Hemodynamic monitoring in LT.
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These books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\\n\\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\\n\\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
\\n\\n\\n\\n\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
IntechOpen and Knowledge Unlatched formed a partnership to support researchers working in engineering sciences by enabling an easier approach to publishing Open Access content. Using the Knowledge Unlatched crowdfunding model to raise the publishing costs through libraries around the world, Open Access Publishing Fee (OAPF) was not required from the authors.
\n\nInitially, the partnership supported engineering research, but it soon grew to include physical and life sciences, attracting more researchers to the advantages of Open Access publishing.
\n\n\n\nThese books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\n\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\n\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
\n\n\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"1615",leadTitle:null,fullTitle:"Advances in Quantum Theory",title:"Advances in Quantum Theory",subtitle:null,reviewType:"peer-reviewed",abstract:"The quantum theory is the first theoretical approach that helps one to successfully understand the atomic and sub-atomic worlds which are too far from the cognition based on the common intuition or the experience of the daily-life. 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\r\n\tThe ultimate goal of many fields of neuroscience research is to harness the ability of the mammalian brain to reorganize. The ability to control cortical reorganization in the adult cortex, either by controlling existing adult mechanisms for plasticity or by reactivating mechanisms of developmental plasticity, would be a tremendous advancement in the treatment of cortical damage and neurodegenerative diseases. Consequently, the specifics of the timing and types of reorganization possible in the mammalian visual cortex, in particular, have consistently generated tremendous interest in both the scientific community and the general public. Few sources, however, provide a combined look into the plasticity of the visual cortex in both juvenile and adult mammalian brains.
\r\n\r\n\tWhile it is clear that visual representations in the mammalian cortex can undergo significant reorganization during an early critical period of development, the extent of reorganization possible in the developing visual cortex is still an area of active investigation. This dynamic nature of cortical circuitry is important for learning, as well as for repair following nervous system injury. Similarly, several aspects of the visual cortex are thought to remain plastic into adulthood, allowing cortical sensorimotor maps to be modified continuously by experience. Because studies of the extent of cortical reorganization in the adult mammalian visual cortex have at times produced quite disparate results, many pioneering studies are now attempting to address these controversial measurements.
\r\n\r\n\tThis proposed book topic will examine our current understanding of the interplay of plasticity and stability in the developing and adult mammalian visual systems as well as our progress towards translating these fundamental research findings into updates for clinical practice.
\r\n\t
In the past years, liver transplantation (LT) has made leaps and evolved from an endeavor in specialized centers to a worldwide definitive and gold standard treatment of the end-stage liver disease (ESLD), acute liver failure, and various cancer types [1, 2].
\nThe advances in perioperative management, including the improvement of surgical techniques, preservation solutions, perioperative management, and monitoring, as well as advances in immunosuppression and postoperative care have led not only to an increased number of transplantations but also to better outcomes [2]. According to recent studies in the United Kingdom, the 1- and 5-year survival rate for liver transplant recipients has reached 92 and 80%, respectively [3]. However, there are still certain challenges in LT. Scarcity of allografts and disparity between supply and demand has led the transplantation community to expand the donor pool by utilizing split grafts, allografts from living donors after cardiac death and including marginal donors of older age and with extended steatosis [4]. Additionally, recipients are sicker, given that priority of graft allocation is based on higher MELD scores, older and with co-morbidities such as metabolic syndrome, cardiac disease, and diabetes mellitus [5, 6]. Postoperative liver transplant patient care requires careful accounting of the recipient’s pre-existing pathophysiology, intraoperative events, and donor’s quality. Moreover, the implanted liver represents a unique biological entity that has undergone physiological changes and has to adapt to a new environment. This donor-recipient interaction is the key of a successful transplantation [7].
\nThe intensivist’s role is essential as a multifaceted approach is critical for optimal transplantation outcomes. The main hurdles to tackle are early recognition and immediate treatment of the hemodynamic and metabolic disorders, restoration of intravascular volume, avoidance of coagulation disorders, optimization of organs function affected by hepatic failure, prophylaxis and treatment of infections, early enteral nutrition, and evaluation of graft function. Technological advances offer the possibility of continuous cardiovascular and allograft function monitoring facilitating improved endpoint results.
\nThe aim of immediate postoperative support is the adequate O2 supply to tissues and graft by ensuring hemodynamic stabilization, fluid balance, restoration of diuresis, optimal ventilation, and supporting graft function. It should be noted that graft recovery depends primarily on the intrinsic hepatocyte recovery capacity and secondly on optimizing liver hemodynamics and preventing venous stasis.
\nThe primary goal of hemodynamic monitoring is to prevent inadequate cardiac filling and the subsequent tissue hypoperfusion, and also to avoid overloading leading to congestion of the lungs and sinusoids and hence allograft dysfunction [8]. The intravascular volume, cardiac output (CO), and systematic vascular resistance (SVR) are important parameters vital in determining the success of a LT. The treatment becomes even more complicated when renal and/or heart failure, portopulmonary hypertension, or hepatopulmonary syndromes are also present [9].
\nSuccessful management of patients with end-stage liver disease (ESLD) requires a complete understanding of their hemodynamic profile that is often characterized by high cardiac output (CO) with decreased systemic vascular resistance, depleted intravascular volume, and compensatory tachycardia with concomitant renal vasoconstriction and dilutional hyponatremia, due to excessive production of vasodilators during the development of hepatic failure [10]. Following LT, vasodilation and hyperdynamic circulation remain until the graft begins to function and excretes excess vasodilatory agents that are almost completely restored after 6 months [11].
\nUpon the arrival of a liver transplant recipient in the ICU, advanced monitoring, which estimates CO and volume status, additionally to standard hemodynamic monitoring, that is electrocardiogram, pulse-oximetry, and invasive blood pressure, are deemed essential [12].
\nHemodynamic depression may be the result of hypovolemia, prolonged reperfusion syndrome, cardiac dysfunction, either caused by pre-existing or emerging ischemic cardiomyopathy, and metabolic disorders such as acidosis, hypocalcaemia, hypothermia, vasodilation due to sepsis, or graft dysfunction.
\nThe assessment of the intravascular volume is of vital importance given that volume status can be affected by contradictory factors such hypovolemia or hypervolemia, both detrimental for graft and patient survival. Restoring volume status, a continually dynamic parameter, and achieving optimal CO are crucial in order to maintain the delicate balance between preload optimization and avoidance of pulmonary edema [13].
\nHypovolemia, possibly due to continued bleeding, occult or overt, inadequate fluid replacement and/or loss in the third space, can lead to reduced preload and CO and hence hypoperfusion resulting in additional lesions in the newly transplanted liver [14]. The aim is to replace the intravascular fluid and maintain the circulating blood volume. There is still controversy over the type of fluids administered, with crystalloids gaining ground against the colloids (hydroxyl ethyl starches), which have been associated with renal injury and increased mortality in critically ill patients [15], a conclusion that is not supported by convincing evidence in LT. Nevertheless, the appropriate crystalloid should be carefully selected taking into account its special characteristics and based on its metabolism, electrolyte composition, pH and osmolarity, and considering patients’ status [16]. Albumin (Alb) administration as a replacement fluid has been a matter of debate. In some centers, a large amount of Alb is exogenously administered following the LT to support circulatory stability. Moreover, a concentration of 25 g/L is considered necessary for the immunosuppressive drugs to be effective [17]. Beneficial properties were attributed to Alb in recent studies; whereas, postoperative hypoalbuminemia has been linked to the development of acute kidney injury (AKI) [18]. It has been found that during LT there is translocation of Alb, probably to the interstitial space, which persists until the third postoperative day and whose role has not been clearly clarified [19]. Certain centers choose to replace two-thirds of the required fluids with crystalloids and one-third of drain losses with albumin [14]. Although, blood and blood products transfusion strategies vary between institutions, it is considered that postoperative hematocrit (Hct) values, ranging between 25 and 30%, are safe for adequately transporting O2 to the new graft [14]. The rational use of blood products depends on the monitoring of the coagulation mechanism. Whole-blood viscoelastic tests, such as thromboelastogram (TEG) and rotational thromboelastometry (ROTEM), that illustrate each step of thrombus formation and fibrinolysis are useful tools to guide transfusions and drug administration (anti-fibrinolytics, coagulation factors) [20, 21] by limiting the number of transfusions, as there has been an association between them and increased morbidity/mortality, prolonged stay in the hospital, postoperative sepsis, increased risk of acute rejection, and hepatic artery thrombosis [22, 23, 24].
\nHypervolemia occurs either from intraoperative over-resuscitation or coexistence of renal dysfunction. It can result in capillary leak syndrome with loss of fluids in the third space, further congestion and graft edema due to vascular permeability disorder, caused by ischemia/reperfusion injury (I/R) that is more pronounced in grafts with higher preservation injury, greater steatosis, or in older donors [7, 25]. Studies also indicate that massive administration of fluids and blood is a risk factor for complications of the respiratory system postoperatively and is correlated with increased mortality [26]. On the contrary, conservative resuscitation strategy and negative fluid balance during the first three postoperative days, if hemodynamic stability has been achieved, act protectively. Codes et al. [27] concluded that a continuous positive balance in the first 4 days after surgery correlates with the development of ΑΚΙ and the need for renal replacement therapy (RRT). Goal directed therapy (GDT) strategy, which has been successfully applied in major surgical interventions, is proposed. It aims at maintaining an adequate supply of O2 to the end organs by a bundle of measures including fluid titration in conjunction with blood transfusions as well as administration of vasopressors and/or inotropic agents [28]. The hemodynamic targets are predefined and specific variables are used to control fluid adequacy, improvement of CO, and tissue perfusion. GDT has beneficial effects compared to liberal fluid administration, reducing postoperative ileus, mechanical ventilation time, and respiratory system complications, as it has been indicated in relevant, although limited, studies [29]. Jiang et al. [30] suggests the individualization of fluid administration in the perioperative period as an optimal recovery strategy. They estimated that transfusions >100 ml/kg and fluid balance ≤−14 ml/kg during the first postoperative days result in prolonged mechanical ventilation, extubation time, and ICU stay. Prudent use of vasopressor agents is proposed since they increase arterial tone and improve perfusion pressure avoiding overload. Noradrenaline (0.01–1 μg/kg/min) with mixed α-β-adrenergic effects is most commonly administered to maintain CO and organ perfusion. Vasopressin (0.5–0.6 U/h) and terlipressin (1.5 μg/kg/h) have also been used in recent years because of their modifying effect on visceral circulation, where approximately 37% of the total blood volume is located in cirrhotic patients, and of their ability to reduce pressure in the portal vein [31, 32].
\nSince there has been no consensus on hemodynamic monitoring in LT yet, there is a number of invasive and noninvasive CO monitors available in order to evaluate hemodynamic fluctuations (Table 1) [13, 36].
