tension (like tendons and ligaments), Polypropylene and Nylon, causes minimal tissue reaction.
Silk: Suitable for skin suture and for removable sutures in general, it is easy to handle and tie.
Nylon: Indicated for precise skin sutures and internal structures that must maintain constant tension.
Polypropylene: Indicated in continuous intradermal skin closure. It is a very soft suture with high package memory and, therefore, it requires more knots for secure tying, and it is more expensive than Nylon.
Absorbable sutures: A suture is considered absorbable if, when placed under the skin surface, it loses most of its tensile strength in 60 days. It has low tissue reactivity, high tensile strength. They are use in dermal suturing, subcutaneous tissue, deep suturing and ligatures of small vessels. The most commonly used, are the synthetic sutures (polyglactin 910 [Vicryl], polyglycolic acid [Dexon]…).
The period of time (in days) recommended for the extraction of points, together with an indication of the type of suture is described in Table 1.
Anatomical region | Skin suturing | Subcutaneous suturing (Vicryl® or Dexon®) | Stitch removal | |
---|---|---|---|---|
Adults | children | |||
Scalp | Staples 2/0 silk | 3/0 | 7–9 | 6–8 |
Eyelids | 6/0 monofilament or silk | — | 3–5 | 3–5 |
Ears | 4/0–5/0 monofilament or silk | — | 4–5 | 3–5 |
Face, neck, nose, forehead | 4/0 monofilament or silk | 4/0 | 4–6 | 3–5 |
Lips | 4/0 monofilament or silk | 4/0 | 4–6 | 4–5 |
Trunk/abdomen | 3/0–4/0 monofilament | 3/0 | 7–12 | 7–9 |
Back | 12–14 | 14 | ||
Lower extremity | 3/0 monofilament | 3/0 | 8–12 | 7–10 |
Penis | 4/0 monofilament | 3/0 | 7–10 | 6–8 |
Foot and pulp of fingers | 10–12 | 8–10 | ||
Upper limb/hand | 8–10 | 7–9 | ||
Mouth and tongue | 3/0 Vicryl® | — | — | — |
Indications of types of sutures and time for stitch removal.
Needle selection depends on the type of tissue to be sutured, its accessibility and suture thickness.
Needles are classified as triangular, spatulate or conical, according to their section. Triangular needles are considered the first choice in minor surgery, as they have sharp edges that allow suturing through highly-resistant tissues such as subcutaneous tissue, skin or fascia.
Curved needles are used with the needle holder, that is designed to hold needles atraumatically and safely. Short needle holders are preferred in minor surgery; however, they should be selected in accordance with the size of the needle and the surgical area.
Staples are applied by disposable staplers and they are available in different widths (R: normal staples, W: Wide staples). Staplers are preloaded with a variable number of staples. It has certain advantages such as the speed with which the suture is performed, low resistance and no tissue reaction.
They are applied with the dominant hand, while the non dominant hand everts the skin edges using dissecting forceps with teeth. Staple removal is performed using a staple extractor.
Indications: In linear wounds on the scalp, trunk and limbs, and for temporary closure of wounds in patients to be transferred or with other serious injuries.
Contraindications: Wounds on face and hands and regions that are going to be studied through CT or MRI.
It consists of adhesive tapes made of porous paper and capable of approximating the edges of a wound or incision. They are available in various widths and lengths, and it can be cut.
Indications: linear and superficial wounds with little tension. The regions where they are used most are: the face, chest, non-articular surfaces of the limbs and fingertips. They are also a good choice for elderly patients and to wound-reinforcement after stitch removal.
Any wound closed with adhesive suture should not be wet for the first few days, due to the risk of tape detachment.
Contraindications: irregular wounds, on the scalp and hairy areas, skin folds and joint surfaces.
Application and removal of adhesive sutures: For a good application the wound should be free of blood or secretions and dry. The suture tape is applied to the wound using dissecting forceps without teeth or fingers, first on one edge of the wound and then the other and along the wound.
Time for adhesive suture removal parallels time for conventional suture.
These products (cyanoacrylates) act as an adhesive, producing an epidermal plane closure, so they bind the most superficial epithelial layer (stratum corneum) and hold together the wound edges for 7–14 days. After this time, adhesive and stratum corneum are shed along.
Adhesive can be used in deeper wounds or with great tension, associated at sutures in the subcutaneous plane.
It have advantages when compared with sutures: More rapid repair time, less painful procedure, better acceptance by patients, no need for suture removal or follow-up, good cosmetically results. Finally they are safer than sutures because needlesticks are avoided [1, 7].
After cleanliness and hemostasis of the wound, tissue adhesive will be applied:
Using fingers or dissecting forceps to approximate the wound edges, apply the adhesive on the outer surface of the skin. Then Keep the edges in contact for 30–60 seconds. The process can be repeated 3 times.
The wound does not require dressings but should be kept dry 5 days. The glue will disappear after 7–10 days.
If adhesive contact the eyes, use of a generous amounts of ophthalmic antibiotic ointment should be placed within the eye and on the eyelid to break down the adhesive and reopening of eyelids with a gentle manual traction. If adhesive reach the cornea, it should be assessed for corneal abrasion.
