Characteristics of an ideal intubation device.
\r\n\t
\r\n\tContamination with biomedical waste and its impact on the environment are global concerns. Biomedical waste that has not been collected and disposed in accordance with the regulations can become a total environmental hazard and cause negative impact on human health and the environment. Medical centers including hospitals, clinics, and places where diagnosis and treatment are conducted generate waste that is highly hazardous and put people under risk of fatal diseases. On the other hand, food waste is commonly produced in all the steps of food life cycle, such as during agricultural production, industrial manufacturing, processing and distribution, and is even consumer-generated within private households. Food waste mostly contains high-value components such as phytochemicals, proteins, flavor compounds, polysaccharides, and fibers, which can be reused as nutraceuticals and functional ingredients. Adsorption is a practicable separation method for purification, along with bulk separation where surface characteristics and pore structures are the main properties in determining equilibrium rate. Managing waste materials on the whole is often unsatisfactory, especially in developing countries, and the unreasonable disposal of waste is a major issue worldwide.
\r\n\tThe following issues will be of particular interest for this book: effects of waste on environment and health, biomedical waste - storage, management, treatment, and disposal, biomedical waste contamination, food waste, potential applications of low-cost sorbents in agricultural and food sectors, biosorbents and bioadsorbents, adsorption of modified agricultural and biological wastes (biosorption), compounds recovered from food waste, and agricultural and food waste-derived sorbents.
",isbn:null,printIsbn:"979-953-307-X-X",pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"fef68f549e98b68c60ae17bb2b3c64e4",bookSignature:"Dr. Parisa Ziarati",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9842.jpg",keywords:"Biomedical waste, Food waste, Classification, Hazardous waste, Sources, Treatment and disposal, Contamination, Bioaccumulation, Sorbents, Sorption, Biosorption, Food waste recovery",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"December 4th 2019",dateEndSecondStepPublish:"March 3rd 2020",dateEndThirdStepPublish:"May 2nd 2020",dateEndFourthStepPublish:"July 21st 2020",dateEndFifthStepPublish:"September 19th 2020",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 years",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"312371",title:"Dr.",name:"Parisa",middleName:null,surname:"Ziarati",slug:"parisa-ziarati",fullName:"Parisa Ziarati",profilePictureURL:"https://mts.intechopen.com/storage/users/312371/images/system/312371.jpg",biography:"Parisa Ziarati currently works at Nutrition and Food Sciences Research Center, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran. She is a hardworking researcher since she has published 168 research articles in leading technical and scientific journals. She is the author of 3 books. She has delivered 138 lectures at national and international conferences on relevant subjects, primarily environmental chemistry. She has also supervised 118 master’s theses and mediated 108 theses as an advisor. She has also published several papers on new findings in phytoremediation, a topic of current and original research attracting commercial interest. Moreover, she has worked exhaustively on turning low-cost waste products (food, agricultural, forestry, industrial, and mine waste) into valuable resources for water / wastewater remediation and pollution prevention. It is notable that remediation of soils contaminated with heavy metals and organics, detoxification and removal of heavy metals from foods, including rice and vegetables by adsorbents / bio adsorbents is her current research passion.",institutionString:"Nutrition and Food Sciences Research Center",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"12",title:"Environmental Sciences",slug:"environmental-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"297737",firstName:"Mateo",lastName:"Pulko",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/297737/images/8492_n.png",email:"mateo.p@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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The fundamental difference is that these patients are frequently in a situation of hypoxemia and cardiovascular collapse, so in many situations, the airway management in these clinical conditions is often complicated, if not emergency. Therefore, it is usually considered that these patients present, at the beginning, a possible difficult airway (DA).
Although failure to manage AM sometimes occurs unexpectedly, it is known to be the second most common event reflected in NAP4 in the ICU [1]. So, all patients admitted in the ICU should be considered at risk.
The airway approach in this environment has gained interest in recent years, especially after NAP4, in which airway complications were found to be more likely to occur in the ICU than in the operating room (severe hypoxemia, in addition to arrhythmias, hypotension, and cardiovascular collapse), and more frequently caused harm to the patient. This study specifically mentioned the theoretical benefit of videolaryngoscopes (VL), since their proper and correct use would offer the potential to reduce the difficulty of intubation in the ICU (Figure 1).
Airtraq videolaryngoscope.
Other important conclusions drawn from the NAP4 were the scarce airway assessment performed in the critical units and did not allow us to anticipate a DA, resulting in poor planning. It was also observed that, in the context of an unexpected DA, the limited ability to modify the established plan may lead to a failure to resolve the situation.
The utility of videolaryngoscopy in anesthesia is widely recognized and endorsements advocating its use have been incorporated in the UK and American Difficult Airway Society guidelines [2, 3].
The degree of difficulty with face mask ventilation (FMV) and intubation with direct laryngoscopy (DL) is very variable according to the studies and although the degree of difficulty for intubation does not have to correspond to the difficulty for ventilation with facial masks, if they occur together in the same patient, the consequences can be catastrophic [4].
Traditionally, the difficulty for laryngoscopy vision is difficult to intubate [5, 6].
In general, the incidence of Cormack-Lehane grades 3/4 and 4/4 ranges from 1 to 10%, and 2–8%, respectively. These figures are up to 7.9% in pregnant women requiring general anesthesia, with 2% of cases being “
Finally, the catastrophic situation of “
All these figures vary between studies, mainly because there is no unanimity in the definitions or terms related to AM.
Within the specific context of an ICU, the incidence of DA rises to 10–20% [7, 8, 9, 10, 11, 12].
Facial mask ventilation (FMV) is a fundamental element of the AM that would ensure patient oxygenation between the different intubation attempts. It has been classically described an incidence of difficulty FMV of 0.08% [5].
In 2004, a scale of 4 degrees of difficulty FMV was established, assigning a score of 0–4 according to the difficulty found [13], which was later used in a study of 22,660 patients [14], Finding a degree of difficulty of:
Grade 1: easy FMV (77.4%).
Grade 2: easy FMV with an oral cannula or other adjuvants (21.1%).
Grade 3: difficult FMV (inadequate, unstable or requiring two operators) (1.4%).
Grade 4: inability FMV (0.16%).
Grade 3 or 4 + difficult intubation: 0.37%.
In order to increase statistical power in some variables of the previous study, in 2009, a new study was carried out, collecting more than 50,000 patients [15]. It was recognized that the incidence of impossible FMV, defined as “
Critical patient intubation is often performed in ICU, but can also be performed in locations away from the operating room, where working conditions and available materials are often inadequate. The difficulty rate of orotracheal intubation in emergency situations is 3 times higher than the programmed procedure, with a reported incidence of 10–20% failure at the first-attempt [7], with a complication rate 50 times higher than those found during anesthesia [1].