\nMonitors | \nPrinciple | \nAdvantages | \nLimitations | \n
---|---|---|---|
PAC | \nThermodilution | \nAccurate continuous measures of CO Direct measures of PAP and RVEDVI Gold standard in POPH | \nInvasive CVP, PCWP static pressures measurement Unreliable indicators of volume status, SV and fluid responsiveness | \n
PiCCO | \nPulse contour analysis | \nLess invasive Continuous CO, SV measures ITBVI, EVLWI, PPV, SVV Reliable indicators of fluid responsiveness | \nNeed for recalibration in marked changes of SVR Inaccurate CO measures in Child-Pugh Band C stages in cirrhosis Requires sinus rhythm and certain ventilator setting | \n
LiDCO | \nPulse contour analysis | \nContinuous CO, SV measures comparable to PAC measures PPV, SVV Indicative of volume status | \nCalibration with lithium Inaccurate CO measures in Child-Pugh Band C stages in cirrhosis | \n
FlowTrac/Vigileo | \nPulse contour analysis | \nNo need for calibration Continuous CO, SV measures PPV, SVV, indicative of volume status | \nNot reliable in hyperdynamic circulation with very low SVR | \n
TEE | \nUltrasound, Doppler | \nLess invasive Direct visualization of cardiac function and volume status | \nAdvanced training is required Risk of rupture in 3rd or 4th grade of esophageal varices | \n
Hemodynamic monitoring in LT.
The pulmonary artery (PAC) catheter has traditionally been used for hemodynamic monitoring in LT. It provides the possibility of measuring the CO by the thermodilution method, which is considered the gold standard, but also the cardiac filling pressures, the CVP, and especially the PCWP for assessing the preload [33]. Numerous studies have shown that static preload measurements are indirect markers of the end diastolic volume and have a poor predictive value for fluid management, improvement of hepatic perfusion, and recovery guidance [34]. Although still under debate, current data favor the use of a modified pulmonary artery catheter, with an incorporated heating coil, that provide continuous measurement of CO (CCO) and right ventricular end diastolic volume (RVEDV) as the more reliable preload indicator. Patients with portopulmonary hypertension are highly benefited from PAC, as it is the method of choice for measuring and monitoring pulmonary artery pressures intraoperatively and directly postoperatively [13, 35].
\nIn recent years, interest has shifted to the dynamic parameters and expanding data yielded from existing monitoring of blood pressure to assess the CO, the preload and the afterload. There is technology available to accurately analyze pressure waveforms and sufficient knowledge to generate algorithms that are interpreted by the complex pulse wave morphology [36, 37].
\nThe PiCCO system (Pulsion Medical System, Munich, Germany) uses the method of transpulmonary thermodilution, single indicator technique, and arterial pulse contour analysis which by means of an algorithm can continuously calculate CO and preload markers: global end diastolic volume (GEDVI), extra vascular lung water index (EVLWI), and intrathoracic blood volume index (ITBVI) which is considered a reliable preload indicator in LT. In transplant patients, the CO measurements deriving from the PiCCO system are consistent with those of PAC [38, 39].
\nFurthermore, this system offers the capability of functional hemodynamic monitoring by detecting the changes in left ventricular pulse volume caused by changes in preload due to mechanical ventilation. Stroke volume variation (SVV) and pulse pressure variation (PPV) have been used successfully to assess the intravascular volume and fluid responsiveness in critically ill patients [12, 13, 40]. Certain LT studies have concluded that the SVV is a better indicator for RVEDVI than CVP, while a SVV greater than 9% is an indicator of low RVEDVI which means fluid responsiveness [41, 42]. However, there are always limitations deriving from the presence of arrhythmia and mechanical ventilation settings.
\nThe LiDCO system (LiDCO Plus, Cambridge, United Kingdom) is similar to the PiCCO system, but in its case the lithium indicator dilution technique is applied in order to calibrate the arterial waveform analysis algorithm [40].
\nThe Flowtrac/Vigileo system (Edwards Lifesciences, Irvine, CA United States) is a special energy converter that links the arterial line with a CO monitor and uses arterial waveform analysis with an algorithm for real-time CO measurement in conjunction with patient demographics without the need for calibration. However, a poor correlation has been found between findings of waveform analysis CO when compared to PAC thermodilution, mainly in patients with cirrhosis B and C according to Child-Pugh classification [43, 44]. Biais et al. came to the same conclusion, using the recent third generation, FloTrac system, pointing out that there was great discrepancy in cases of significantly low SVR [45, 46].
\nIn recent years, the use of transesophageal echocardiography (TEE) has been gaining ground not only because it is considered a noninvasive method, but also because it provides the ability to directly visualize the contractility of the left and right heart, preload status, and differential diagnosis of various pathological conditions such as pulmonary embolism, pleural, or pericardial effusion [47]. The CO can be estimated with measurements of flow across the cardiac valve, left ventricular outflow tract, or the flow in the main pulmonary artery. The ability to instantly display real-time preload is considered its biggest advantage. The functional application of TEE is limited by the risk of rupture of the third or fourth grade esophageal varices, but it is considered a reliable hemodynamic monitoring method when used by experienced intensivists [12, 13].
\nAssessment of graft function is necessary and is performed by combining clinical parameters, laboratory values, and imaging examinations. The first positive signs of adequate function of the new liver can be evident by the correction of metabolic acidosis, coagulation disturbances, hemodynamic stabilization, and temperature normalization in addition to diuresis restoration. Continuous monitoring in the postoperative period is required for the immediate recognition of early, subtle findings of graft dysfunction which necessitate aggressive treatment. Traditionally, the evaluation of liver function involves static and dynamic tests [48].
\nStatic tests include hematology, coagulation, and biochemistry blood tests, in order to evaluate the main liver functions. The hepatic enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT), which rather indicate hepatocyte necrosis, display a rise postoperatively reaching their peak during the first 2 days before they finally start decreasing. Their elevation is attributed to preservation injuries and/or prolonged cold ischemia time (CIT). A persisting elevated value raises concerns about liver function and requires further investigation. The canalicular enzymes γ-glutamyl transferase and alkaline phosphatase increase after day four and usually five-fold before their decline begins. The synthetic function of the liver is evaluated by the prothrombin time or international normalized ratio (INR), which estimate the production of coagulation factors by the liver. Bilirubin levels define the liver excretory function while its metabolic function is assessed by glucose and lactate levels. A resistant to the treatment hypoglycemia is an indicator of graft dysfunction. The levels of lactates should also be carefully considered, if increased, due to the fact that such result may derive from peripheral tissue hypoxia.
\nThe dynamic tests express the ability of the liver to metabolize or excrete certain substances. The lidocaine conversion to monoethylglycinexylidide metabolite (MEGX test) assesses the metabolic capacity and the liver blood flow [48, 49].
\nThe indocyanine green (ICG) clearance test is routinely used in several centers. The functional activity of the graft is assessed by ICG dye administration, which is almost exclusively eliminated from the liver into the bile without undergoing enterohepatic circulation. Its removal from the blood depends on the hepatic blood flow, parenchymal cell function, and biliary excretion. It is expressed as half-life time, blood clearance, or plasma disappearance rate (ICG-PDR) smaller than 15% associated with a higher rate of primary dysfunction [50]. The bedside ultrasound imaging methods with hepatic blood vessel Doppler examination are usually performed on the day of surgery or on the first postoperative one in order to evaluate the patency of the hepatic artery, the portal vein, and the hepatic vein. It is particularly useful in the presence of intraoperative technical difficulties or when there is graft dysfunction, with a view to identify vascular abnormalities that could be treated [51].
\nRecovery of the graft is a combination mainly of the severity of the recipient’s condition, donor quality, intraoperative events, perioperative hemodynamic stability, and preservation injuries, while adequate blood flow to the organs and prevention of venous stasis in the new liver have to be ensured (Table 2) [49]. On the other hand, the risk of poor outcome is increased in case of ESLD-associated syndromes and co-morbidities coexistence, especially in sicker patients, as estimated by the MELD score [4, 7].
\nDonor related | \nRecipient related | \nIntraoperative events | \nAllograft related | \n
---|---|---|---|
Donor age Macrovesicular steatosis >30% High dose of vasopressors Hypernatremia Prolonged ICU stay Prolonged CIT Donation after cardiac death | \nESLD-associated syndromes Pretransplant HD/renal dysfunction Cardiovascular disease BMI < 18.5 kg/m2 | \nMassive transfusion Reperfusion syndrome High vasopressors dose | \nI/R Injury Graft inflow (Right HF, Hepatic vein stenosis/thrombosis) Graft outflow (Hepatic artery and portal vein patency) Small-for-size syndrome | \n
Factors related to graft function.
Donor quality has a major impact on the graft function since the use of marginal donors is now commonplace [4]. The prolonged time of cold ischemia for more than 12 h increases ischemia reperfusion injuries. Macrosteatosis greater than 30% reduces tolerances in such injuries, while the risk of rejection and PNF is increased. Grafts from donors older than 60 years of age are considered to be of higher risk for PNF or exhibit delayed recovery mainly owing to cholestasis, whereas grafts from donors older than 75 show reduced liver regeneration capacity [52, 53, 54]. Nevertheless, the results in the literature are contradictory; and in 2016, the donors older than 65 years old reached a percentage of 20.7%. In a recent study, Gilbo et al. concluded that older grafts can be safely used in older recipients without endangering their survival, if the remaining risk factors have been minimized [55]. The best practice for graft allocation is the use of scores that include donor and recipient data, such as the survival outcomes following liver transplantation (SOFT) and/or the BAR-score, which offer excellent prognostic ability for survival after transplantation and could lead to the final decision on using or rejecting the graft [56].
\nThe intraoperative use of short-acting anesthetics and neuromuscular blocking agents allows a prompt recovery of consciousness and facilitates the rapid release from mechanical support and early extubation (EE), which can occur in the operating theater or within the first three postoperative hours and is associated with shorter ICU and hospital stay. In a recent meta-analysis comparing early versus conventional extubation, the authors report a reduction in re-intubation rate, morbidity, respiratory complications, incidence of graft dysfunction, and ICU/hospital stay [57, 58, 59]. In a study published by Taner et al., it was exhibited that early extubation failed only in 1.90% of patients when performed on selected cases. According to these researchers, patients with HCC and low MELD score are appropriate candidates for EE [60].
\nProlonged mechanical ventilation (MV) remains a critical risk factor for infections development, especially ventilator-associated pneumonia, tracheal trauma, prolongation of neuromuscular recovery, graft venous congestion due to positive intrathoracic pressures, and reduced venous return to the inferior vena cava and hepatic veins [61, 62]. It has also been correlated by Yuan et al. with the recipient’s age, female gender, preoperative need for renal replacement therapy (RRT), ascites, higher MELD score, prolonged cold ischemia, and the number of transfusions [62].