The practice of any surgical procedure, however minimal, is not without risks. The possibility of complications during and after surgery must always be kept in mind. The results of surgical treatment are not always predictable, and depend on many factors, involving not only the physician’s skills, but also the patient.
There are two ways to dissect tissue: with a blunt dissection, separating the tissue, using Metzenbaum scissors or mosquito forceps, or cutting dissection, with a scalpel or scissors.
Incisions must parallel the minimal tension lines, which match skin relaxation lines and facial expression. Thus, they result in an acceptable scar, both functionally and cosmetically. There are diagrams of the relaxed skin tension lines, for correct incision planning before surgery.
The incision can be marked prior to skin antiseptic preparation or a previously sterilized marking pen can be used in the surgical field after skin preparation and draping.
For excisional biopsies, it is necessary to leave an adequate margin (1–2 mm) of healthy skin both around the lesion and in depth, depending on each lesion.
Incision: Used for drainage of abscesses or surgical exposure of deeper tissues (e.g., epidermal cysts, lipomas, lymph node biopsies). Depending of surgery or the anatomic area, Incisions can be angled, curved or straight.
Elliptical excision: Its should be oriented along the lines of minimal tension.
Usually the length of the ellipse should be 3 times its width and the ends form a 30° angle. Its used to remove skin lesions with a margin of healthy skin in depth and around lesion, and include all skin layers plus some subcutaneous fat (Figure 5). This technique allows diagnosis, treatment and facilitates closure producing good cosmetic results.
Characteristics of the elliptical excision.
It is the ideal technique to remove the majority of skin lesions [8, 9, 10].
The procedure involves the following steps:
Design of the incision
Preparation of the surgical field
Local anesthetic injection.
Superficial skin incision along the marked ellipse, going through the entire dermis to prevent jagged edges.
Using the nondominant hand the deep wedge-shaped incision is made (always under direct vision), until fat is reached and the lesion is, thus, removed en bloc.
Hemostasis of the surgical area.
Wound closure by layers
Cleaning the surgical area and dressing placement
After 48 hours the wound can be washed gently
Tangential excision: it is the technique of choice to remove very superficial lesions using scalpel or scissors, eliminating only the most superficial layers of the skin and for which diagnosis is certain. The defect created is allowed to heal by secondary intention. Tangential excision also called “skin shave”.
No surgical procedure is complete until the pathology report has been received and the patient informed of the results and prognosis.
Most episodes of bleeding in minor surgery can be controlled with pressure with a gauze or a surgical towel. It is recommended to apply a compressive bandage on the wound in the immediate postoperative period to reduce hematoma or seroma.
Tourniquet: Its allows the exploration of the wound and reduces the surgical time. Its use is limited to distal areas (the fingers nail surgery, etc.) and should not exceed 15 minutes.
The hemostats: The surgeon holds bleeding vessel with the tip of a hemostat without teeth and controls the bleeding. To avoid damaging important structures (for example, tendons or nerves) it is necessary to identify the bleeding vessel.
The ligatures: they are threads that tied around a blood vessel, occlude their light and prevent bleeding. After that, vessel should be fixed with a hemostat. The ligature should pass under the clamp and several knots must be tied.
In the hemostasis by electrocoagulation, the Bovie is used in coagulation mode.
This is the most appropriate for minor surgery, as it helps to distribute stress, and promotes the drainage of the wound. The number of sutures needed varies according to the length, shape and location of the laceration. In general, the sutures are placed away from each other so that no space appears on the edges of the wound.
Simple stitch (percutaneous): It is used alone or in combination with buried stitches in deeper wounds and it is considered the technique of choice.
Simple stitch with buried knot: Used to reduce tension within the wound and approximate the deep planes, before skin suturing. Absorbable material is used, the knot leaving in the depth of the wound, and is cut flush.
Mattress stitch or “U” stitch: It is useful in areas of loose skin (e.g., elbow, back of the hand), where the wound edges tend to invaginate. In addition this suture provides good obliteration of dead space, avoiding the need for buried sutures in shallow wounds.
Horizontal mattress stitch: provides a good eversion of wound edges, especially in areas where the dermis is thick or with high tension [6]
Half-buried horizontal mattress stitch: is used to suture wound angles or surgical edges of uneven thickness.
They are contraindicated if an infection is suspected and in very contaminated wounds.
Simple running suture: is a sequence of points with an initial knot and a final knot. It takes a short time to do it, but it makes it difficult to adjust the tension of the skin. It is rarely used in minor surgery.
Continuous intradermal suture (subcuticular): this type of suture allows the wound to be sutured without breaking the skin, avoids the “cross-hatching” and provides an optimal esthetic result. Non-absorbable monofilament suture material or absorbable material can be used. Intradermal sutures are used in wounds where it will be necessary to maintain the suture for more than 15 days. In minor surgery its usefulness is limited.