The AM of the critically ill patient may be complicated by the anatomical characteristics involving the visualization of glottis opening, or the difficult passage of the tracheal tube through the vocal cords, or by the clinical situation itself, which may contribute to the cardiovascular collapse. Among these causes of physiologic DA are hypoxemia, hypotension, severe metabolic acidosis, and right ventricular failure [16]. In fact, approximately 20% of patients in the ICU will experience critical hypoxemia, which, in the worst case, leads to death. Other common complications are esophageal intubation, aspiration, and selective bronchial intubation, among others.
DA is defined as “
However, despite handling the DA forced to take decisions and perform actions quickly and effectively, the truth is that there is no unanimity in the definitions or terms related to AM, because “the DA not exists, in reality, but is a complex interaction between the patient, the anesthetist, the available equipment and other circumstances” [17].
Until a few years ago, the available systems of evaluation have had in little consideration factors not related to the patient. Some factors that complicate and diminish the safety of the management of the AM such as:
Experience.
Pressure of time-urgency.
Availability of suitable equipment.
Location.
Human factors.
However, it is currently considered “
Facial mask.
Supraglottic or extraglottic devices.
Endotracheal tube.
Surgical AM.
The use of any of these methods depends not only on the devices but also on the situation facing the professional. In this management of context-sensitive MA, maintenance of the patient’s gauche exchange is the priority and should not be “
The concept “
Non-patient dependent:
Who manages airway?
Where is the patient?
What equipment and medication are available?
Who helps?
Dependent patient:
Predictive tests of AD.
Pathology of the patient (hemorrhage, edema, trauma, increased secretions, etc.).
The primary indication for OTI in ICU is the acute respiratory failure. Weakness and fatigue of respiratory muscles (ventilatory failure) and disruption of gas exchange (respiratory failure) are common, and the risk of hypoxemia and cardiovascular shock during the OTI process is high, ranging from 15 to 50%.
Critical patient intubation presents life-threatening complications in more than one-third of cases [19]. The most common are respiratory and hemodynamic alterations [20]. The main adverse event associated with the technique is hypoxemia with a dramatic decrease in peripheral oxygen saturation (SapO2) despite adequate preoxygenation. In almost half of the cases, the indication for tracheal intubation is due to an acute respiratory failure with a previous SapO2 of less than 90% that supports the appearance of severe hypoxemia.
The second complication due to its frequency is hemodynamic alteration with hypotension after intubation, associated or not with desaturation. Mort reported 60 cardiac arrests during 3035 intubations outside the operating room (incidence of 2%) [21]. About 83% of these patients experienced severe hypoxemia (SatpO2 < 70%). The choice of the drug suitable for anesthetic induction is very important to minimize hypotension in the critical.
Other complications described in the literature are esophageal intubation and pulmonary aspiration. The former increases the risk of cardiac arrest by 15 times.
NAP4 reported that ICU, far from representing a safe place to operate the airway, were a place of potential danger. Airway-related complications were more likely to occur in the ICU than in the operating room, and more often resulted in harm to the patient. Thus, the rate of airway complications that appeared in the ICU was more than 50 times higher than those found during anesthesia, and 61% of the ICU patients reported on NAP4 suffered neurological damage or death, compared to 14% during the anesthetic procedure and 33% in the emergency department. Although most of the potentially fatal airway events in the ICU were due to especially tracheal tube displacement or tracheostomy (especially in obese patients), difficulties were also identified associated with esophageal intubation, rapid sequence intubation, and failure techniques of the rescue of the airways [1].
There are four factors that are independently associated with a serious complication during the procedure:
Age is a factor that cannot be modified and is accompanied by a worse response of the organism to any aggression.
Second, there are two factors depending on the patient’s previous physiological status, the presence of hypotension, and/or hypoxemia conditions an increased risk of complications. In some cases, these factors can be modified by optimizing blood pressure and oxygenation.
The presence of secretions in the oropharyngeal cavity hinders laryngoscopic vision and has been associated with an increase in the rate of failure of tracheal intubation.
Lastly, the need for more than one attempt for intubation increases the risk of complications. A number greater than two attempts increases the risk of hypoxemia, bradycardia, aspiration of gastric contents, and cardiac arrest exponentially [21].
The presence of two clinicians reduces the risk of complications.
The aims of the AM, understood as the accomplishment of maneuvers and the use of devices that allow adequate and safe ventilation to patients who need it, is to guarantee the oxygenation in a situation of potential vital risk for that patient.
The optimal AM and ventilation of critical patients remain a basic pillar in survival, evolution, and prognosis, with OTI being the gold standard in these situations.
Most patients requiring tracheal intubation and mechanical ventilation in the ICU are, in contrast to those requiring these procedures in an operating room, patients with a circulatory and/or respiratory compromise. Therefore, the intubation procedure should be non-aggressive and atraumatic.
The cardiorespiratory instability usually presented by the seriously ill patient (with reduced functional residual capacity and safe apnea time), together with the urgent nature of the situation, the low predictability of the possible scenarios, jointly with the fact that it is often not possible ensure adequate gastric emptying, determine that the intubation of critical airway is a high-risk procedure. For this reason, all critical patients should be initially managed as potential AD.
The results of the NAP4 audit are parallel to other studies that consider that multiple attempts at intubation in the critical patient result in a high incidence of adverse events [22]. In order to limit the number of attempts to two and to ensure success, interventions such as an adequate patient position and the existence, at the bedside, of correct material equipment and experienced personnel are necessary.
The assessment of the airway in the critical patient may be complex, but adequate planning should be part of the daily approach to the airway. This assessment must include the factors that predict a DA that we routinely use in the anesthesia consultation. The patient’s position, the additional help present, and the available material must be evaluated prior to anesthetic induction. In addition, the physiological characteristics of the subject such as the full stomach and situations that favor desaturation (obesity and pulmonary shunt) should be considered.
The oxygenation of patients before and during intubation is of paramount importance [23]. Premaneuver denitrogenate has been shown to be useful as oxygenation with nasal goggles during apnea. The administration of high concentrations of oxygen through high-flow nasal glasses (HFNG) seems to offer advantages over the classic preoxygenation models. It provides some degree of positive pressure even during laryngoscopy without requiring patient collaboration [24].
Historically, direct laryngoscopy has been the most commonly used method for intubation in critically ill patients. Alternatives such as luminous stylet, supraglottic device, and flexible fibrobronchoscope are hardly used outside the surgical area. VLs have been proposed as an initial approach by some authors, but their implementation is being limited and reserved as a rescue technique. It is true that these devices improve the vision of the glottis, but in less-experienced hands, they slow the procedure and, in critical patients with few reserves, additional few seconds can have fatal consequences.