\nEmphasis is placed on the fact that optimal selection criteria and timing of EE have not been clearly defined yet. Patients with encephalopathy, marked hypoxemia, obesity (BMI > 30), severe hemodynamic instability, pulmonary edema, cardiac or renal dysfunction, and multiple transfusions are not indicated for EE. The personalized and selective approach is likely to be the best strategy with a focus on avoiding delayed extubation, preserving hemodynamic stabilization, and ensuring graft functionality [63].
\nThe criteria of weaning from MV applied to liver transplanted patients in ICU conform to those of the rest patient groups [64]. Distinct sequelae may often arise from ESLD-related disorders such as encephalopathy, massive transfusions, graft dysfunction, preoperative nutrition disorders, volume overload, and postoperative respiratory complications including pulmonary edema, pleural effusions, or pneumonia. During MV, lungs and liver allograft interaction should be taken into account with the aim of improving oxygenation without impairing the outflow of the liver graft. Implementation of daily withdrawal of sedation combined with spontaneous breathing trial facilitates weaning from MV [63].
\nAcute respiratory distress syndrome (ARDS), one of the prominent respiratory complications following LT, is usually attributed to reperfusion syndrome, substantial blood loss and transfusions, prolonged operation time, and early postoperative infections and sepsis. Lung-protective ventilator strategies with low tidal volumes (6 ml/kg IBW), higher respiratory rate, and positive end-expiratory pressure (PEEP) are recommended to limit lung injury from shear forces and atelectasis [64]. There is debate about optimum PEEP in LT since some consider that higher PEEP values impair venous return and visceral blood flow leading to hepatic edema. Evaluation of transpulmonary pressure has been proposed to optimize PEEP titration [65]. Saner et al. concluded that PEEP up to 15 cm H2O affects neither blood flow to the liver, nor flow and velocity in the hepatic artery, right hepatic vein, and portal vein [66]. In refractory ARDS and persistent hypoxia, prone positioning, high frequency ventilation, and extracorporeal membrane oxygenation support have been utilized as rescue therapy [67, 68, 69].
\nThere are certain syndromes related to ESLD characterized by severe hypoxemia which require special management in the ICU such as hepatopulmonary syndrome and portopulmonary hypertension.
\nHepatopulmonary syndrome is caused by intrapulmonary capillary dilatation that leads to hypoxemia and shortness of breath. LT is considered the treatment of choice; however, in most cases, severe hypoxemia might persist for a 6–12 months period. In the ICU, fluids should be managed carefully and lung-protective strategies should be employed during MV. In persistent hypoxemia, high frequency ventilation and/or venovenous extracorporeal membrane oxygenation is recommended. Some authors suggest early extubation and the immediate application of noninvasive ventilation with high-inspired fraction of oxygen [70, 71].
\nPortopulmonary hypertension resulting from pulmonary vasoconstriction due to portal hypertension requires prevention of hypoxemia, maintaining oxygen saturation >90% and correcting factors involved such as acidemia, arrhythmia, and anemia. Administration of diuretics and/or renal replacement therapy is advised if volume overload cannot be avoided. MV can both compromise venous return from the allograft and increase pulmonary vascular resistance through alveolar overdistension; therefore, lung-protective ventilation is considered to be the most appropriate strategy. The use of pulmonary vasodilators, that can be both administered IV such as epoprostenol and orally, via nasogastric tube, such as phosphodiesterase V inhibitor or nonselective endothelin receptor antagonist, is recommended during ICU stay [71].
\nAdvances in immunosuppression have greatly impacted the survival of patients following LT. The initial endpoint was to prevent rejection; but in recent years, the interest has also been shifted to avoiding long-term complications from immunosuppressant agents and relapsing of the disease. In spite of the latest developments in this field, most centers commence immunosuppression with calcineurin inhibitors (CNIs) and corticosteroids with or without an anti-proliferative agent depending on protocols [72, 73].
\nMycophenolate mofetil has been widely used as an adjuvant and alternative immunosuppressive agent. It is a potential inhibitor of B- and T-cell proliferation. It is mainly utilized when a dose reduction or discontinuation of CNI is demanded due to certain adverse effects such as nephrotoxicity and neurotoxicity [72].
\nMammalian target of rapamycin (mTor) inhibitors, sirolimus, and everolimus, prevent B- and T-cell proliferation prompting the cell to arrest at G1 to S phase of the cell cycle. Although accounted for wound healing delay incidents, they can be administered as primary and rescue immunosuppression therapy with the advantages of being renal sparing as well as reducing the need for high doses of steroids. The newer IL-2 receptor-blocking antibody preparations daclizumab (Zenapax) and basiliximab (Simulect) are often used to initiate immunosuppression and avoid CNIs, and can also play a part in steroid-resistant rejection [72].
\nPrevention of infections is a major problem as they are the leading cause of death following LT [74]. The most common ones in the immediate postoperative period are of bacterial or fungal origin and include bloodstream, catheter related, surgical site, pulmonary, urinary tract,
Herpes family viral infections, due to immunosuppression mainly by administration of T-cell-specific agents, are adequately treated with acyclovir. Ganciclovir or valganciclovir is sufficient for CMV seronegative recipients with CMV-seropositive grafts, or after rejection treatment. In case of suspected infection during hospitalization, broad spectrum antimicrobial therapy is administered and reviewed according to cultures results [75].
\nPost-LT nutritional support in ICU is an essential adjunct to transplant recovery. Malnutrition, which characterizes many patients with ESLD being evident at rates of up to 80%, deteriorates with the progression of liver failure, and affects the patients’ outcome [80]. On the other hand, it is associated with prolonged ICU and hospital stay, infections, respiratory complications, graft impairment, and mortality. Sarcopenia, defined as severe muscle wasting, is also a determining factor of the outcome, and it can be easily diagnosed with bioelectrical impedance. Patients with cirrhosis often present carbohydrate, fat, and protein disorders, characterized by elevated levels of aromatic amino acids and methionine while lowering plasma levels of branched-chain amino acids are detected [81, 82]. The immediate postoperative energy demands are increased, especially in patients with a high MELD score [82]. Factors such as operational stress, release of catabolic hormones, administration of immunosuppressants, mainly corticosteroids, as well as ICU factors including mechanical ventilation and hemodialysis, contribute to increased metabolic needs. For the above reasons, the aim is to ensure adequate intake of protein and calories in addition to protein breakdown protection [81]. An increase in nonprotein calories, estimated at 25–35% kcal/kg per day, is recommended when indirect calorimetry is not available. It should always be in accordance with the metabolic and inflammatory status, and it should be reviewed in hemodynamically unstable patients [83]. Due to elevated protein catabolism, it is necessary to obtain 1.5–2 g/kg of protein. Enteral nutrition (EN) has the edge over the parenteral one, assisting in maintaining intestinal integrity, by supporting the diversity of the microbiome, and helping the immune and metabolic response. The rapid onset of EN even 12 h after LT is recommended by some authors. It has been reported to reduce viral infections and contribute to a better N2 balance. If postoperative encephalopathy remains, the amount of protein intake is not reduced but the type of nutrition is altered by the addition of branched-chain amino acid (BCCA) enriched formulae, while the administration of immunonutrition remains under discussion. Frequent screening of electrolytes is required to prevent and correct disorders, while re-feeding syndrome is also considered a risk factor for these disorders [83].
\nRenal impairment is a very common complication after LT. Its presence ranges from 19 to 64%. Even with the application of the RIFLE and AKIN criteria, the percentage reaches from 39 to 54% [84, 85]. In cases of living donors, acute kidney injury (AKI) has been estimated at around 23% [86]. AKI occurrence is complex and multifactorial in origin, depending on the existence of the preoperative hepatorenal syndrome as well as various intraoperative and postoperative factors. High MELD score, perioperative transfusions, hemodynamic instability, vasoactive agents, graft dysfunction, infections, and nephrotoxic agents are mainly accountable for renal function deterioration [87]. Systematic evaluation of renal function is required with close monitoring of urine output, fluid balance, and hemodynamic parameters [18]. The treatment is mainly supportive and includes: restoring CO with sufficient preload for optimization of renal perfusion, administering loop diuretics, and efforts to avoid nephrotoxic agents. Renal replacement therapy is recommended in cases of volume overload, electrolyte disturbances, and acidemia in an attempt to avoid pulmonary edema and hepatic congestion. Immunosuppressants, antibiotics, and contrast agents are commonplace nephrotoxic agents. The dosage of CNIs should be minimized or they should be converted into mTOR inhibitors combined with anti-proliferative agents. In ICU, CVVDHF is the renal replacement therapy of choice and favors the outcome of patients [88].
\nPrimary graft dysfunction (PGD) is a major complication after LT and is associated with prolonged hospital and ICU stay jeopardizing graft viability, being responsible for its high rejection rates as well as higher mortality and morbidity. It describes different degrees of graft impairment which begins intraoperatively, divided into early or initial poor function (IPF) and primary nonfunction (PNF) [89, 90, 91]. IPF represents the clinical phenotype of severe ischemia-reperfusion injury due to various donor and/or recipient-related factors. Expanding the criteria to marginal donors has increased the use of allografts with a higher likelihood of initial malfunction. It affects the survival of both graft and patient, whether the transplant comes from living or deceased donors. Dysfunction may be transient and possibly reversible with appropriate supportive treatment. There are no clear definitions, nevertheless, there are suggested scores, such as MEAF and LGrAFT, that could help in early detection and classification of early hepatic impairment [92, 93]. On the contrary, PNF is a catastrophic injury characterized by hepatic necrosis, aminotransferase elevation, coagulation disorders, lactate elevation, hemodynamic instability, persistent hypoglycemia, and respiratory and renal failure with an incidence ranging from 0.9 to 7%. The treatment is immediate re-transplantation. There are certain risk factors related to donors, recipients, intraoperative events, and allograft preservation [91] (Table 2).
\nAcute cellular rejection (ACR), usually mediated by T-cells, has decreased in recent years with the use of improved potent immunosuppressants, but still ranges from 15 to 25% and usually occurs 7–14 days after surgery [94]. Hyperacute liver rejection is controversial, but undoubtedly early accelerated rejection occurs in the first 7 days and is associated with preformed antibodies. Risk factors include adequacy, type, and level of immunosuppression, underlying immune disease, biliary complications, certain transplant-related features such as donor-negative recipient-positive CMV mismatch, sex mismatch with a female donor. ACR is not significantly associated with long-term graft failure unless it concerns HCV-positive patients in which case it may result in corticosteroid-resistant rejection and graft loss. Early ACR is associated with better graft outcomes [95]. It is even hypothesized that such activation of the immune system may be beneficial and may induce a degree of tolerance. Manifestations of ACR include elevated levels of aminotransferase, alkaline phosphatase, bilirubin, and fever in later stages. Hepatic artery or portal vein thrombosis, biliary leak, CMV infection, and delayed graft function should be excluded. Diagnosis is finally confirmed by percutaneous liver biopsy prior to initiation of treatment, which depends on patient severity and current immunosuppression [94]. Cyclosporine is converted to tacrolimus or the sub-therapeutic levels of tacrolimus are increased and/or mycophenolate mofetil is added. In moderate to severe ACR, high doses of corticosteroids, usually methylprednizolone, are administered as a first-line medicine in a dose ranging from 500 to 1000 mg for 1–3 days depending on the center protocol [94].
\nCirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with cirrhosis characterized by a blunted contractile responsiveness to stress and/or diastolic dysfunction and electrophysiological abnormalities in the absence of known cardiac disease [96]. Diagnostic features include a reduced ejection fraction (EF), an E/A ratio < 1, and electrocardiographic abnormalities such as a prolonged QTc interval. Diagnostic approaches involve transthoracic ultrasound, dobutamine stress echocardiography (DSE), as well as cardiac magnetic resonance (CMR). The concept of “ventriculo-arterial coupling” (VAC) has recently been suggested as a means of assessing cardiac function in ESLD. The VAC (ratio of ventricular elastance to arterial elastance) is measured conventionally by ultrasound and has been correlated with prognosis. Moreover, cardiac biomarkers such as troponin and brain natriuretic peptide (BNP) are deemed early markers [97].
\nIt is difficult to define the exact impact of CCM due to the fact that its clinical course is usually silent, especially in early stages, due to the profound vasodilatation in cirrhosis and offloading of the left ventricle. It only becomes apparent in conditions of stress and increased afterload. LT is a cause of significant cardiovascular stress since there are marked variations in preload and afterload, cardiac workload increases and the existing underlying cardiac dysfunction may become overt heart failure during LT or several days postoperatively. Complete recovery has been recorded at 6 months [98].
\nCardiac dysfunction and pulmonary edema are encountered in almost half of the patients within a week after LT. They have been identified as the third most important cause of mortality during the first year following the surgery. High MELD score and AKI have been considered as risk factors. Early diagnosis can prevent acute onset or deterioration of heart failure. An empirical and supportive therapeutic approach is applied which includes optimization of volume status and cardiac monitoring via echo and/or PAC [99, 100].
\nPrevalence of coronary artery disease (CAD) in cirrhosis reaches 5–26% and has been associated with poor prognosis. It has been correlated with a number of cardiac adverse events: myocardial infraction, arrhythmias, and cardiac death. LT can be postponed in cases with known CAD for medical optimization and/or revascularization [99, 100].
\nNeurological complications (NC) are still common after LT with a 15–30% incidence rate. In recipients from living donors, this percentage does not exceed 20% [101, 102]. Major neurologic complications immediately postoperatively include alterations of consciousness, seizures, hepatic encephalopathy, CNI neurotoxicity, cerebrovascular complications, central nervous system infections, and central pontine myelinolysis (CPM) [103]. They can delay recovery and make immunosuppression and patient management difficult. Rapid patient recovery requires daily evaluation of mental status and neurological assessment in the ICU.
\nImmunosuppression-related neurotoxicity can range from headaches and convulsions to posterior reversible encephalopathy (PRES). Immunosuppressants have the potential to reduce the seizure threshold that is enhanced by electrolytic disorders mainly hypomagnesaemia and hypophosphatemia. CNIs are mainly implicated while incidents of PRES have been reported even in treatment with sirolimus. The treatment is conservative involving reduction of dosage and/or interchange with CNI-sparing regimens. Neurotoxicity of corticosteroids can be manifested either in the form of convulsions or myopathy and behavioral disorders [103].
\nPost-transplant encephalopathy is responsible for 12% of NC. It relates closely to metabolic disorders, CNS infections and/or septic encephalopathy, cerebrovascular events, history of severe encephalopathy, and graft dysfunction [78]. Seizures are one of the most common postoperative neurological consequences and may be the effect of various factors, mainly drug toxicity and metabolic disorders. Correction of underlying causes and administration of anti-convulsive medicines are the appropriate treatment.
\nCentral pontine myelinolysis (CPM) represents a serious complication, with a low incidence of approximately 1–3.5% that may affect the postoperative course of patients. It has been associated with large fluid shift and rapid correction of prolonged hyponatremia. The indicated treatment is supportive and requires careful correction of severe hyponatremia (serum Na <125 mEq/L), which is encountered in approximately 17% of patients with ESLD, using sodium chloride and adjusting Na serum values to 8–10 mEq/L per day [104, 105].
\nIschemia-reperfusion injury is related with the degree of transaminitis and primary and/or delayed graft dysfunction. Mitochondria are more prone to I/R injuries with subsequent alterations that can lead to dysfunction or even to necrosis of hepatocytes following LT. Alternatively, machine reperfusion has been proposed to preserve the donor organ. It promises to restore energy balance, extend preservation time while offering the ability to “test” the organ performance [106, 107].
\nIn the early postoperative period, according to Parikh et al., 79.3% of patients are present with at least one complication with 62.8% of the recipients suffering severe complications. The incidence of those related to surgical techniques range from 5 to 10% and can be categorized into abdominal bleedings, vascular complications, and biliary complications. Treatment can be determined by the severity of each case and its spectrum includes simple surgical interventions, or even re-transplantation. The main complications are illustrated in Tables 3 and 4 along with diagnostic and therapeutic approaches [108, 109].
\nComplications | \nDiagnosis-treatment | \nTherapeutic approach | \n
---|---|---|
Abdominal bleeding | \nAnastomosis site Graft surface Diffusion bleeding | \nRe-operation | \n
Biliary Complications | \nBiloma, Hemobilia Bile leaks Anastomosis necrosis Anastomotic stricture | \nERCP, PTC, MRCP EUS-guided approach HIDA Digital Cholagiography or Surgical re-intervention | \n
Immediate surgical complications after LT.
Vascular complications | \nDiagnosis | \nTreatment | \n
---|---|---|
Hepatic artery thrombosis (HAT) 2.9% | \nDUS, CT Angiography | \nEmergent revascularization (endovascular or surgical) or re-LT | \n
Hepatic artery stenosis (HAS) 1–2% | \nDUS, CT Angiography | \nEndovascular intervention or surgical HA revision | \n
Hepatic artery rupture (HAR) 0.64% | \nAngiography None in emergency | \nEmergent surgical hemostasis and surgical repair | \n
Portal vein thrombosis (PVT) 5% | \nDUS, CT (portal phase) Venography | \nSurgical revision Endovascular intervention or re-LT | \n
Portal vein stenosis (PVS) 2% | \nDUS, CT (portal phase) Venography | \nEndovascular intervention | \n
Vascular complications after LT.
LT has been established as the gold standard treatment for patients with ESLD and following successful postoperative course, organs previously affected return to normal functionality in due time. Postoperative ICU stay is often imperative, especially in cases of adverse events during operation, delayed cardiovascular resuscitation, utilization of marginal donors, and distant organ dysfunction. Early recognition, evaluation, and treatment of hemodynamic instability, distant organ complications, impaired graft functionality, and use of optimal immunosuppressive agents are of paramount importance.
\nPrompt recognition and treatment of life-threatening sequelae following LT in addition with optimal management of immunosuppression are keys to successful postoperative care and have led to improved overall survival although recipients are in relatively worse condition and the use of marginal donors is more widespread.
\nFurthermore, overall survival of LT patients has improved dramatically in recent years due to the formation of LT specific centers and medical teams, which follow each patient from admission to the donor list up to the operation itself as well as during their postoperative course. Therefore, according to the authors, the creation of LT specific ICUs that provide a postoperative continuation of excellency in managing the intricacies of those patients is paramount. Those units will not only provide prompt treatment in cases of a complication but will also act as additional reinforcement against postoperative infections.