When a multifilament yarn is knotted (for example, Silk), three loops are usually sufficient (first a double loop plus two simple loops). When knotting a monofilament yarn (e.g., Nylon, polypropylene), an additional loop must be added to increase knot security. The knots should be placed on one side of the wound, rather than placed on top of the incision. This will allow a better visualization of the wound and will interfere less with the healing and facilitate the removal of points.
Local anesthetics block the transmission of nerve impulses and they causing, the absence of sensation in a specific part of the body, also other local senses may be affected.
Local anesthetics can be classified into two groups: esters and amides (lidocaine, mepivacaine, bupivacaine, prilocaine, etidocaine and ropivacaine). For their remarkable safety and efficacy we will only use amides. The association of vasoconstrictors allows better visualization of the surgical field. The most widely used is adrenaline and the maximum dose must not exceed 250 micrograms in adults or 10 micrograms/kg in children [11].
The concentration of the anesthetic is expressed in %. We must know that a concentration of 1% means that 100 ml of the solution contain 1 g of anesthetic. Therefore a 2 ml ampoule of 2% mepivacaine, its contain 40 mg (Table 2).
Due to the risk of necrosis and other alteration like delayed healing, adrenaline should not be used in acral areas (e.g., toes), or in traumatized and devitalized skin.
It is use in an intact skin and for lacerations and mucosae, especially in children. And their characteristics are shown in the Table 2.
Anesthetic | Mode of use | characteristics | Indications | Complications | Not indicated |
---|---|---|---|---|---|
LET® (4% lidocaine, 0.1% epinephrine 1:2000, 0.5% tetracaine) | 1–3 ml applied directly on wound for 15–30 minutes | Onset 20–30 minutes after application. | Can be effective in children for face and scalp lacerations and less effective in limbs | No important adverse effects reported | For mucosae and acral areas |
EMLA® lidocaine 25 mg/ml plus prilocaine 25 mg/ml, | 1–2 g of cream should be applied for each 10 cm2 of intact skin and occluded. Maximum dose is 10 g | Onset 60–120 minutes after application. Duration of effect is 30–120 minutes. Not useful on palms of hands and soles of feet | Admitted for procedures on intact skin: scraping and shaving, cryosurgery, electrosurgery, laser hair removal, pre-anesthesia for infiltration | Local mild irritation, contact dermatitis. There have been reports of Methemoglobinemia in children aged <6 months | For wounds or deep tissues |
Topical anesthetics used in minor surgical procedures and their characteristics.
Angular infiltration: From the point of entry, the anesthetic is infiltrated in three or more different directions, like a fan (Figure 6).
Perilesional infiltration: Starting from each point of entry the anesthetic is infiltrated in a single direction. The different points of entry will be forming a polyhedral figure.
Linear infiltration: If the lesion to be operated on is a skin laceration, the anesthetic should be directly infiltrated into the wound edges in a linear fashion. If the wound is bruised and has irregular edges, it is preferable to use a perilesional technique from the uninjured area, and follow along the margins of the wound to avoid introducing microbial contamination.
Anesthetic angular infiltration: it infiltrates following three or more different directions, like a fan.
The needle is inserted at the base of the proximal phalanx in a dorsal and lateral location, in the collateral palmar digital nerve, and then local anesthetic is injected (maximum 4 ml). The needle is removed and after aspiration proceeds to infiltrate again the subcutaneous plane.
The surgeon must wait 10–15 minutes to obtain a complete effect of the blockage.
It is important that general practitioners have an extensive knowledge of the lesions most frequently treated by minor surgery [12].
The following paragraphs contain an overview of the most important diagnostic consideration in lesions usually treated with minor surgery.
These lesions are easily treated with curettage, electrosurgery or cryosurgery. In case of doubt, an incisional biopsy should be sent for histopathological analysis.
They are also known as epithelial cysts, epidermoid cysts, or improperly, “sebaceous cysts.” The cyst wall consists of normal stratified squamous epithelium derived from the follicular infundibulum. Queratin is the main component inside the cyst. Their treatment is surgical removal for cosmetic reasons or due to recurrent infections.
They are a form of benign epithelial hyperplasia induced by the human papillomavirus (HPV). Clinical presentations of cutaneous HPV infection include:
Verruca Vulgaris or plantar wart: you can use liquid nitrogen or salicylic acid.
It is presents as pearly white papules of 1–5 mm (sometimes even bigger) with central dimpling. They may appear isolated or in groups in the neck, trunk, anogenital area or eyelids. Their first choice treatment is cryosurgery, curettage.
Lipomas are slow-growing benign tumors of mature adipose tissue. They appear as soft, elastic, smooth or multilobulated tumors of variable size, with ill-defined borders, and not adherent to deep planes. The diagnosis is usually made clinically. But ultrasound can be helpful to distinguish a lipoma from an epidermoid cyst or a ganglion cyst [13]. They are generally asymptomatic and they are treated by surgical removal [2].
They are not malignant and their treatment is justified for cosmetic reasons.
They are acquired lesions in the form of macules or papules or small nodules (<1 cm) and are constituted by groups of melanocytes located in the epidermis, dermis or both areas and rarely in the subcutaneous tissue. Sun exposure contributes to the induction of these lesions.