In conventional airway management, routine OTI with traditional direct laryngoscopy (DL) is still the common practice [25, 26], with the Macintosh as standard gold DL, a device created just 10 years before the first ICU was Inaugurated by the anesthesiologist Bjorn Ibsen in Copenhagen (December 1953) [27, 28]. On the other hand, in DA cases, the technique of choice for intubation is the use of the fiber optic bronchoscopy (FOB), although there are more and more studies in which videolaryngoscopy is used as an alternative approach in induced/sleep or awake patient, since FOB is an expensive, fragile, and requires regular maintenance, is complex to dispose of in emergency situations or in prehospital emergencies, and requires previous training.
Failure of endotracheal intubation using Classical Direct Laryngoscopy with a Macintosh laryngoscope or other technique may occur unexpectedly. And, since the second most common event reflected in the NAP4 reports on the ICU was failed intubation, proper and correct use of videolaryngoscopes (VL) would offer the potential to reduce the difficulty of intubation in general in the ICU [1, 29].
Numerous studies have shown increased morbidity when performing multiple attempts at tracheal intubation. Videolaryngoscopes allow a view of the entrance of glottis independent of the line of sight (LI), especially those that have angled blades. The fact that the image sensor is in the distal part of the blade causes us to have a panoramic view of the glottis, without the need to “
Glottic view differences.
VL have also been shown to improve glottis and intubation success rates in emergency and emergency services, in the prehospital setting, and specifically in patients with known predictors of DA [30].
However, achieving CL grade 1 laryngoscopy (CL 1/4) in laryngoscopy with a VL does not guarantee the success of OTI, which is relatively frequent in VLs that have a curved leaf, especially during the learning stage [31, 32].
Previous studies with novice and experienced anesthetists have suggested that the learning curve with an optical device can be around 20 applications to be competent to manage [33].
Although these numbers are lower than those suggested by Greaves (80% of competence acquired with 30 cases, and complete with 100 cases), the video imaging technology of these new devices offers a shared vision between instructor and student [34], which can facilitate the teaching of airway anatomy, critical assessment of technique, and feedback. This may lead to skill acquisition faster than that achieved with traditional training with direct laryngoscopy [35].
This difficulty in achieving intubation despite the correct exposure of the larynx even in expert hands may be finally impossible, and success depends more on the operator’s ability and patient’s airway characteristics than on the own device [36]. However, in an attempt to overcome this problem, channeled videolaryngoscopes have the advantage of orienting the endotracheal tube (ETT) toward the trachea, allowing directed intubation with a little manipulation of the airway.
On the other hand, the evidence suggests that the use of indirect laryngoscopy (IL) improves the overall success rate of emergency/emergency tracheal intubation, as well as reduces the incidence of esophageal intubation when compared to conventional direct laryngoscopy (LD) [36].
In addition to this, we must mention that the VL, thanks to its good image quality, allow to easily recognize the structures of the larynx to achieve an image with a field between 45° and 60°, as opposed to the distant and tubular vision of the classical laryngoscopy (about 15°).
This image also allows to be certain about both the success of the intubation and the depth of insertion of the ETT, and can also easily recognize and correct esophageal intubation, a serious cause of morbidity and mortality. And another added advantage is that they provide an LED light, of greater luminous intensity than the conventional one and with a spectral irradiation closer to the human eye.
The NAP4 (the 4th National Audit Project on Major Complications in Airway Management in the UK) specifically mentions the theoretical benefit of videolaryngoscopes [1], with evidence that they can be more efficient than a Macintosh laryngoscope conventional.
For these and other reasons, these optical devices were incorporated into the airway management guidelines by the ASA as valid options in both the DA as usual, including, without excluding or limiting, laryngoscopes with different sizes and types of blades, VL, facial masks or supraglottic airway devices (SAD) such as laryngeal mask (LMA) or Fastrach® (ILMA), laryngeal tube, etc., fibrobronchoscope (FBO), extraglottic device (Frova, Eischman, etc.), nasal intubation, etc. [2].
The characteristics that would define an ideal intubation device are described in Table 1.
|
Characteristics of an ideal intubation device.
During the last few years, many types of rigid, semi-rigid, optical, fiber optic and video-assisted laryngoscopes have been developed, as well as stiff and flexible stylets, as well as the classic flexible fibrobronchoscope, all of them with a common goal: to solve a classic problem for anesthesiologists, the difficult airway. The clinical evidences tell us about the real usefulness of all these devices in the solution of the problem for which they were designed. Scientific evidence of its use, the advantage of one over another, and the choice of each of them in a particular patient are yet to be determined.
At the moment, all the VL present as common characteristics [37, 38, 39, 40, 41, 42, 43, 44]:
Camcorder whose digital image is transmitted to a screen of an external monitor.
Beam of optical fibers.
System of prisms, which transmit the image through a system of lenses.
Resulting the classifications proposed by Pott et al. [43], Healy et al. [38], and Niforopoulou et al. [44], although all VLs allow a view of the entrance of glottis independent of the line of sight (indirect laryngoscopy [LI]), could be classified according to the type of blade [42]:
VL with “
Other advantages common to all of them are the ease of visualization of the glottic structures, which allow to use any type of endotracheal tube (ETT) and the longer duration than the fiberscope, combined with the lowest cost.
The disadvantage is that, even in most of cases CL improves, the introduction of ETT is sometimes difficult and a certain practice is required, so eventually ETT must be performed with a guarantor (contrary to which occurs with angled blades).
VL with
All of them present advantages common to all of them: ease of visualization of glottic structures, allow to use any type of ETT and longer duration than the fiberscope.
The disadvantage is that, although Cormack-Lehane improves in most cases, the introduction of ETT is sometimes difficult.
The lack of a channel in which to put the ETT usually requires a certain practice and, often, it is necessary to preform the ETT with a catcher that provides the same the angulation that has the blade of the VL so as to be able to direct it to the entrance of the glottis.
Videolaryngoscopes with
They all have a channel through which the ETT slides for intubation. As the ETT is directed by the channel, we must do any modification of movements on the device and not on the tube.
The tube does not need to be preformed with a stylet and generally enhances the Cormack-Lehane.
The new optical devices are recommended to improve the management of the airway, both in anesthetic care and in critical patients [41, 42, 45, 46]. In recent years, the role of videolaryngoscopes has been debated, especially its use in the ICU [29, 31, 37, 42, 47, 48, 49, 50, 51], where there is a lack of scientific evidence and, in general, intubation is performed in more complicated conditions than in the operating room [52]. However, this evidence is supported in the surgical setting as there are randomized controlled trials (RCTs), meta-analyses, and systematic reviews. Although the environments are different, neither the techniques for the acquisition of competencies, and in one place as in the other, there are situations of unexpected vital commitment and/or deterioration of respiratory and hemodynamic function [7, 21, 41, 53, 54]. Therefore, the results of existing studies in surgical areas can be extrapolated to the field of ICU for many of the above-mentioned plots.