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In the system in constant torque region, is a technique for adapting the speed controller to the presence of the reactive motor torque component, which improves the quality of the transient processes, is proposed. It is also recommended to approximate the dependence of the flux-forming current component on the motor torque by the “dead zone” nonlinearity, which will simplify the optimal control algorithm and avoid solving the fourth-degree algebraic equation in real time. For the speed control with field weakening technique, a novel system is recommended. In this system, the control algorithms are switched by the variable of the direct stator current component constraint generated in accordance with the MTA law: the upper limit is calculated in accordance with the “field weakening control” (FWC) strategy, and the lower limit in accordance with the MTV strategy. The steady-state stator voltage constraint is implemented through the variable quadrature stator current component limitation. The effectiveness of the proposed solutions is confirmed by the simulation results.",book:{id:"7485",slug:"applied-modern-control",title:"Applied Modern Control",fullTitle:"Applied Modern Control"},signatures:"Olga Tolochko",authors:[{id:"249845",title:"Dr.",name:"Tolochko",middleName:null,surname:"Olga",slug:"tolochko-olga",fullName:"Tolochko Olga"}]},{id:"62036",doi:"10.5772/intechopen.78786",title:"Development of a Genetic Fuzzy Controller and Its Application to a Noisy Inverted Double Pendulum",slug:"development-of-a-genetic-fuzzy-controller-and-its-application-to-a-noisy-inverted-double-pendulum",totalDownloads:769,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"Fuzzy logic is used in a variety of applications due to its universal approximator attribute and non-linear characteristics. The tuning of the parameters of a fuzzy logic system, viz. the membership functions and the rulebase, requires a lot of trial and error. This process could be simplified by using a heuristic search algorithm like genetic algorithm (GA). In this chapter, we discuss the design of such a genetic fuzzy controller that can control an inverted double pendulum. GA improves the fuzzy logic controller (FLC) with each generation during the training process to obtain an FLC that can bring the pendulum to its inverted position. After training, the effectiveness of the FLC is tested for different scenarios by varying the initial conditions. We also show the effectiveness of the FLC even when subjected to noise and how the performance improves when the controller is tuned with noise.",book:{id:"6806",slug:"fuzzy-logic-based-in-optimization-methods-and-control-systems-and-its-applications",title:"Fuzzy Logic Based in Optimization Methods and Control Systems and Its Applications",fullTitle:"Fuzzy Logic Based in Optimization Methods and Control Systems and Its Applications"},signatures:"Anoop Sathyan and Kelly Cohen",authors:[{id:"200834",title:"Dr.",name:"Kelly",middleName:null,surname:"Cohen",slug:"kelly-cohen",fullName:"Kelly Cohen"},{id:"243285",title:"Dr.",name:"Anoop",middleName:null,surname:"Sathyan",slug:"anoop-sathyan",fullName:"Anoop Sathyan"}]}],mostDownloadedChaptersLast30Days:[{id:"75699",title:"Data Clustering for Fuzzyfier Value Derivation",slug:"data-clustering-for-fuzzyfier-value-derivation",totalDownloads:276,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The fuzzifier value m is improving significant factor for achieving the accuracy of data. Therefore, in this chapter, various clustering method is introduced with the definition of important values for clustering. To adaptively calculate the appropriate purge value of the gap type −2 fuzzy c-means, two fuzzy values m1 and m2 are provided by extracting information from individual data points using a histogram scheme. Most of the clustering in this chapter automatically obtains determination of m1 and m2 values that depended on existent repeated experiments. Also, in order to increase efficiency on deriving valid fuzzifier value, we introduce the Interval type-2 possibilistic fuzzy C-means (IT2PFCM), as one of advanced fuzzy clustering method to classify a fixed pattern. In Efficient IT2PFCM method, proper fuzzifier values for each data is obtained from an algorithm including histogram analysis and Gaussian Curve Fitting method. Using the extracted information form fuzzifier values, two modified fuzzifier value m1 and m2 are determined. These updated fuzzifier values are used to calculated the new membership values. Determining these updated values improve not only the clustering accuracy rate of the measured sensor data, but also can be used without additional procedure such as data labeling. It is also efficient at monitoring numerous sensors, managing and verifying sensor data obtained in real time such as smart cities.",book:{id:"9976",slug:"fuzzy-systems-theory-and-applications",title:"Fuzzy Systems",fullTitle:"Fuzzy Systems - Theory and Applications"},signatures:"JaeHyuk Cho",authors:[{id:"329648",title:"Prof.",name:"JaeHyuk",middleName:null,surname:"Cho",slug:"jaehyuk-cho",fullName:"JaeHyuk Cho"}]},{id:"62600",title:"Introductory Chapter: Which Membership Function is Appropriate in Fuzzy System?",slug:"introductory-chapter-which-membership-function-is-appropriate-in-fuzzy-system-",totalDownloads:1893,totalCrossrefCites:31,totalDimensionsCites:52,abstract:null,book:{id:"6806",slug:"fuzzy-logic-based-in-optimization-methods-and-control-systems-and-its-applications",title:"Fuzzy Logic Based in Optimization Methods and Control Systems and Its Applications",fullTitle:"Fuzzy Logic Based in Optimization Methods and Control Systems and Its Applications"},signatures:"Ali Sadollah",authors:[{id:"147215",title:"Dr.",name:"Ali",middleName:null,surname:"Sadollah",slug:"ali-sadollah",fullName:"Ali Sadollah"}]},{id:"63216",title:"The Design and Development of Control System for High Vacuum Deoxygenated and Water-Removal Glove Box with Cycling Cleaning and Regeneration",slug:"the-design-and-development-of-control-system-for-high-vacuum-deoxygenated-and-water-removal-glove-bo",totalDownloads:1034,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"This study proposed a high vacuum deoxygenated and water removal glove box control system. Through parameter setting, the system can automatically perform various glove box cleaning operations and quickly reach the micro-oxygen and micro-water concentration requirements. In addition, two sets of reaction tanks are built in the system, and the hardware pipeline switching design and monitoring software control are used to provide two sets of reaction tanks to execute the cycling cleaning and cycling regeneration operation procedures synchronously, which can effectively solve the problem of interruption of the experimental process, improve the efficiency of its cleaning operations, and greatly reduce the manpower and material costs of the glove box operation. In addition, the system can automatically record the relevant data during various operations for the analysis of glove box monitoring effectiveness.",book:{id:"7485",slug:"applied-modern-control",title:"Applied Modern Control",fullTitle:"Applied Modern Control"},signatures:"Ming-Sen Hu",authors:[{id:"248986",title:"Associate Prof.",name:"Ming-Sen",middleName:null,surname:"Hu",slug:"ming-sen-hu",fullName:"Ming-Sen Hu"}]},{id:"63072",title:"Fuzzy Controller-Based MPPT of PV Power System",slug:"fuzzy-controller-based-mppt-of-pv-power-system",totalDownloads:1894,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"The power demand has been increasing day by day due to population growth, new industrial development, etc. Meeting power demand is one of the challenge factors for fossil fuel-based power generation alone as well as the environmental issue of carbon footprint. Consequently, there is a need to concentrate on alternate energy sources to meet the power demand. In this chapter, the photovoltaic (PV) cell operation under various weather conditions is analysed, and based on the performance, the MPPT controller is developed by using fuzzy logic controller. The proposed system has been modelled in MATLAB environment, and the system performance has been analysed. Finally, the simulation results are evaluated and compared with IEEE 1547 standard for proving the effectiveness of the proposed system.",book:{id:"6806",slug:"fuzzy-logic-based-in-optimization-methods-and-control-systems-and-its-applications",title:"Fuzzy Logic Based in Optimization Methods and Control Systems and Its Applications",fullTitle:"Fuzzy Logic Based in Optimization Methods and Control Systems and Its Applications"},signatures:"M. Venkateshkumar",authors:[{id:"243101",title:"Dr.",name:"M",middleName:null,surname:"Mven",slug:"m-mven",fullName:"M Mven"}]},{id:"62654",title:"Fuzzy Information Measures with Multiple Parameters",slug:"fuzzy-information-measures-with-multiple-parameters",totalDownloads:937,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Information theory deals with the study of problems concerning any system. This includes information processing, information storage, information retrieval and decision making. Information theory studies all theoretical problems connected with the transmission of information over communication channels. This includes the study of uncertainty (information) measures and various practical and economical methods of coding information for transmission. In this chapter, the introduction of a new generalised measure of fuzzy information involving two real parameters is given. The proposed measure satisfies all the necessary properties of being a measure. Some additional properties of the proposed measure have also been studied. Further, the monotonic nature of generalised fuzzy information measure with respect to the parameters is studied and validity of the same is checked by constructing the computed tables and plots on taking different fuzzy sets and different values of the parameters. Also, a new generalised fuzzy information measure involving three parameters has been introduced.",book:{id:"6806",slug:"fuzzy-logic-based-in-optimization-methods-and-control-systems-and-its-applications",title:"Fuzzy Logic Based in Optimization Methods and Control Systems and Its Applications",fullTitle:"Fuzzy Logic Based in Optimization Methods and Control Systems and Its Applications"},signatures:"Anjali Munde",authors:[{id:"254393",title:"Dr.",name:"Anjali",middleName:null,surname:"Munde",slug:"anjali-munde",fullName:"Anjali Munde"}]}],onlineFirstChaptersFilter:{topicId:"721",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[],lsSeriesList:[],hsSeriesList:[],sshSeriesList:[],testimonialsList:[]},series:{item:{id:"7",title:"Biomedical Engineering",doi:"10.5772/intechopen.71985",issn:"2631-5343",scope:"Biomedical Engineering is one of the fastest-growing interdisciplinary branches of science and industry. The combination of electronics and computer science with biology and medicine has improved patient diagnosis, reduced rehabilitation time, and helped to facilitate a better quality of life. Nowadays, all medical imaging devices, medical instruments, or new laboratory techniques result from the cooperation of specialists in various fields. The series of Biomedical Engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine, and biology. 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He is the author or co-author of more than seventy papers in peer-reviewed journals and conferences as well as the co-author of several books. He serves as a reviewer for many scientific journals, international conferences, and research foundations. Since 2010, Dr. Placzek has been a reviewer of grants and projects (including EU projects) in the field of information technologies.",institutionString:"University of Silesia",institution:{name:"University of Silesia",country:{name:"Poland"}}},{id:"35000",title:"Prof.",name:"Ulrich H.P",middleName:"H.P.",surname:"Fischer",slug:"ulrich-h.p-fischer",fullName:"Ulrich H.P Fischer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/35000/images/3052_n.jpg",biography:"Academic and Professional Background\nUlrich H. P. has Diploma and PhD degrees in Physics from the Free University Berlin, Germany. He has been working on research positions in the Heinrich-Hertz-Institute in Germany. Several international research projects has been performed with European partners from France, Netherlands, Norway and the UK. He is currently Professor of Communications Systems at the Harz University of Applied Sciences, Germany.