It is located in sun-exposed areas such as bald scalp, the face, shoulders, ears, neck and the back of the hands. It is caused by damage from exposure to ultraviolet radiation. Actinic keratoses are more prevalent in males of middle-aged.
Actinic keratosis is considered a precancer. 13–25% it could develop into a squamous cell carcinoma.
If lesions are scarce and localized, they may be treated with liquid nitrogen.
It is the most common skin malignancy. Approximately 70% of basal cell carcinoma occurs on the face, and 15% presents on the trunk [14]. Exposure to ultraviolet (UV) radiation in sunlight, especially during childhood, is the most important factors that contribute to the development of Basal cell carcinoma.
This is a malignant tumor that usually appears on a previous premalignant lesion and requires a multidisciplinary therapeutical approach involving dermatologists, surgeons, radiotherapists, and chemotherapists [14].
Of all skin malignancies, melanoma has the worst prognosis, Five-year survival rates for people with melanoma depend on the stage of the disease at the time of diagnosis.
High-risk areas for minor surgery include the facial and cervical regions, axillary and supraclavicular regions, wrists, hands and fingers, the groin, the popliteal fossa and the feet.
We must consider those regions with a greater tendency to develop pathological scars (e.g., shoulder, sternal and interscapular region). Also the skin of black patients and children are especially prone.
For most basic minor surgical procedures, no preoperative work-up is needed. Table 3 summarizes the precautions of minor surgery in primary care.
-Surgery in the lower extremities in patients with Diabetes Mellitus and peripheral vascular disease. -In patients with arrhythmia, severe hypertension, hyperthyroidism, pheochromocytoma or pregnancy, do not add vasoconstrictor to local anesthetic -Anatomic areas of risk -In patients with chronic use of corticosteroids. Protocol for minor surgery in anticoagulated patients - 3 Day Suspend Sintrom ® - 2 Day Suspend Sintrom ® and add subcutaneous LMWH - 1 Day Suspend Sintrom ® and add subcutaneous LMWH, single dose - 0 Day INR Control. If between 1 and 1.6 proceed to surgery. LMWH single subcutaneous dose. Patient will take the usual dose of Sintrom ® (the same as before the suspension). +1 Day LMWH single subcutaneous dose usual dose of Sintrom ® +2 Day usual dose of Sintrom ® +3 Day LMWH single subcutaneous dose. Usual dose of Sintrom ® +4 Day usual dose of Sintrom ® INR will be obtained on day +10 (seven days after surgery) |
Precautions of minor surgery.
In patients with increased anxiety, 5–10 mg oral or sublingual diazepam, or 1–5 mg sublingual lorazepam can be administered 30 minutes before surgery.
Contraindications for minor surgery: Malignant skin lesion, allergy to local anesthetics, pregnancy (surgery should be deferred until the end of pregnancy, if malignancy is suspected, the patient should be referred to a specialist), an acute illness, doubt about patient’s motivations, patients with psychiatric disorders or uncooperative patients or refusal to sign the informed consent form is a contraindication for any minor surgery procedure or technique.
Direct oral anticoagulants [DOACs] (Dabigatran, Rivaroxaban, Apixaban, Edoxaban): If a moderate or high bleeding risk surgery, it can be omitted for approximately 2–3 days before a procedure, and resume 24 hours after surgery. However, cutaneous procedures (e.g., skin biopsy, tumor excision, bone marrow biopsy) generally considered to confer a low risk of bleeding [15].
Vasovagal syncope is the most frequent complication and is more common in young men. Even some patients lose consciousness.
Treatment consists in administering oxygen and iv. fluids if needed and, in severe cases use atropine (0.5–1 mg sc or iv). Generally, most of patients recover spontaneously over a period of seconds to a few minutes.
Infection can occur in up to 1% of minor surgical patients, symptoms such as fever and/or chills are only rarely seen. Infections are treated by removing some of the stitches, plus daily cleaning and disinfection of the wound and allowing the wound to close by secondary intention. If necessary an oral antibiotic regimen may be initiated and inserted drain into the wound.
Hematoma-seroma: is paramount suturing the wound in layers with no gaps and, applying a compressive bandage to prevent their formation.
Wound dehiscence: After wound dehiscence, repairs will take place by secondary intention.
Hypertrophic scar and keloid scarring.
The authors declare no conflict of interest.
IntechOpen aims to guarantee that original material is published while at the same time giving significant freedom to our Authors. We uphold a flexible Copyright Policy, guaranteeing that there is no transfer of copyright to the publisher and Authors retain exclusive copyright to their Work.