In this sense, Healy et al. published an updated systematic review of Videolaringoscopes in 2012 with the objective of organizing the literature about the effectiveness of modern VL in the OTI and then performing a quality assessment and making recommendations for its use [38].
The comparison of VL with LD was based on three main results: global success, first-attempt success, and successful intubation time.
The vision of the glottis was a desirable result, but since with the VL the intubation can be performed despite having a limited view of it and, on the other hand, a good view of the larynx does not always guarantee a successful intubation, it was not considered a target for the recommendation.
The final recommendations of the study could be summarized in three points:
In patients at risk of difficult laryngoscopy, the use of Airtraq, C-Trach, GlideScope, Pentax AWS, and V-MAC is recommended for successful intubation.
The use of the Airtraq, Bonfils, Bullard, C-Trach, GlideScope, and Pentax AWS by an operator with reasonable prior experience is recommended for successful intubation in CLD (CL ≥ 3).
There is additional evidence to support the use of Airtraq, Bonfils, C-Trach, GlideScope, McGrath, and Pentax AWS after intubation failed by direct laryngoscopy to achieve successful intubation.
Be that as it may, the use of VLs not only improves glottic vision, and in the ICU they also present other advantages such as positive effects on teamwork, communication and knowledge of the situation, as well as on technical skills. The use of VL on the training of residents, with an adjunct that shares their opinion as responsible for intubation seen on the screen, giving advice to help intubation, training nurses of the ICU allowing them to control the effect of the pressure on the cricoid during the sellick, adjusting it as necessary. In addition, the VL is immediately available, which means an improvement in the management of the unexpected DA [37, 55].
A major advantage of standard “
The study by De Jong et al., from the Montpellier group, evaluated the McGrath MAC (Aircraft Medical, Edinburgh, Scotland), a VL with a Macintosh type spade that allows intubation using conventional or indirect direct laryngoscopy. The results reported by these authors are similar to other studies, noting that it is easier to visualize the glottis using VL and that fewer attempts are required to achieve intubation. However, although De Jong et al. showed a significant reduction in the incidence of difficult laryngoscopy and/or difficult intubation with VL McGrath MAC (4 vs. 16%) in ICU patients did not provide information on whether or not actual intubation time was shorter [51].
In ICU, where patients are often under a cardiorespiratory compromise, reducing the time the patient is without adequate ventilation/oxygenation is probably more important than the time it takes to visualize the glottis. In the study by Yeatts et al. was found that a shorter time was required to insert an ETT when a conventional direct laryngoscopy was performed [56]. In fact, in this study, an IL with Glidescope (Verathon Médico, Bothell, WA) was associated with prolonged intubation times in trauma patients, with a longer time of hypoxemia and a higher mortality in patients with traumatic brain injury [57]. These results coincide with those of the ICU study carried out by Griesdale et al., who found that intubation with Glidescope VL resulted in lower oxygen saturations [58].
In addition, the study by De Jong et al., from the Montpellier group, evaluated McGrath MAC, a “
In the multivariate analysis, the use of a standard laryngoscope was an independent risk factor for difficult laryngoscopy and/or difficult intubation, as was the Mallampati III or IV score and the status of nonexpert operator. On the other hand, in the subgroup of patients with difficult intubation predicted by the MACOCHA score (Figure 3), the incidence of difficult intubation was much higher in the standard laryngoscope group (47%) than in the “
Macocha score.
Cameron et al. perform a study to evaluate the odds of first-attempt success with video laryngoscopy compared with direct laryngoscopy, using a propensity-matched analysis to reduce the risk of bias, for intubations performed in a medical ICU. They accomplish an analysis of prospectively collected data for 809 consecutive intubations performed between 2012 and 2014 in the ICU of an academic tertiary referral center that supports fellowship training programs in pulmonary and critical care medicine [59].
This study comparing video laryngoscopy with direct laryngoscopy as performed by nonanesthesiologist trainees in a medical ICU demonstrates improved first-attempt success associated with video laryngoscopy. Author’s findings are clinically significant and consistent with other reports and meta-analyses. These results, in combination with the existing literature on the success of video laryngoscopy and the availability of video laryngoscopy in most academic medical ICUs, suggest that video laryngoscopy should be considered the primary method of laryngeal visualization for intubations performed in ICUs, where there is increased risk of intubation-related complications.
A 2014 meta-analysis found that, compared with direct laryngoscopy, videolaryngoscopy improved glottis view and first-attempt success for orotracheal intubation in ICU [10]. However, both randomized controlled trials (RCTs) and observational studies were included in that study, and evidence from RCTs was limited. In the past months, new RCTs have debated the application of videolaryngoscopy in airway management in ICU [60, 61]. Bing-Cheng Zhao et al. performs a meta-analysis of RCTs to evaluate the effects of video laryngoscopy on first-attempt success and complications related to intubation in ICU patients [50].
Four RCTs enrolling 678 patients were included [60, 61, 62, 63], and compared with direct laryngoscopy, videolaryngoscopy did not significantly improve first-attempt success rate (RR 1.17, 95% CI 0.89–1.53). In videolaryngoscopy groups, poor glottis visualization was less common (RR 0.30, 95% CI 0.14–0.64), and incidence of esophageal intubation was lower (RR 0.31, 95% CI 0.11–0.90). However, videolaryngoscopy did not reduce the time for successful intubation and other outcomes, including severe hypoxemia, hypotension, mechanical ventilation duration, and ICU mortality.
Nonetheless, trial sequential analysis showed that the current evidence on the use of videolaryngoscopy is still inconclusive. The prima facie question is whether there may be a type H error due to an inadequate sample size, seeing that there already exists a trend favoring the use of videolaryngoscopy in relation to the primary outcome of successful first-attempt intubation. A previously published meta-analysis of nine studies by De Jong et al. demonstrated the superiority of videolaryngoscopy versus direct laryngoscopy with an odds ratio (OR) of 2.07 (95% CI 1.35–3.16) [10]. Significant heterogeneity exists in the forest plot (P test 73%) with appreciable differences between the operators from inexperienced medical students to critical care medicine experts [50]. Nonanaesthesiologist as operator has been validated to be a risk factor for difficulty in intubation in ICU [64]. The operator’s training and experience in comparative studies is, in our opinion, a critical factor which influences reported differences among various intubation devices. Out of the four randomized trials included for the meta-analysis [50], data from Silverberg et al. [61] was excluded for the analysis of time for successful intubation on the grounds of high bias risk (due to suboptimal allocation concealment and randomization strategy). The study by Silverberg demonstrated statistically and clinically significant differences in the time for successful intubation favoring videolaryngoscopy. Non-inclusion may affect the pooled data analysis by Zhao et al. [50]. Curiously, data from the same study was included for pooled analysis of the primary outcome (rate of successful intubation on the first-attempt). Two of the included studies compared the performance of the Glidescope with direct laryngoscopy, and two pooled data sets were included from studies comparing the McGrath videolaryngoscope against direct laryngoscope. Not all videolaryngoscopes are the same and the airway literature distinguishes channeled videolaryngoscopes versus the anteriorly angulated variety versus the Macintosh-like videolaryngoscopes—appreciating peculiar advantages and disadvantages of each. Combining results from all videolaryngoscopes as an entity may have its limitations.