\n\nPublications and Publishing\nHe has edited one book, a special interest book about ‘Optoelectronic Packaging’ (VDE, Berlin, Germany), and has published over 100 papers and is owner of several international patents for WDM over POF key elements.\n\nKey Research and Consulting Interests\nUlrich’s research activity has always been related to Spectroscopy and Optical Communications Technology. Specific current interests include the validation of complex instruments, and the application of VR technology to the development and testing of measurement systems. He has been reviewer for several publications of the Optical Society of America\\'s including Photonics Technology Letters and Applied Optics.\n\nPersonal Interests\nThese include motor cycling in a very relaxed manner and performing martial arts.",institutionString:null,institution:{name:"Charité",country:{name:"Germany"}}},{id:"341622",title:"Ph.D.",name:"Eduardo",middleName:null,surname:"Rojas Alvarez",slug:"eduardo-rojas-alvarez",fullName:"Eduardo Rojas Alvarez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/341622/images/15892_n.jpg",biography:null,institutionString:null,institution:{name:"University of Cuenca",country:{name:"Ecuador"}}},{id:"215610",title:"Prof.",name:"Muhammad",middleName:null,surname:"Sarfraz",slug:"muhammad-sarfraz",fullName:"Muhammad Sarfraz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/215610/images/system/215610.jpeg",biography:"Muhammad Sarfraz is a professor in the Department of Information Science, Kuwait University, Kuwait. His research interests include optimization, computer graphics, computer vision, image processing, machine learning, pattern recognition, soft computing, data science, and intelligent systems. Prof. Sarfraz has been a keynote/invited speaker at various platforms around the globe. He has advised/supervised more than 110 students for their MSc and Ph.D. theses. He has published more than 400 publications as books, journal articles, and conference papers. He has authored and/or edited around seventy books. Prof. Sarfraz is a member of various professional societies. He is a chair and member of international advisory committees and organizing committees of numerous international conferences. He is also an editor and editor in chief for various international journals.",institutionString:"Kuwait University",institution:{name:"Kuwait University",country:{name:"Kuwait"}}},{id:"32650",title:"Prof.",name:"Lukas",middleName:"Willem",surname:"Snyman",slug:"lukas-snyman",fullName:"Lukas Snyman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/32650/images/4136_n.jpg",biography:"Lukas Willem Snyman received his basic education at primary and high schools in South Africa, Eastern Cape. He enrolled at today's Nelson Metropolitan University and graduated from this university with a BSc in Physics and Mathematics, B.Sc Honors in Physics, MSc in Semiconductor Physics, and a Ph.D. in Semiconductor Physics in 1987. After his studies, he chose an academic career and devoted his energy to the teaching of physics to first, second, and third-year students. After positions as a lecturer at the University of Port Elizabeth, he accepted a position as Associate Professor at the University of Pretoria, South Africa.\r\n\r\nIn 1992, he motivates the concept of 'television and computer-based education” as means to reach large student numbers with only the best of teaching expertise and publishes an article on the concept in the SA Journal of Higher Education of 1993 (and later in 2003). The University of Pretoria subsequently approved a series of test projects on the concept with outreach to Mamelodi and Eerste Rust in 1993. In 1994, the University established a 'Unit for Telematic Education ' as a support section for multiple faculties at the University of Pretoria. In subsequent years, the concept of 'telematic education” subsequently becomes well established in academic circles in South Africa, grew in popularity, and is adopted by many universities and colleges throughout South Africa as a medium of enhancing education and training, as a method to reaching out to far out communities, and as a means to enhance study from the home environment.\r\n\r\nProfessor Snyman in subsequent years pursued research in semiconductor physics, semiconductor devices, microelectronics, and optoelectronics.\r\n\r\nIn 2000 he joined the TUT as a full professor. Here served for a period as head of the Department of Electronic Engineering. Here he makes contributions to solar energy development, microwave and optoelectronic device development, silicon photonics, as well as contributions to new mobile telecommunication systems and network planning in SA.\r\n\r\nCurrently, he teaches electronics and telecommunications at the TUT to audiences ranging from first-year students to Ph.D. level.\r\n\r\nFor his research in the field of 'Silicon Photonics” since 1990, he has published (as author and co-author) about thirty internationally reviewed articles in scientific journals, contributed to more than forty international conferences, about 25 South African provisional patents (as inventor and co-inventor), 8 PCT international patent applications until now. Of these, two USA patents applications, two European Patents, two Korean patents, and ten SA patents have been granted. A further 4 USA patents, 5 European patents, 3 Korean patents, 3 Chinese patents, and 3 Japanese patents are currently under consideration.\r\n\r\nRecently he has also published an extensive scholarly chapter in an internet open access book on 'Integrating Microphotonic Systems and MOEMS into standard Silicon CMOS Integrated circuitry”.\r\n\r\nFurthermore, Professor Snyman recently steered a new initiative at the TUT by introducing a 'Laboratory for Innovative Electronic Systems ' at the Department of Electrical Engineering. The model of this laboratory or center is to primarily combine outputs as achieved by high-level research with lower-level system development and entrepreneurship in a technical university environment. Students are allocated to projects at different levels with PhDs and Master students allocated to the generation of new knowledge and new technologies, while students at the diploma and Baccalaureus level are allocated to electronic systems development with a direct and a near application for application in industry or the commercial and public sectors in South Africa.\r\n\r\nProfessor Snyman received the WIRSAM Award of 1983 and the WIRSAM Award in 1985 in South Africa for best research papers by a young scientist at two international conferences on electron microscopy in South Africa. He subsequently received the SA Microelectronics Award for the best dissertation emanating from studies executed at a South African university in the field of Physics and Microelectronics in South Africa in 1987. In October of 2011, Professor Snyman received the prestigious Institutional Award for 'Innovator of the Year” for 2010 at the Tshwane University of Technology, South Africa. This award was based on the number of patents recognized and granted by local and international institutions as well as for his contributions concerning innovation at the TUT.",institutionString:null,institution:{name:"University of South Africa",country:{name:"South Africa"}}},{id:"317279",title:"Mr.",name:"Ali",middleName:"Usama",surname:"Syed",slug:"ali-syed",fullName:"Ali Syed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/317279/images/16024_n.png",biography:"A creative, talented, and innovative young professional who is dedicated, well organized, and capable research fellow with two years of experience in graduate-level research, published in engineering journals and book, with related expertise in Bio-robotics, equally passionate about the aesthetics of the mechanical and electronic system, obtained expertise in the use of MS Office, MATLAB, SolidWorks, LabVIEW, Proteus, Fusion 360, having a grasp on python, C++ and assembly language, possess proven ability in acquiring research grants, previous appointments with social and educational societies with experience in administration, current affiliations with IEEE and Web of Science, a confident presenter at conferences and teacher in classrooms, able to explain complex information to audiences of all levels.",institutionString:null,institution:{name:"Air University",country:{name:"Pakistan"}}},{id:"75526",title:"Ph.D.",name:"Zihni Onur",middleName:null,surname:"Uygun",slug:"zihni-onur-uygun",fullName:"Zihni Onur Uygun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/75526/images/12_n.jpg",biography:"My undergraduate education and my Master of Science educations at Ege University and at Çanakkale Onsekiz Mart University have given me a firm foundation in Biochemistry, Analytical Chemistry, Biosensors, Bioelectronics, Physical Chemistry and Medicine. After obtaining my degree as a MSc in analytical chemistry, I started working as a research assistant in Ege University Medical Faculty in 2014. In parallel, I enrolled to the MSc program at the Department of Medical Biochemistry at Ege University to gain deeper knowledge on medical and biochemical sciences as well as clinical chemistry in 2014. In my PhD I deeply researched on biosensors and bioelectronics and finished in 2020. Now I have eleven SCI-Expanded Index published papers, 6 international book chapters, referee assignments for different SCIE journals, one international patent pending, several international awards, projects and bursaries. In parallel to my research assistant position at Ege University Medical Faculty, Department of Medical Biochemistry, in April 2016, I also founded a Start-Up Company (Denosens Biotechnology LTD) by the support of The Scientific and Technological Research Council of Turkey. Currently, I am also working as a CEO in Denosens Biotechnology. The main purposes of the company, which carries out R&D as a research center, are to develop new generation biosensors and sensors for both point-of-care diagnostics; such as glucose, lactate, cholesterol and cancer biomarker detections. My specific experimental and instrumental skills are Biochemistry, Biosensor, Analytical Chemistry, Electrochemistry, Mobile phone based point-of-care diagnostic device, POCTs and Patient interface designs, HPLC, Tandem Mass Spectrometry, Spectrophotometry, ELISA.",institutionString:null,institution:{name:"Ege University",country:{name:"Turkey"}}},{id:"246502",title:"Dr.",name:"Jaya T.",middleName:"T",surname:"Varkey",slug:"jaya-t.-varkey",fullName:"Jaya T. Varkey",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/246502/images/11160_n.jpg",biography:"Jaya T. Varkey, PhD, graduated with a degree in Chemistry from Cochin University of Science and Technology, Kerala, India. She obtained a PhD in Chemistry from the School of Chemical Sciences, Mahatma Gandhi University, Kerala, India, and completed a post-doctoral fellowship at the University of Minnesota, USA. She is a research guide at Mahatma Gandhi University and Associate Professor in Chemistry, St. Teresa’s College, Kochi, Kerala, India.