',metaTitle:"Publication Agreement - Monograph",metaDescription:"IntechOpen aims to guarantee that original material is published while at the same time giving significant freedom to our authors. For that matter, we uphold a flexible copyright policy meaning that there is no transfer of copyright to the publisher and authors retain exclusive copyright to their work.",metaKeywords:null,canonicalURL:"/page/publication-agreement-monograph",contentRaw:'[{"type":"htmlEditorComponent","content":"When submitting a manuscript, the Author is required to accept the Terms and Conditions set out in our Publication Agreement – Monographs/Compacts as follows:
\\n\\nCORRESPONDING AUTHOR'S GRANT OF RIGHTS
\\n\\nSubject to the following Article, the Author grants to IntechOpen, during the full term of copyright, and any extensions or renewals of that term, the following:
\\n\\nThe foregoing licenses shall survive the expiry or termination of this Publication Agreement for any reason.
\\n\\nThe Author, on his or her own behalf and on behalf of any of the Co-Authors, reserves the following rights in the Work but agrees not to exercise them in such a way as to adversely affect IntechOpen's ability to utilize the full benefit of this Publication Agreement: (i) reprographic rights worldwide, other than those which subsist in the typographical arrangement of the Work as published by IntechOpen; and (ii) public lending rights arising under the Public Lending Right Act 1979, as amended from time to time, and any similar rights arising in any part of the world.
\\n\\nThe Author, and any Co-Author, confirms that they are, and will remain, a member of any applicable licensing and collecting society and any successor to that body responsible for administering royalties for the reprographic reproduction of copyright works.
\\n\\nSubject to the license granted above, copyright in the Work and all versions of it created during IntechOpen's editing process, including all published versions, is retained by the Author and any Co-Authors.
\\n\\nSubject to the license granted above, the Author and Co-Authors retain patent, trademark and other intellectual property rights to the Work.
\\n\\nAll rights granted to IntechOpen in this Article are assignable, sublicensable or otherwise transferrable to third parties without the specific approval of the Author or Co-Authors.
\\n\\nThe Author, on his/her own behalf and on behalf of the Co-Authors, will not assert any rights under the Copyright, Designs and Patents Act 1988 to object to derogatory treatment of the Work as a consequence of IntechOpen's changes to the Work arising from the translation of it, corrections and edits for house style, removal of problematic material and other reasonable edits as determined by IntechOpen.
\\n\\nAUTHOR'S DUTIES
\\n\\nWhen distributing or re-publishing the Work, the Author agrees to credit the Monograph/Compacts as the source of first publication, as well as IntechOpen. The Author guarantees that Co-Authors will also credit the Monograph/Compacts as the source of first publication, as well as IntechOpen, when they are distributing or re-publishing the Work.
\\n\\nThe Author agrees to:
\\n\\nThe Author will be held responsible for the payment of the agreed Open Access Publishing Fee before the completion of the project (Monograph/Compacts publication).
\\n\\nAll payments shall be due 30 days from the date of issue of the invoice. The Author or whoever is paying on behalf of the Author and Co-Authors will bear all banking and similar charges incurred.
\\n\\nThe Author shall obtain in writing all consents necessary for the reproduction of any material in which a third-party right exists, including quotations, photographs and illustrations, in all editions of the Work worldwide for the full term of the above licenses, and shall provide to IntechOpen, at its request, the original copies of such consents for inspection or the photocopies of such consents.
\\n\\nThe Author shall obtain written informed consent for publication from those who might recognize themselves or be identified by others, for example from case reports or photographs.
\\n\\nThe Author shall respect confidentiality during and after the termination of this Agreement. The information contained in all correspondence and documents as part of the publishing activity between IntechOpen and the Author and Co-Authors are confidential and are intended only for the recipients. The contents of any communication may not be disclosed publicly and are not intended for unauthorized use or distribution. Any use, disclosure, copying, or distribution is prohibited and may be unlawful.
\\n\\nAUTHOR'S WARRANTY
\\n\\nThe Author and Co-Authors confirm and warrant that the Work does not and will not breach any applicable law or the rights of any third party and, specifically, that the Work contains no matter that is defamatory or that infringes any literary or proprietary rights, intellectual property rights, or any rights of privacy.
\\n\\nThe Author and Co-Authors confirm that: (i) the Work is their original work and is not copied wholly or substantially from any other work or material or any other source; (ii) the Work has not been formally published in any other peer-reviewed journal or in a book or edited collection, and is not under consideration for any such publication; (iii) Authors and any applicable Co-Authors are qualifying persons under section 154 of the Copyright, Designs and Patents Act 1988; (iv) Authors and any applicable Co-Authors have not assigned, and will not during the term of this Publication Agreement purport to assign, any of the rights granted to IntechOpen under this Publication Agreement; and (v) the rights granted by this Publication Agreement are free from any security interest, option, mortgage, charge or lien.
\\n\\nThe Author and Co-Authors also confirm and warrant that: (i) he/she has the power to enter into this Publication Agreement on his or her own behalf and on behalf of each Co-Author; and (ii) has the necessary rights and/or title in and to the Work to grant IntechOpen, on behalf of themselves and any Co-Author, the rights and licences in this Publication Agreement. If the Work was prepared jointly by the Author and Co-Authors, the Author confirms that: (i) all Co-Authors agree to the submission, license and publication of the Work on the terms of this Publication Agreement; and (ii) the Author has the authority to enter into this biding Publication Agreement on behalf of each Co-Author. The Author shall: (i) ensure each Co-Author complies with all relevant provisions of this Publication Agreement, including those relating to confidentiality, performance and standards, as if a party to this Publication Agreement; and (ii) remain primarily liable for all acts and/or omissions of each Co-Author.