In this regard, Joshi et al. [65] have tried to identify characteristics associated with first-attempt failure at intubation when using videolaryngoscopy in the ICU. They perform an observational study of 906 consecutive patients intubated in the ICU with a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt.
In this single-center study, there were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7–27.0% vs. 13.3%, 95% CI, 8.0–18.8%).
Presence of blood in the airway (OR, 2.63, 95% CI, 1.64–4.20), airway edema (OR, 2.85; 95% CI, 1.48–5.45), and obesity (OR, 1.59, 95% CI, 1.08–2.32) were significantly associated with higher odds of first-attempt failure, when intubation was performed with videolaryngoscopy in an ICU.
In a second logistic model to examine cases in which these additional difficult airway characteristics were collected (n = 773), the presence of blood (OR, 2.73, 95% CI, 1.60–4.64), cervical immobility (OR, 3.34, 95% CI, 1.28–8.72), and airway edema (OR, 3.10; 95% CI, 1.42–6.70) were associated with first-attempt failure [65].
There are important limitations in this study, such that when certain difficult airway characteristics such as blood, vomit, or airway edema could have been known before the intubation attempt or encountered during the attempt, it is possible that operator reporting of these difficult airway characteristics was more common when they were unexpectedly encountered. Moreover, multivariable analyses account for experience of the operator. The generalization of these study results may be limited given the exposure, airway curriculum, and experience of trainees at this institution compared to others.
Nevertheless, the intensive care professional should account for these difficult airway characteristics, blood, cervical immobility, and airway edema, when preparing for endotracheal intubation with video laryngoscopy in addition to standard practices employed to optimize first-attempt success.
Janz et al. [62] evaluates the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt in a randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy among 150 critically ill adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows in a Medical ICU in a tertiary, academic medical center.
The primary outcome was the rate of intubation on first-attempt, adjusted for the operator’s previous experience with the intubating device at the time of the procedure. Adjustment for the operator’s previous device experience was performed by collecting the number of times the operator had previously used a VL or DL at the time of each intubation event during the trial, such that the adjustment for prior experience with a specific device was updated constantly as the trial progressed.
Videolaryngoscopy improves glottic visualization but does not appear to increase procedural success in unadjusted analyses or after adjustment for the operator’s previous experience with the assigned device (OR for video laryngoscopy on intubation on first-attempt 2.02, 95% CI, 0.82–5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy [62].
The results of all of these studies are in contrast with results of prior studies demonstrating improved procedural success with VL [30, 36, 61]. There are several potential explanations for this difference, as that prior study limited to noncritically ill populations [66] may not apply to the patient, operator, and procedural conditions surrounding intubation in the ICU.
A lack of accounting of the experience of the operator at the time of the procedure [30, 36, 49, 61, 67] may also confound the results all of these works.
Several studies have shown that videolaryngoscopy enhances the laryngeal view in patients with apparently normal and anticipated difficult airways [32, 33, 39, 53, 68, 69, 70]. And there are a number of possible reasons why improving glottis view with VL does not translate into procedural success. Therefore, these data may not be generalizable to operators using videolaryngoscopes other than the McGrath MAC and direct laryngoscopes with straight blades. And some authors theorize that improving glottic view with VL may only matter to less-experienced operators [62].
The MACMAN trial (McGrath Mac Videolaryngoscope Versus Macintosh Laryngoscope for Orotracheal Intubation in the Critical Care Unit) is a multicentre, open-label, randomized controlled superiority trial published in JAMA [63]. It was a multicenter, randomized, open-label trial, which included all ICU patients that needed orotracheal intubation.
Lascarrou et al. try to determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients. They perform a randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between 2015 and 2016, and there was 28 days of follow-up.
The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications.
The first intubation attempts were made by a nonexpert in 83.8% of patients. There were no difference in first-pass success between the VL (67.7%) and the ML (70.3%) groups (absolute difference, −2.5% [95% CI, −11.9% to 6.9%]; p = 0.60. These results were sustained even after adjusting for operator expertise and MACOCHA score.
The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with videolaryngoscopy vs. 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, −6.3% to 8.6%]; p = 0.76). The median time to successful intubation was 3 min (range, 2–4 min) for both videolaryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; p = 0.95). Videolaryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs. 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, −2.7% to 10.4%]; p = 0.25). In post hoc analysis, videolaryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs. 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; p = 0.01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs. 14/181 [7.7%]; absolute difference, −2.3% [95% CI, −7.4% to 2.8%]; p = 0.37).
The main reason for intubation failure in the ML group was inability to see the glottis, and in the VL group was failure of tracheal catheterization.
The ability to see the glottis is related to the expertise with the procedure and the equipment you are using, either way, since the groups were balanced regarding the physicians’ expertise, the difference found between the two groups here might be because it is easier to visualize the glottis with the VL. The failure of tracheal catheterization, 70.7% (VL) vs. 23.5% (ML), can be explain with the learning curve or because they study a non-channeled VL. Eye-hand coordination, especially when looking through a monitor, is not learned with a few training sessions. Stratified by center and “
Several studies comparing videolaryngoscopy with direct laryngoscopy have demonstrated improved rates of first-attempt success in the operating room, emergency department, trauma unit, and simulation laboratory, as well as during active cardiopulmonary resuscitation [56, 57, 58, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80]. Data comparing videolaryngoscopy with direct laryngoscopy on first-attempt success in the ICU are limited to a small number of observational studies [30, 36, 81, 82, 83], a meta-analysis of those studies [10], and some randomized controlled trials [60, 61].
Randomized controlled trial data comparing video laryngoscopy with direct laryngoscopy in the medical ICU are limited in number and external validity, especially for intubations performed by nonanesthesiologists.
Videolaryngoscopes have among their disadvantages the cost, which mainly restriction access in areas outside the operating room. Devices need to be connected to the mains or batteries, and those that have an external monitor connected by cable may be little “
Because they provide an indirect image, the blood, secretions, and fogging of the lens obscure the image.