\nDr. Varkey received a National Young Scientist award from the Indian Science Congress (1995), a UGC Research award (2016–2018), an Indian National Science Academy (INSA) Visiting Scientist award (2018–2019), and a Best Innovative Faculty award from the All India Association for Christian Higher Education (AIACHE) (2019). She Hashas received the Sr. Mary Cecil prize for best research paper three times. She was also awarded a start-up to develop a tea bag water filter. \nDr. Varkey has published two international books and twenty-seven international journal publications. She is an editorial board member for five international journals.",institutionString:"St. Teresa’s College",institution:null},{id:"250668",title:"Dr.",name:"Ali",middleName:null,surname:"Nabipour Chakoli",slug:"ali-nabipour-chakoli",fullName:"Ali Nabipour Chakoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/250668/images/system/250668.jpg",biography:"Academic Qualification:\r\n•\tPhD in Materials Physics and Chemistry, From: Sep. 2006, to: Sep. 2010, School of Materials Science and Engineering, Harbin Institute of Technology, Thesis: Structure and Shape Memory Effect of Functionalized MWCNTs/poly (L-lactide-co-ε-caprolactone) Nanocomposites. Supervisor: Prof. Wei Cai,\r\n•\tM.Sc in Applied Physics, From: 1996, to: 1998, Faculty of Physics & Nuclear Science, Amirkabir Uni. of Technology, Tehran, Iran, Thesis: Determination of Boron in Micro alloy Steels with solid state nuclear track detectors by neutron induced auto radiography, Supervisors: Dr. M. Hosseini Ashrafi and Dr. A. Hosseini.\r\n•\tB.Sc. in Applied Physics, From: 1991, to: 1996, Faculty of Physics & Nuclear Science, Amirkabir Uni. of Technology, Tehran, Iran, Thesis: Design of shielding for Am-Be neutron sources for In Vivo neutron activation analysis, Supervisor: Dr. M. Hosseini Ashrafi.\r\n\r\nResearch Experiences:\r\n1.\tNanomaterials, Carbon Nanotubes, Graphene: Synthesis, Functionalization and Characterization,\r\n2.\tMWCNTs/Polymer Composites: Fabrication and Characterization, \r\n3.\tShape Memory Polymers, Biodegradable Polymers, ORC, Collagen,\r\n4.\tMaterials Analysis and Characterizations: TEM, SEM, XPS, FT-IR, Raman, DSC, DMA, TGA, XRD, GPC, Fluoroscopy, \r\n5.\tInteraction of Radiation with Mater, Nuclear Safety and Security, NDT(RT),\r\n6.\tRadiation Detectors, Calibration (SSDL),\r\n7.\tCompleted IAEA e-learning Courses:\r\nNuclear Security (15 Modules),\r\nNuclear Safety:\r\nTSA 2: Regulatory Protection in Occupational Exposure,\r\nTips & Tricks: Radiation Protection in Radiography,\r\nSafety and Quality in Radiotherapy,\r\nCourse on Sealed Radioactive Sources,\r\nCourse on Fundamentals of Environmental Remediation,\r\nCourse on Planning for Environmental Remediation,\r\nKnowledge Management Orientation Course,\r\nFood Irradiation - Technology, Applications and Good Practices,\r\nEmployment:\r\nFrom 2010 to now: Academic staff, Nuclear Science and Technology Research Institute, Kargar Shomali, Tehran, Iran, P.O. Box: 14395-836.\r\nFrom 1997 to 2006: Expert of Materials Analysis and Characterization. Research Center of Agriculture and Medicine. Rajaeeshahr, Karaj, Iran, P. O. Box: 31585-498.",institutionString:"Atomic Energy Organization of Iran",institution:{name:"Atomic Energy Organization of Iran",country:{name:"Iran"}}},{id:"248279",title:"Dr.",name:"Monika",middleName:"Elzbieta",surname:"Machoy",slug:"monika-machoy",fullName:"Monika Machoy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/248279/images/system/248279.jpeg",biography:"Monika Elżbieta Machoy, MD, graduated with distinction from the Faculty of Medicine and Dentistry at the Pomeranian Medical University in 2009, defended her PhD thesis with summa cum laude in 2016 and is currently employed as a researcher at the Department of Orthodontics of the Pomeranian Medical University. She expanded her professional knowledge during a one-year scholarship program at the Ernst Moritz Arndt University in Greifswald, Germany and during a three-year internship at the Technical University in Dresden, Germany. She has been a speaker at numerous orthodontic conferences, among others, American Association of Orthodontics, European Orthodontic Symposium and numerous conferences of the Polish Orthodontic Society. She conducts research focusing on the effect of orthodontic treatment on dental and periodontal tissues and the causes of pain in orthodontic patients.",institutionString:"Pomeranian Medical University",institution:{name:"Pomeranian Medical University",country:{name:"Poland"}}},{id:"252743",title:"Prof.",name:"Aswini",middleName:"Kumar",surname:"Kar",slug:"aswini-kar",fullName:"Aswini Kar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252743/images/10381_n.jpg",biography:"uploaded in cv",institutionString:null,institution:{name:"KIIT University",country:{name:"India"}}},{id:"204256",title:"Dr.",name:"Anil",middleName:"Kumar",surname:"Kumar Sahu",slug:"anil-kumar-sahu",fullName:"Anil Kumar Sahu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204256/images/14201_n.jpg",biography:"I have nearly 11 years of research and teaching experience. I have done my master degree from University Institute of Pharmacy, Pt. Ravi Shankar Shukla University, Raipur, Chhattisgarh India. I have published 16 review and research articles in international and national journals and published 4 chapters in IntechOpen, the world’s leading publisher of Open access books. I have presented many papers at national and international conferences. I have received research award from Indian Drug Manufacturers Association in year 2015. My research interest extends from novel lymphatic drug delivery systems, oral delivery system for herbal bioactive to formulation optimization.",institutionString:null,institution:{name:"Chhattisgarh Swami Vivekanand Technical University",country:{name:"India"}}},{id:"253468",title:"Dr.",name:"Mariusz",middleName:null,surname:"Marzec",slug:"mariusz-marzec",fullName:"Mariusz Marzec",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/253468/images/system/253468.png",biography:"An assistant professor at Department of Biomedical Computer Systems, at Institute of Computer Science, Silesian University in Katowice. Scientific interests: computer analysis and processing of images, biomedical images, databases and programming languages. He is an author and co-author of scientific publications covering analysis and processing of biomedical images and development of database systems.",institutionString:"University of Silesia",institution:null},{id:"212432",title:"Prof.",name:"Hadi",middleName:null,surname:"Mohammadi",slug:"hadi-mohammadi",fullName:"Hadi Mohammadi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/212432/images/system/212432.jpeg",biography:"Dr. Hadi Mohammadi is a biomedical engineer with hands-on experience in the design and development of many engineering structures and medical devices through various projects that he has been involved in over the past twenty years. Dr. Mohammadi received his BSc. and MSc. degrees in Mechanical Engineering from Sharif University of Technology, Tehran, Iran, and his PhD. degree in Biomedical Engineering (biomaterials) from the University of Western Ontario. He was a postdoctoral trainee for almost four years at University of Calgary and Harvard Medical School. He is an industry innovator having created the technology to produce lifelike synthetic platforms that can be used for the simulation of almost all cardiovascular reconstructive surgeries. He’s been heavily involved in the design and development of cardiovascular devices and technology for the past 10 years. He is currently an Assistant Professor with the University of British Colombia, Canada.",institutionString:"University of British Columbia",institution:{name:"University of British Columbia",country:{name:"Canada"}}},{id:"254463",title:"Prof.",name:"Haisheng",middleName:null,surname:"Yang",slug:"haisheng-yang",fullName:"Haisheng Yang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/254463/images/system/254463.jpeg",biography:"Haisheng Yang, Ph.D., Professor and Director of the Department of Biomedical Engineering, College of Life Science and Bioengineering, Beijing University of Technology. He received his Ph.D. degree in Mechanics/Biomechanics from Harbin Institute of Technology (jointly with University of California, Berkeley). Afterwards, he worked as a Postdoctoral Research Associate in the Purdue Musculoskeletal Biology and Mechanics Lab at the Department of Basic Medical Sciences, Purdue University, USA. He also conducted research in the Research Centre of Shriners Hospitals for Children-Canada at McGill University, Canada. Dr. Yang has over 10 years research experience in orthopaedic biomechanics and mechanobiology of bone adaptation and regeneration. He earned an award from Beijing Overseas Talents Aggregation program in 2017 and serves as Beijing Distinguished Professor.",institutionString:"Beijing University of Technology",institution:null},{id:"255757",title:"Dr.",name:"Igor",middleName:"Victorovich",surname:"Lakhno",slug:"igor-lakhno",fullName:"Igor Lakhno",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255757/images/system/255757.jpg",biography:"Lakhno Igor Victorovich was born in 1971 in Kharkiv (Ukraine). \nMD – 1994, Kharkiv National Medical Univesity.\nOb&Gyn; – 1997, master courses in Kharkiv Medical Academy of Postgraduate Education.\nPhD – 1999, Kharkiv National Medical Univesity.\nDSc – 2019, PL Shupik National Academy of Postgraduate Education \nLakhno Igor has been graduated from an international training courses on reproductive medicine and family planning held in Debrecen University (Hungary) in 1997. Since 1998 Lakhno Igor has worked as an associate professor of the department of obstetrics and gynecology of VN Karazin National University and an associate professor of the perinatology, obstetrics and gynecology department of Kharkiv Medical Academy of Postgraduate Education. Since June 2019 he’s a professor of the department of obstetrics and gynecology of VN Karazin National University and a professor of the perinatology, obstetrics and gynecology department of Kharkiv Medical Academy of Postgraduate Education . He’s an author of about 200 printed works and there are 17 of them in Scopus or Web of Science databases. Lakhno Igor is a rewiever of Journal of Obstetrics and Gynaecology (Taylor and Francis), Informatics in Medicine Unlocked (Elsevier), The Journal of Obstetrics and Gynecology Research (Wiley), Endocrine, Metabolic & Immune Disorders-Drug Targets (Bentham Open), The Open Biomedical Engineering Journal (Bentham Open), etc. He’s defended a dissertation for DSc degree \\'Pre-eclampsia: prediction, prevention and treatment”. Lakhno Igor has participated as a speaker in several international conferences and congresses (International Conference on Biological Oscillations April 10th-14th 2016, Lancaster, UK, The 9th conference of the European Study Group on Cardiovascular Oscillations). His main scientific interests: obstetrics, women’s health, fetal medicine, cardiovascular medicine.",institutionString:"V.N. Karazin Kharkiv National University",institution:{name:"Kharkiv Medical Academy of Postgraduate Education",country:{name:"Ukraine"}}},{id:"89721",title:"Dr.",name:"Mehmet",middleName:"Cuneyt",surname:"Ozmen",slug:"mehmet-ozmen",fullName:"Mehmet Ozmen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/89721/images/7289_n.jpg",biography:null,institutionString:null,institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"243698",title:"M.D.",name:"Xiaogang",middleName:null,surname:"Wang",slug:"xiaogang-wang",fullName:"Xiaogang Wang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243698/images/system/243698.png",biography:"Dr. Xiaogang Wang, a faculty member of Shanxi Eye Hospital specializing in the treatment of cataract and retinal disease and a tutor for postgraduate students of Shanxi Medical University, worked in the COOL Lab as an international visiting scholar under the supervision of Dr. David Huang and Yali Jia from October 2012 through November 2013. Dr. Wang earned an MD from Shanxi Medical University and a Ph.D. from Shanghai Jiao Tong University. Dr. Wang was awarded two research project grants focused on multimodal optical coherence tomography imaging and deep learning in cataract and retinal disease, from the National Natural Science Foundation of China. He has published around 30 peer-reviewed journal papers and four book chapters and co-edited one book.",institutionString:"Shanxi Eye Hospital",institution:{name:"Shanxi Eye