\\n\\nThe Author agrees to indemnify IntechOpen harmless against all liabilities, costs, expenses, damages and losses, as well as all reasonable legal costs and expenses suffered or incurred by IntechOpen arising out of, or in connection with, any breach of the agreed confirmations and warranties. This indemnity shall not apply in a situation in which a claim results from IntechOpen's negligence or willful misconduct.
\\n\\nNothing in this Publication Agreement shall have the effect of excluding or limiting any liability for death or personal injury caused by negligence or any other liability that cannot be excluded or limited by applicable law.
\\n\\nTERMINATION
\\n\\nIntechOpen has the right to terminate this Publication Agreement for quality, program, technical or other reasons with immediate effect, including without limitation (i) if the Author and/or any Co-Author commits a material breach of this Publication Agreement; (ii) if the Author and/or any Co-Author (being a private individual) is the subject of a bankruptcy petition, application or order; or (iii) if the Author and/or any Co-Author (as a corporate entity) commences negotiations with all or any class of its creditors with a view to rescheduling any of its debts, or makes a proposal for, or enters into, any compromise or arrangement with any of its creditors.
\\n\\nIn the event of termination, IntechOpen will notify the Author of the decision in writing.
\\n\\nIntechOpen’s DUTIES AND RIGHTS
\\n\\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen, at its discretion, agrees to publish the Work attributing it to the Author and Co-Authors.
\\n\\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen agrees to provide publishing services which include: managing editing (editorial and publishing process coordination, Author assistance); publishing software technology; language copyediting; typesetting; online publishing; hosting and web management; and abstracting and indexing services.
\\n\\nIntechOpen agrees to offer free online access to readers and use reasonable efforts to promote the Publication to relevant audiences.
\\n\\nIntechOpen is granted the authority to enforce the rights from this Publication Agreement on behalf of the Author and Co-Authors against third parties, for example in cases of plagiarism or copyright infringements. In respect of any such infringement or suspected infringement of the copyright in the Work, IntechOpen shall have absolute discretion in addressing any such infringement that is likely to affect IntechOpen's rights under this Publication Agreement, including issuing and conducting proceedings against the suspected infringer.
\\n\\nIntechOpen has the right to include/use the Author and Co-Authors names and likeness in connection with scientific dissemination, retrieval, archiving, web hosting and promotion and marketing of the Work and has the right to contact the Author and Co-Authors until the Work is publicly available on any platform owned and/or operated by IntechOpen.
\\n\\nMISCELLANEOUS
\\n\\nFurther Assurance: The Author shall ensure that any relevant third party, including any Co-Author, shall execute and deliver whatever further documents or deeds and perform such acts as IntechOpen reasonably requires from time to time for the purpose of giving IntechOpen the full benefit of the provisions of this Publication Agreement.
\\n\\nThird Party Rights: A person who is not a party to this Publication Agreement may not enforce any of its provisions under the Contracts (Rights of Third Parties) Act 1999.
\\n\\nEntire Agreement: This Publication Agreement constitutes the entire agreement between the parties in relation to its subject matter. It replaces all prior agreements, draft agreements, arrangements, collateral warranties, collateral contracts, statements, assurances, representations and undertakings of any nature made by, or on behalf of, the parties, whether oral or written, in relation to that subject matter. Each party acknowledges that in entering into this Publication Agreement it has not relied upon any oral or written statements, collateral or other warranties, assurances, representations or undertakings which were made by or on behalf of the other party in relation to the subject matter of this Publication Agreement at any time before its signature (known as the "Pre-Contractual Statements"), other than those which are set out in this Publication Agreement. Each party hereby waives all rights and remedies which might otherwise be available to it in relation to such Pre-Contractual Statements. Nothing in this clause shall exclude or restrict the liability of either party arising out of any fraudulent pre-contract misrepresentation or concealment.
\\n\\nWaiver: No failure or delay by a party to exercise any right or remedy provided under this Publication Agreement or by law shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy. No single or partial exercise of such right or remedy shall preclude or restrict the further exercise of that or any other right or remedy.
\\n\\nVariation: No variation of this Publication Agreement shall have effect unless it is in writing and signed by the parties, or their duly authorized representatives.
\\n\\nSeverance: If any provision, or part-provision, of this Publication Agreement is, or becomes invalid, illegal or unenforceable, it shall be deemed modified to the minimum extent necessary to make it valid, legal and enforceable. If such modification is not possible, the relevant provision or part-provision shall be deemed deleted. Any modification to, or deletion of, a provision or part-provision under this clause shall not affect the validity and enforceability of the rest of this Publication Agreement.
\\n\\nNo partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Author or any Co-Author, nor authorize any party to make or enter into any commitments for, or on behalf of, any other party.