The fogging can be prevented by pre-aspirating the pharynx, or by preheating or applying specific solutions to the distal lens if the device does not have a concrete anti-fogging system (such as GlideScope, Airtraq, King Vision, etc.).
Like any other device, VLs require a learning curve. Those who have a shovel similar to that of the Macintosh (without a canal) need a transglottic device (guarantor, Frova, Eschman, etc.), inserted through a technique that must be learned since they can generate traumatisms on the soft palate during its introduction. On the other hand, if the operator cannot properly position the device-channel blade, the tube can be guided into the esophagus. When this occurs, while maintaining a good vision of the glottis and the patient remains stable and well oxygenated, we can try to solve the problem by a light movement of the device (Figure 4) or the ETT (Figure 5), which will help guide the ETT and achieve successful intubation.
Technique to guide endotracheal tube (ETT).
Technique for orienting the endotracheal tube (ETT).
All of these devices allow an optimal visualization of the glottic anatomy, but sometimes the maneuvers required for intubation involve greater complexity because of the difficulty in orienting the ETT.
For this reason, specific guides and catheters have been designed for intubation.
Nevertheless, in parallel with the clinical use of these devices, complications have been described.
Thus, lacerations of the glottic mucosa, vocal cord lesions, subluxations of arytenoids, and supracarinal tears are some of the complications encountered with the use of these new devices.
If we decide to use any device in our patients we think about practical approach of this device and not only in theoretical applications. In the case of videolaryngoscopes, we can raise doubts about how is the procedure different of direct videolaryngoscopy?
When we will perform the intubation, we must take into account that videolaryngoscope intubation is quite different than traditional direct laryngoscopy. The videolaryngoscope blade must be inserted into the middle of the mouth and rotated around the tongue in order to line up the camera lens with the larynx.
Always insert the videolaryngoscope midline into the mouth looking at the patient until its tip has passed the palate.
Once the blade has turned the corner into the pharynx, look at the monitor while glancing at your patient to optimally position the blade.
There are three types of blade. The non-channeled blades can be equal to the traditional direct laryngoscope blade or can be angled. This angle used to be 60° or similar, and make impossible direct visualization of the glottis.
The third type is the channeled blades that have a channel to lead the ETT toward to the glottis.
We have to be very clear that videolaryngoscopes allow a view of the entrance of glottis independent of the line of sight, especially those that have angled blades, but if we use a non-channeled and non-angled blade, it will be equal to the traditional direct laryngoscope blade, and we have a similar glottic view if we perform a direct laryngoscopy.
Other important question is about patient head position regard. One of the most important features of these devices, particularly angled blades, is that the head and neck should be in extreme sniffing position or in a neutral position during all the intubation intent. We can see indirectly glottis, independent of the line of sight, because the image sensor is in the distal part of the blade. This give us a panoramic view of the glottis, without the need to “align the axes”, thus avoiding hyperextension of the head.
But, if we do not need to move head’s patient, do we still lift the jaw upward like in direct videolaryngoscopy? In clinical practice, Cormack-Lehane grade obtained with videolaryngoscopes use to be one or two at last in 99% of the cases. But, this view not guarantees the success of intubation, which is relatively frequent in videolaryngoscopes that have a curved leaf, especially during the learning stage. This difficulty in achieving intubation despite the correct exposure of the larynx even in expert hands may be finally impossible.
So, in practice, sometimes perform the traditional maneuvers as lift the jaw upward, BURP maneuver, wear the epiglottis or move carefully the videolaryngoscope can facilitate the intubation.
As stated above, usually all patients had grade 1 or 2 Cormack-Lehane views (grade 1: full glottic view; grade 2: partial glottic view; grade 3: epiglottis visible but no glottic view; and grade 4: epiglottis not visible) with videolaryngopscopes. However, achieving CL grade 1 laryngoscopy in videolaryngoscopy does not guarantee the success of OTI, which is relatively frequent in VLs that have a curved leaf.
There have been a number of maneuvers suggested to increase the success of passing the endotracheal tube when glottic visualization is excellent and the tube is not easily passed using usual methods.
With non-channeled blades, once the blade is positioned with the larynx in view (as we explain in the previous point), we insert the ETT along the right side of the blade. Even though the magnificent view of the larynx on the monitor at this point, we must remember that the larynx is not in the direct line of sight.
Therefore, a properly curved stylet must be used to guide the endotracheal tube into the larynx. Unlike the typical “hockey-stick” shape used during direct laryngscopy and in the standard videolaryngoscope blades, the stylet should match the curve on the angled blades.
If it is being used a standard stylet, it must be placed into the ETT and then mold it against the blade so that the curves match. The ETT can leave into the sleeve to keep it clean.
Because a standard disposable stylet is so malleable, occasionally it will straighten during insertion, especially if the oral space is tight. This leads to the scenario of being able to see the larynx and not being able to “get there”. There are specific stylets, some of them nondisposable, which are preconfigured to the correct curve of their videolaryngoscope. Some of them are very stiff and can potentially damage pharyngeal structures, so that they must pull back slightly before fully inserting the ETT into the trachea.
Regardless of which stylet you are using, insert the endotracheal tube with the curve aimed toward the right side of the mouth, under direct vision until to see it on the monitor.
At this point rotate the tube back toward the midline, and aim it at the glottic opening.
If the mouth is small, it can be helpful to insert the ETT into the mouth first, slide it far to the right side of the mouth, and then insert the videolaryngoscope non-channeled blade midline.
To avoid lesions, it is mandatory to look at the patient during insertion of the ETT as described above until its tip has passed out of view beyond the tonsillar pillars. Only after the tip of the ETT has turned the corner into the pharynx should you look at the monitor, otherwise you can injure teeth, lips, tongue, and pharyngeal structures. Manipulate the tip of the tube through the glottis, and then pause to withdraw the stylet 2–3 cm. to effectively soften the tip of the ETT. Advance the ETT into the trachea looking at the monitor.
Channeled videolaryngoscopes have the advantage of orienting the ETT toward the trachea, allowing directed intubation with a little manipulation of the airway.
After successful intubation, remove the videolaryngoscope looking at the patient, not the monitor.
And, finally, we must think about regurgitation. Cricoid pressure, also named Sellick maneuver, is a standard anesthetic maneuver used to reduce the risk of aspiration of gastric contents during the induction of general anesthesia, applied after induction, in the period between loss of consciousness and placement of a cuffed tracheal tube. This is also a standard component of a rapid sequence induction technique. Cricoid pressure has been shown to prevent gastric distension during mask ventilation too.
A correct Sellick maneuver should be applied with a force of 10 N when the patient is awake, increasing to 30 N as consciousness is lost. These pressures occlude the esophagus and prevent aspiration during intubation, but often resulting in worsened glottis view and complicate intubation.