Hospital",country:{name:"China"}}},{id:"242893",title:"Ph.D. Student",name:"Joaquim",middleName:null,surname:"De Moura",slug:"joaquim-de-moura",fullName:"Joaquim De Moura",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/242893/images/7133_n.jpg",biography:"Joaquim de Moura received his degree in Computer Engineering in 2014 from the University of A Coruña (Spain). In 2016, he received his M.Sc degree in Computer Engineering from the same university. He is currently pursuing his Ph.D degree in Computer Science in a collaborative project between ophthalmology centers in Galicia and the University of A Coruña. His research interests include computer vision, machine learning algorithms and analysis and medical imaging processing of various kinds.",institutionString:null,institution:{name:"University of A Coruña",country:{name:"Spain"}}},{id:"267434",title:"Dr.",name:"Rohit",middleName:null,surname:"Raja",slug:"rohit-raja",fullName:"Rohit Raja",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRZkkQAG/Profile_Picture_2022-05-09T12:55:18.jpg",biography:null,institutionString:null,institution:null},{id:"294334",title:"B.Sc.",name:"Marc",middleName:null,surname:"Bruggeman",slug:"marc-bruggeman",fullName:"Marc Bruggeman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/294334/images/8242_n.jpg",biography:"Chemical engineer graduate, with a passion for material science and specific interest in polymers - their near infinite applications intrigue me. \n\nI plan to continue my scientific career in the field of polymeric biomaterials as I am fascinated by intelligent, bioactive and biomimetic materials for use in both consumer and medical applications.",institutionString:null,institution:null},{id:"244950",title:"Dr.",name:"Salvatore",middleName:null,surname:"Di Lauro",slug:"salvatore-di-lauro",fullName:"Salvatore Di Lauro",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0030O00002bSF1HQAW/ProfilePicture%202021-12-20%2014%3A54%3A14.482",biography:"Name:\n\tSALVATORE DI LAURO\nAddress:\n\tHospital Clínico Universitario Valladolid\nAvda Ramón y Cajal 3\n47005, Valladolid\nSpain\nPhone number: \nFax\nE-mail:\n\t+34 983420000 ext 292\n+34 983420084\nsadilauro@live.it\nDate and place of Birth:\nID Number\nMedical Licence \nLanguages\t09-05-1985. Villaricca (Italy)\n\nY1281863H\n474707061\nItalian (native language)\nSpanish (read, written, spoken)\nEnglish (read, written, spoken)\nPortuguese (read, spoken)\nFrench (read)\n\t\t\nCurrent position (title and company)\tDate (Year)\nVitreo-Retinal consultant in ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl. National Health System.\nVitreo-Retinal consultant in ophthalmology. Instituto Oftalmologico Recoletas. Red Hospitalaria Recoletas. Private practise.\t2017-today\n\n2019-today\n\t\n\t\nEducation (High school, university and postgraduate training > 3 months)\tDate (Year)\nDegree in Medicine and Surgery. University of Neaples 'Federico II”\nResident in Opthalmology. Hospital Clinico Universitario Valladolid\nMaster in Vitreo-Retina. IOBA. University of Valladolid\nFellow of the European Board of Ophthalmology. Paris\nMaster in Research in Ophthalmology. University of Valladolid\t2003-2009\n2012-2016\n2016-2017\n2016\n2012-2013\n\t\nEmployments (company and positions)\tDate (Year)\nResident in Ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl.\nFellow in Vitreo-Retina. IOBA. University of Valladolid\nVitreo-Retinal consultant in ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl. National Health System.\nVitreo-Retinal consultant in ophthalmology. Instituto Oftalmologico Recoletas. Red Hospitalaria Recoletas. \n\t2012-2016\n2016-2017\n2017-today\n\n2019-Today\n\n\n\t\nClinical Research Experience (tasks and role)\tDate (Year)\nAssociated investigator\n\n' FIS PI20/00740: DESARROLLO DE UNA CALCULADORA DE RIESGO DE\nAPARICION DE RETINOPATIA DIABETICA BASADA EN TECNICAS DE IMAGEN MULTIMODAL EN PACIENTES DIABETICOS TIPO 1. Grant by: Ministerio de Ciencia e Innovacion \n\n' (BIO/VA23/14) Estudio clínico multicéntrico y prospectivo para validar dos\nbiomarcadores ubicados en los genes p53 y MDM2 en la predicción de los resultados funcionales de la cirugía del desprendimiento de retina regmatógeno. Grant by: Gerencia Regional de Salud de la Junta de Castilla y León.\n' Estudio multicéntrico, aleatorizado, con enmascaramiento doble, en 2 grupos\nparalelos y de 52 semanas de duración para comparar la eficacia, seguridad e inmunogenicidad de SOK583A1 respecto a Eylea® en pacientes con degeneración macular neovascular asociada a la edad' (CSOK583A12301; N.EUDRA: 2019-004838-41; FASE III). Grant by Hexal AG\n\n' Estudio de fase III, aleatorizado, doble ciego, con grupos paralelos, multicéntrico para comparar la eficacia y la seguridad de QL1205 frente a Lucentis® en pacientes con degeneración macular neovascular asociada a la edad. (EUDRACT: 2018-004486-13). Grant by Qilu Pharmaceutical Co\n\n' Estudio NEUTON: Ensayo clinico en fase IV para evaluar la eficacia de aflibercept en pacientes Naive con Edema MacUlar secundario a Oclusion de Vena CenTral de la Retina (OVCR) en regimen de tratamientO iNdividualizado Treat and Extend (TAE)”, (2014-000975-21). Grant by Fundacion Retinaplus\n\n' Evaluación de la seguridad y bioactividad de anillos de tensión capsular en conejo. Proyecto Procusens. Grant by AJL, S.A.\n\n'Estudio epidemiológico, prospectivo, multicéntrico y abierto\\npara valorar la frecuencia de la conjuntivitis adenovírica diagnosticada mediante el test AdenoPlus®\\nTest en pacientes enfermos de conjuntivitis aguda”\\n. National, multicenter study. Grant by: NICOX.\n\nEuropean multicentric trial: 'Evaluation of clinical outcomes following the use of Systane Hydration in patients with dry eye”. Study Phase 4. Grant by: Alcon Labs'\n\nVLPs Injection and Activation in a Rabbit Model of Uveal Melanoma. Grant by Aura Bioscience\n\nUpdating and characterization of a rabbit model of uveal melanoma. Grant by Aura Bioscience\n\nEnsayo clínico en fase IV para evaluar las variantes genéticas de la vía del VEGF como biomarcadores de eficacia del tratamiento con aflibercept en pacientes con degeneración macular asociada a la edad (DMAE) neovascular. Estudio BIOIMAGE. IMO-AFLI-2013-01\n\nEstudio In-Eye:Ensayo clínico en fase IV, abierto, aleatorizado, de 2 brazos,\nmulticçentrico y de 12 meses de duración, para evaluar la eficacia y seguridad de un régimen de PRN flexible individualizado de 'esperar y extender' versus un régimen PRN según criterios de estabilización mediante evaluaciones mensuales de inyecciones intravítreas de ranibizumab 0,5 mg en pacientes naive con neovascularización coriodea secunaria a la degeneración macular relacionada con la edad. CP: CRFB002AES03T\n\nTREND: Estudio Fase IIIb multicéntrico, randomizado, de 12 meses de\nseguimiento con evaluador de la agudeza visual enmascarado, para evaluar la eficacia y la seguridad de ranibizumab 0.5mg en un régimen de tratar y extender comparado con un régimen mensual, en pacientes con degeneración macular neovascular asociada a la edad. CP: CRFB002A2411 Código Eudra CT:\n2013-002626-23\n\n\n\nPublications\t\n\n2021\n\n\n\n\n2015\n\n\n\n\n2021\n\n\n\n\n\n2021\n\n\n\n\n2015\n\n\n\n\n2015\n\n\n2014\n\n\n\n\n2015-16\n\n\n\n2015\n\n\n2014\n\n\n2014\n\n\n\n\n2014\n\n\n\n\n\n\n\n2014\n\nJose Carlos Pastor; Jimena Rojas; Salvador Pastor-Idoate; Salvatore Di Lauro; Lucia Gonzalez-Buendia; Santiago Delgado-Tirado. Proliferative vitreoretinopathy: A new concept of disease pathogenesis and practical\nconsequences. Progress in Retinal and Eye Research. 51, pp. 125 - 155. 03/2016. DOI: 10.1016/j.preteyeres.2015.07.005\n\n\nLabrador-Velandia S; Alonso-Alonso ML; Di Lauro S; García-Gutierrez MT; Srivastava GK; Pastor JC; Fernandez-Bueno I. Mesenchymal stem cells provide paracrine neuroprotective resources that delay degeneration of co-cultured organotypic neuroretinal cultures.Experimental Eye Research. 185, 17/05/2019. DOI: 10.1016/j.exer.2019.05.011\n\nSalvatore Di Lauro; Maria Teresa Garcia Gutierrez; Ivan Fernandez Bueno. Quantification of pigment epithelium-derived factor (PEDF) in an ex vivo coculture of retinal pigment epithelium cells and neuroretina.\nJournal of Allbiosolution. 2019. ISSN 2605-3535\n\nSonia Labrador Velandia; Salvatore Di Lauro; Alonso-Alonso ML; Tabera Bartolomé S; Srivastava GK; Pastor JC; Fernandez-Bueno I. Biocompatibility of intravitreal injection of human mesenchymal stem cells in immunocompetent rabbits. Graefe's archive for clinical and experimental ophthalmology. 256 - 1, pp. 125 - 134. 01/2018. DOI: 10.1007/s00417-017-3842-3\n\n\nSalvatore Di Lauro, David Rodriguez-Crespo, Manuel J Gayoso, Maria T Garcia-Gutierrez, J Carlos Pastor, Girish K Srivastava, Ivan Fernandez-Bueno. A novel coculture model of porcine central neuroretina explants and retinal pigment epithelium cells. Molecular Vision. 2016 - 22, pp. 243 - 253. 01/2016.\n\nSalvatore Di Lauro. Classifications for Proliferative Vitreoretinopathy ({PVR}): An Analysis of Their Use in Publications over the Last 15 Years. Journal of Ophthalmology. 2016, pp. 1 - 6. 01/2016. DOI: 10.1155/2016/7807596\n\nSalvatore Di Lauro; Rosa Maria Coco; Rosa Maria Sanabria; Enrique Rodriguez de la Rua; Jose Carlos Pastor. Loss of Visual Acuity after Successful Surgery for Macula-On Rhegmatogenous Retinal Detachment in a Prospective Multicentre Study. Journal of Ophthalmology. 2015:821864, 2015. DOI: 10.1155/2015/821864\n\nIvan Fernandez-Bueno; Salvatore Di Lauro; Ivan Alvarez; Jose Carlos Lopez; Maria Teresa Garcia-Gutierrez; Itziar Fernandez; Eva Larra; Jose Carlos Pastor. Safety and Biocompatibility of a New High-Density Polyethylene-Based\nSpherical Integrated Porous Orbital Implant: An Experimental Study in Rabbits. Journal of Ophthalmology. 2015:904096, 2015. DOI: 10.1155/2015/904096\n\nPastor JC; Pastor-Idoate S; Rodríguez-Hernandez I; Rojas J; Fernandez I; Gonzalez-Buendia L; Di Lauro S; Gonzalez-Sarmiento R. Genetics of PVR and RD. Ophthalmologica. 232 - Suppl 1, pp. 28 - 29. 2014\n\nRodriguez-Crespo D; Di Lauro S; Singh AK; Garcia-Gutierrez MT; Garrosa M; Pastor JC; Fernandez-Bueno I; Srivastava GK. Triple-layered mixed co-culture model of RPE cells with neuroretina for evaluating the neuroprotective effects of adipose-MSCs. Cell Tissue Res. 358 - 3, pp. 705 - 716. 2014.\nDOI: 10.1007/s00441-014-1987-5\n\nCarlo De Werra; Salvatore Condurro; Salvatore Tramontano; Mario Perone; Ivana Donzelli; Salvatore Di Lauro; Massimo Di Giuseppe; Rosa Di Micco; Annalisa Pascariello; Antonio Pastore; Giorgio Diamantis; Giuseppe Galloro. Hydatid disease of the liver: thirty years of surgical experience.Chirurgia italiana. 59 - 5, pp. 611 - 636.\n(Italia): 2007. ISSN 0009-4773\n\nChapters in books\n\t\n' Salvador Pastor Idoate; Salvatore Di Lauro; Jose Carlos Pastor Jimeno. PVR: Pathogenesis, Histopathology and Classification. Proliferative Vitreoretinopathy with Small Gauge Vitrectomy. Springer, 2018. ISBN 978-3-319-78445-8\nDOI: 10.1007/978-3-319-78446-5_2. \n\n' Salvatore Di Lauro; Maria Isabel Lopez Galvez. Quistes vítreos en una mujer joven. Problemas diagnósticos en patología retinocoroidea. Sociedad Española de Retina-Vitreo. 2018.\n\n' Salvatore Di Lauro; Salvador Pastor Idoate; Jose Carlos Pastor Jimeno. iOCT in PVR management. OCT Applications in Opthalmology. pp. 1 - 8. INTECH, 2018. DOI: 10.5772/intechopen.78774.\n\n' Rosa Coco Martin; Salvatore Di Lauro; Salvador Pastor Idoate; Jose Carlos Pastor. amponadores, manipuladores y tinciones en la cirugía del traumatismo ocular.Trauma Ocular. Ponencia de la SEO 2018..\n\n' LOPEZ GALVEZ; DI LAURO; CRESPO. OCT angiografia y complicaciones retinianas de la diabetes. PONENCIA SEO 2021, CAPITULO 20. (España): 2021.\n\n' Múltiples desprendimientos neurosensoriales bilaterales en paciente joven. Enfermedades Degenerativas De Retina Y Coroides. SERV 04/2016. \n' González-Buendía L; Di Lauro S; Pastor-Idoate S; Pastor Jimeno JC. Vitreorretinopatía proliferante (VRP) e inflamación: LA INFLAMACIÓN in «INMUNOMODULADORES Y ANTIINFLAMATORIOS: MÁS ALLÁ DE LOS CORTICOIDES. 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