\\n\\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
\\n\\nPolicy last updated: 2018-09-11
\\n"}]'},components:[{type:"htmlEditorComponent",content:'When submitting a manuscript, the Author is required to accept the Terms and Conditions set out in our Publication Agreement – Monographs/Compacts as follows:
\n\nCORRESPONDING AUTHOR'S GRANT OF RIGHTS
\n\nSubject to the following Article, the Author grants to IntechOpen, during the full term of copyright, and any extensions or renewals of that term, the following:
\n\nThe foregoing licenses shall survive the expiry or termination of this Publication Agreement for any reason.
\n\nThe Author, on his or her own behalf and on behalf of any of the Co-Authors, reserves the following rights in the Work but agrees not to exercise them in such a way as to adversely affect IntechOpen's ability to utilize the full benefit of this Publication Agreement: (i) reprographic rights worldwide, other than those which subsist in the typographical arrangement of the Work as published by IntechOpen; and (ii) public lending rights arising under the Public Lending Right Act 1979, as amended from time to time, and any similar rights arising in any part of the world.
\n\nThe Author, and any Co-Author, confirms that they are, and will remain, a member of any applicable licensing and collecting society and any successor to that body responsible for administering royalties for the reprographic reproduction of copyright works.
\n\nSubject to the license granted above, copyright in the Work and all versions of it created during IntechOpen's editing process, including all published versions, is retained by the Author and any Co-Authors.
\n\nSubject to the license granted above, the Author and Co-Authors retain patent, trademark and other intellectual property rights to the Work.
\n\nAll rights granted to IntechOpen in this Article are assignable, sublicensable or otherwise transferrable to third parties without the specific approval of the Author or Co-Authors.
\n\nThe Author, on his/her own behalf and on behalf of the Co-Authors, will not assert any rights under the Copyright, Designs and Patents Act 1988 to object to derogatory treatment of the Work as a consequence of IntechOpen's changes to the Work arising from the translation of it, corrections and edits for house style, removal of problematic material and other reasonable edits as determined by IntechOpen.
\n\nAUTHOR'S DUTIES
\n\nWhen distributing or re-publishing the Work, the Author agrees to credit the Monograph/Compacts as the source of first publication, as well as IntechOpen. The Author guarantees that Co-Authors will also credit the Monograph/Compacts as the source of first publication, as well as IntechOpen, when they are distributing or re-publishing the Work.
\n\nThe Author agrees to:
\n\nThe Author will be held responsible for the payment of the agreed Open Access Publishing Fee before the completion of the project (Monograph/Compacts publication).
\n\nAll payments shall be due 30 days from the date of issue of the invoice. The Author or whoever is paying on behalf of the Author and Co-Authors will bear all banking and similar charges incurred.
\n\nThe Author shall obtain in writing all consents necessary for the reproduction of any material in which a third-party right exists, including quotations, photographs and illustrations, in all editions of the Work worldwide for the full term of the above licenses, and shall provide to IntechOpen, at its request, the original copies of such consents for inspection or the photocopies of such consents.
\n\nThe Author shall obtain written informed consent for publication from those who might recognize themselves or be identified by others, for example from case reports or photographs.
\n\nThe Author shall respect confidentiality during and after the termination of this Agreement. The information contained in all correspondence and documents as part of the publishing activity between IntechOpen and the Author and Co-Authors are confidential and are intended only for the recipients. The contents of any communication may not be disclosed publicly and are not intended for unauthorized use or distribution. Any use, disclosure, copying, or distribution is prohibited and may be unlawful.
\n\nAUTHOR'S WARRANTY
\n\nThe Author and Co-Authors confirm and warrant that the Work does not and will not breach any applicable law or the rights of any third party and, specifically, that the Work contains no matter that is defamatory or that infringes any literary or proprietary rights, intellectual property rights, or any rights of privacy.
\n\nThe Author and Co-Authors confirm that: (i) the Work is their original work and is not copied wholly or substantially from any other work or material or any other source; (ii) the Work has not been formally published in any other peer-reviewed journal or in a book or edited collection, and is not under consideration for any such publication; (iii) Authors and any applicable Co-Authors are qualifying persons under section 154 of the Copyright, Designs and Patents Act 1988; (iv) Authors and any applicable Co-Authors have not assigned, and will not during the term of this Publication Agreement purport to assign, any of the rights granted to IntechOpen under this Publication Agreement; and (v) the rights granted by this Publication Agreement are free from any security interest, option, mortgage, charge or lien.
\n\nThe Author and Co-Authors also confirm and warrant that: (i) he/she has the power to enter into this Publication Agreement on his or her own behalf and on behalf of each Co-Author; and (ii) has the necessary rights and/or title in and to the Work to grant IntechOpen, on behalf of themselves and any Co-Author, the rights and licences in this Publication Agreement. If the Work was prepared jointly by the Author and Co-Authors, the Author confirms that: (i) all Co-Authors agree to the submission, license and publication of the Work on the terms of this Publication Agreement; and (ii) the Author has the authority to enter into this biding Publication Agreement on behalf of each Co-Author. The Author shall: (i) ensure each Co-Author complies with all relevant provisions of this Publication Agreement, including those relating to confidentiality, performance and standards, as if a party to this Publication Agreement; and (ii) remain primarily liable for all acts and/or omissions of each Co-Author.