If initial attempts at videolaryngoscopy are difficult during rapid sequence induction, cricoid pressure should be released. This should be done under vision and suction available and, if we see regurgitation, cricoid pressure should be immediately reapplied.
In most cases, there is sufficient time to improve the intubation conditions, to perform an initial assessment and to evaluate the risk of intubation, to verify the availability of material, inductive agents and to plan alternatives.
Even so, on other occasions, the urgency of intubation in ICU is extreme (cardiorespiratory arrest, polytrauma, coma, etc.), and OTI should be performed in an optimal attempt of intubation with little time to optimize the patient.
Critical patient may present, mainly, hypoxemia, severe metabolic acidosis, hypotension, and right ventricular insufficiency [9, 16, 19, 20], with a degree of hemodynamic instability resulting in a low cardiopulmonary reserve, in addition to a full stomach, etc., and the implementation of a package of measures for intubation can reduce the incidence of life-threatening complications from 32 to 17% (p = 0.01) during intubation (biblioUCI46). This package of measures should consist of 10 key points (Table 2).
1. Presence of two operators. 2. Perform a loading of fluids (500 ml of isotonic saline or 250 ml of colloid) in the absence of cardiopulmonary edema. 3. Preparation of maintenance sedation. 4. Preoxygenation for 3 min with noninvasive mechanical ventilation (NIMV) in case of acute respiratory failure (100% FiO2, ventilatory support pressure between 5 and 15 cm H2O, to obtain an expiratory volume between 6 and 8 ml kg−1 and a PEEP of 5 cm H2O). |
5. |
6. Immediate confirmation of the position of the ETT by 7. Noradrenaline if diastolic BP remains <35 mmHg. 8. Initiate long-term sedation. 9. Initiate |
Package of measures for intubation in ICU.
Of these recommendations, six have individually demonstrated their benefit, both in anesthetic practice and in critical care (noninvasive mechanical ventilation [NIM], the presence of two operators, rapid sequence intubation [drugs and Sellick maneuver], capnography, and protection ventilation pulmonary).
The presence of a second operator in crisis situations has been shown to reduce the complications associated with the OTI procedure such as esophageal intubation (0.9% vs. 3.4%), traumatic intubation (1.7% vs. 6.8%), bronchoaspiration (0.9% vs. 5.8%), tooth damage (0% vs. 1.0%), and selective intubation (2.6% vs. 7.2%). The overall rate of complications also decreased significantly (6.1% vs. 21.7%, p < 0.0001) [89].
Therefore, prior to anesthetic induction, at least the presence of two operators, water overload and preoxygenation with NIMV is recommended for 3 min in case of acute respiratory failure.
Before the AM should be prepared the basic material:
Ventilation: facial mask of adequate size, manual resuscitator, oropharyngeal cannula.
Intubation: laryngoscopes, videolaryngoscopes, endotracheal tubes, extraglottic devices (such as FROVA or an introducer of Eschmann).
Position: the position of the patient is an important factor and limits the reduction of functional residual capacity. Several studies have shown that prior oxygenation in the semi-seated position or with the head at 25° can achieve greater PaO2 [90, 91].
Vacuum cleaner.
Medication.
In the case of expected intubation difficulty, there should be a practically immediate availability of advanced AM material with different rescue devices of ventilation and intubation difficulty, as well as a Coniotomy cannula in the event of an eventual CICO situation.
The ICU should have prepared a difficult airway trolley, similar to those that can be found in the surgical blocks [1] (Figure 6).
Reanimation difficult airway trolley examples. Left, Infanta Leonor University Hospital. Right, Getafe University Hospital, Madrid, Spain.
Acute hypoxemic insufficiency is the main cause of intubation in the ICU.
One-third of patients had severe arterial desaturation (SatO2 < 80%) during intuation manevers.
Hypoxemia may favor the complications observed during intubation such as arrhythmias, myocardial ischemia, cardiac arrest, and hypoxia in the brain.
Preoxygenation is the administration of 100% FiO2 before induction. This maneuver aims to displace the alveolar nitrogen (N2) by replacing it with oxygen (denitrogenation), in order to obtain an intrapulmonary O2 reserve that allows the maximum apnea time with the lowest desaturation [92, 93, 94, 95, 96].
Traditional preoxygenation, performed with ventilation at current volume with Mapleson circuit and well-sealed facial mask, using a fresh gas flow of 5 L/min. of 100% oxygen for 3–5 min [94], is insufficient in the critical patient [97]. And only 50% of these patients will experience an increase of their PaO2 higher than 5% compared to their baseline values after conventional preoxygenation for 4 min [98].
In all ICU patients, preoxygenation should be performed using a NIMV with PEEP 5–10 cm H2O + PS 5–15 with FiO2 100%, a management that has been shown to prevent patient desaturation during the procedure [98].
The mean pressure on AM will lead to alveolar recruitment, with the temporary reduction of intrapulmonary shunt [99] and an improvement in oxygenation. However, when this positive pressure is removed for OTI there is a risk of alveolar dis-reclusion, which will cause rapid desaturation.
Maintenance of continuous positive pressure during intubation with the use of a nasal mask has been shown to be beneficial in the operating room to patients with hypoxemic respiratory insufficiency and may be useful in ICU [100]. This apnea (or apneic) oxygenation is based on the alveolar pressure exerted by the blood circulation in the alveoli at slightly sub-atmospheric levels, generating a negative pressure gradient.
Another option is the high-flow nasal cannula (CNAF), a system that can provide up to 100% warm and humidified FiO2 at a maximum flow of 60 L/min. [101].
This system allows an increase in CO2 clearance due to better pharyngeal space clearance [102], in addition to the generation of a continuous positive pressure in flow-dependent AM (CPAP) (up to 7.4 cm H2O to 60 L/min), with the reduction of respiratory resistance and maintenance of alveolar opening.
Idea of NIMV use during preoxygenation is to recruit lung tissue available for gas exchange: “
The combination of preoxygenation/denitrogenation (with FiO2 100%) and the apneic period associated with the OTI procedure can dramatically decrease the pulmonary ventilation volume ratio, causing atelectasis.
Recruitment maneuver (RM) consists of a transient increase in inspiratory pressure, and there are several possible maneuvers such as applying a CPAP of 40 cm H2O during 30–40 s immediately after the OTI. When compared with not do, RM is associated with a higher PaO2 (with FiO2 100%) 5 min (93 ± 36 vs. 236 ± 117 mmHg) and 30 min (39 ± 180 vs. 110 ± 79 mmHg) after intubation [103, 104].
Peri-OTI hypotension is a risk factor for adverse events, including cardiorespiratory arrest related to the management of AM, and up to 30% of critically ill patients may present post-OTI cardiovascular collapse [21, 54, 105, 106, 107].