\n\nThe Author agrees to indemnify IntechOpen harmless against all liabilities, costs, expenses, damages and losses, as well as all reasonable legal costs and expenses suffered or incurred by IntechOpen arising out of, or in connection with, any breach of the agreed confirmations and warranties. This indemnity shall not apply in a situation in which a claim results from IntechOpen's negligence or willful misconduct.
\n\nNothing in this Publication Agreement shall have the effect of excluding or limiting any liability for death or personal injury caused by negligence or any other liability that cannot be excluded or limited by applicable law.
\n\nTERMINATION
\n\nIntechOpen has the right to terminate this Publication Agreement for quality, program, technical or other reasons with immediate effect, including without limitation (i) if the Author and/or any Co-Author commits a material breach of this Publication Agreement; (ii) if the Author and/or any Co-Author (being a private individual) is the subject of a bankruptcy petition, application or order; or (iii) if the Author and/or any Co-Author (as a corporate entity) commences negotiations with all or any class of its creditors with a view to rescheduling any of its debts, or makes a proposal for, or enters into, any compromise or arrangement with any of its creditors.
\n\nIn the event of termination, IntechOpen will notify the Author of the decision in writing.
\n\nIntechOpen’s DUTIES AND RIGHTS
\n\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen, at its discretion, agrees to publish the Work attributing it to the Author and Co-Authors.
\n\nUnless prevented from doing so by events beyond its reasonable control, IntechOpen agrees to provide publishing services which include: managing editing (editorial and publishing process coordination, Author assistance); publishing software technology; language copyediting; typesetting; online publishing; hosting and web management; and abstracting and indexing services.
\n\nIntechOpen agrees to offer free online access to readers and use reasonable efforts to promote the Publication to relevant audiences.
\n\nIntechOpen is granted the authority to enforce the rights from this Publication Agreement on behalf of the Author and Co-Authors against third parties, for example in cases of plagiarism or copyright infringements. In respect of any such infringement or suspected infringement of the copyright in the Work, IntechOpen shall have absolute discretion in addressing any such infringement that is likely to affect IntechOpen's rights under this Publication Agreement, including issuing and conducting proceedings against the suspected infringer.
\n\nIntechOpen has the right to include/use the Author and Co-Authors names and likeness in connection with scientific dissemination, retrieval, archiving, web hosting and promotion and marketing of the Work and has the right to contact the Author and Co-Authors until the Work is publicly available on any platform owned and/or operated by IntechOpen.
\n\nMISCELLANEOUS
\n\nFurther Assurance: The Author shall ensure that any relevant third party, including any Co-Author, shall execute and deliver whatever further documents or deeds and perform such acts as IntechOpen reasonably requires from time to time for the purpose of giving IntechOpen the full benefit of the provisions of this Publication Agreement.
\n\nThird Party Rights: A person who is not a party to this Publication Agreement may not enforce any of its provisions under the Contracts (Rights of Third Parties) Act 1999.
\n\nEntire Agreement: This Publication Agreement constitutes the entire agreement between the parties in relation to its subject matter. It replaces all prior agreements, draft agreements, arrangements, collateral warranties, collateral contracts, statements, assurances, representations and undertakings of any nature made by, or on behalf of, the parties, whether oral or written, in relation to that subject matter. Each party acknowledges that in entering into this Publication Agreement it has not relied upon any oral or written statements, collateral or other warranties, assurances, representations or undertakings which were made by or on behalf of the other party in relation to the subject matter of this Publication Agreement at any time before its signature (known as the "Pre-Contractual Statements"), other than those which are set out in this Publication Agreement. Each party hereby waives all rights and remedies which might otherwise be available to it in relation to such Pre-Contractual Statements. Nothing in this clause shall exclude or restrict the liability of either party arising out of any fraudulent pre-contract misrepresentation or concealment.
\n\nWaiver: No failure or delay by a party to exercise any right or remedy provided under this Publication Agreement or by law shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy. No single or partial exercise of such right or remedy shall preclude or restrict the further exercise of that or any other right or remedy.
\n\nVariation: No variation of this Publication Agreement shall have effect unless it is in writing and signed by the parties, or their duly authorized representatives.
\n\nSeverance: If any provision, or part-provision, of this Publication Agreement is, or becomes invalid, illegal or unenforceable, it shall be deemed modified to the minimum extent necessary to make it valid, legal and enforceable. If such modification is not possible, the relevant provision or part-provision shall be deemed deleted. Any modification to, or deletion of, a provision or part-provision under this clause shall not affect the validity and enforceability of the rest of this Publication Agreement.
\n\nNo partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Author or any Co-Author, nor authorize any party to make or enter into any commitments for, or on behalf of, any other party.
\n\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by and construed in accordance with the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
\n\nPolicy last updated: 2018-09-11
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I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. 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He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). 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