Systolic blood pressure (SBP) <70 mmHg complicates 10% of intubations in ICU patients [9, 54, 106, 107], and when the patient has a preinduction gravity HR/SBP > 0.8, hemodynamic optimization should be performed pre-OTI and use inducing drugs with little response.
In responder patients, resuscitation with volume [108, 109, 110] can be made, while in the nonresponders, a perfusion of noradrenaline will be initiated [111, 112].
If pre-OTI resuscitation is not feasible due to the critical situation of the patient, vasoactive drugs will be prepared for bolus administration in order to maintain blood pressure during OTI and subsequent resuscitation. Although there is insufficient evidence, adrenaline diluted at a concentration of 1–10 mcg mL−1, to be administered in boluses of 10–50 mcg, may be most indicated because of its inotropic effect [16, 109, 110, 113, 114].
In patients who are not in shock but exhibit a transient drop in post-OTI blood pressure due to the vasodilatory effects of induction agents or the onset of positive pressure ventilation, diluted phenylephrine at a concentration of 100 mcg mL−1 will be administered in boluses at 50–200 mcg [16, 109, 110].
When acidemia develops from respiratory acidosis, it can be corrected rapidly by increasing alveolar ventilation. However, when acidemia depends on metabolic acidosis, maintenance of acid-base homeostasis depends on compensatory respiratory alkalosis based on alveolar hyperventilation.
In situations of severe metabolic acidosis such as diabetic ketoacidosis, poisoning salicylate, or severe lactic acidosis, the patient may not be able to make an alveolar hyperventilation that achieves buffering generated organic acids with a worsening acidosis [9, 16, 19, 20, 105, 115].
When OTI is required in these patients, even a brief apnea time can lead to a significant drop in pH given the loss of respiratory compensation that was already insufficient.
Therefore, OTI should be avoided in patients with severe metabolic acidosis in whom adequate ventilation with the ventilator cannot be ensured, and NIV can be used to adequately support respiratory work until correction of underlying metabolic acidosis.
If the OTI cannot be delayed, getting the patient to maintain spontaneous ventilation becomes a critical action during intubation and mechanical ventilation, as this will allow the patient to maintain their own minute ventilation. For this, agents with a low probability of generating apnea should be used. In addition, rapid sequence intubation should be avoided if possible, and if deemed necessary, a short-acting neuromuscular blocker such as succinylcholine should be used.
Once OTI is achieved, a ventilator mode should be chosen that allows the patient to establish and maintain their own minute ventilation to maintain respiratory compensation better.
The main function of the right ventricle and pulmonary circulation is gas exchange. Under normal conditions, these are a low pressure and high-volume system which, in addition, must dampen the dynamic changes in volume and blood flow resulting from breathing, positional changes, and changes in left ventricular cardiac output. The adaptations needed to meet these conflicting requirements result in reduced compensation capacity in the event of a rise in afterload or pressure [105, 113, 116].
The failure of the system generates right heart failure, so that the right ventricle becomes unable to meet the demands, dilating, retrograde flow, decreased coronary perfusion and, ultimately, systemic hypotension and cardiovascular collapse [107, 110, 117].
When a patient with right heart failure requires OTI, increased afterload and decreased preload associated with invasive mechanical ventilation often leads to this cardiovascular collapse [21, 54, 105, 107, 113, 118].
In these patients, we should try to achieve pre-OTI hemodynamic optimization, including reduction of afterload with inhaled pulmonary artery vasodilators such as inhaled nitric oxide (INO) [119] or inhaled epoprostenol (Flolan) [113, 120].
In addition, good preoxygenation due to the reduction of intrapulmonary shunt [99], as well as apneic oxygenation [98, 106] will be essential, as well as avoid hypercapnia and high alveolar pressures, because they lead to vasoconstriction.
As in the surgical setting, in order to limit the incidence of serious complications during OTI in the ICU, the entire process (pre-, peri-, and post-intubation) should be guided by protocols oriented to patient safety [2, 46, 121, 122, 123, 124].
This critical AM algorithm will be based, firstly, on the outcome of the assessment of the difficulty of intubation according to the MACOCHA score [51] (Figure 7).
Macocha score protocol.
Always check the availability of the equipment for the AM and an eventual DA before the OTI. And, in the case of desaturation <80% during the procedure, the patient will be ventilated.
In the case of failure of intubation and ventilation, emergency ventilation through NIMV through a SAD allowing intubation [125] will be performed.
Two operators should always be present, especially if an AD with a MACOCHA score ≥3 is predicted, an extraglottic device (e.g. FROVA or an Eschmann introducer) should be used, and a rapid sequence induction be performed.
The use of a VL is also recommended in cases of difficult intubation. Nonetheless, in cases of abundant secretions, even after aspiration, direct laryngoscopy will be preferable to videolaryngoscopy.
Finally, in case of failure of intubation, an extraglottic device (e.g. FROVA or an Eschmann introducer) will be used first, followed by a VL if it was not initially used, rescue with a supraglottic airway device (SAD) that allows intubation, fiber optic bronchoscopy (FOB) and, at last, percutaneous or surgical rescue in situations of failure of intubation, ventilation, and oxygenation (CICO).
It will be those patients who present a MACOCHA score <3.
The R rapid sequence induction (RSI) SI techniques are indicated in these cases, among others, in the ICU, hospital emergency services and out-of-hospital emergencies.
The purpose of the RSI is to make emergency intubation easier and safer, and thus increase the success rate and reduce potential complications.
There is no single RSI technique due to its numerous indications, so the choice of the drug and the regimen of administration will be conditioned, not only by the reduction of the risk of aspiration and the facilitation of intubation but also by the characteristics of patient [88, 115, 126, 127]. However, the key elements that remain in all RSI protocol are:
Preoxygenation/denitrogenation to prolong apnea time.
Prevention of hypoxia and hypotension during induction and intubation.
Use of a cuffed ETT, and capnographic confirmation of the placement of the tube.
In spite of the lack of a single RSI technique, the main steps could be summarized in [85, 88, 126, 127]:
Valuation, planification, and preparation.
Preoxygenation.
Premedication.
Induction and relaxation.
Application of the Sellick maneuver.
Laryngoscopy.
Intubation. The RSI should allow us to intubate in a time no longer than 60 s from the administration of inducing drugs.
Checking the placement of the ETT.
Apnea following induction and neuromuscular relaxation may lead to rapid desaturation in the critical patient, if not in severe complications. In patients with previously DA [6, 40, 128, 129] or in those who were suspected according to a MACOCHA score ≥ 3, awake intubation would represent a valid option from the point of view of safety of the procedure [23, 29, 123, 130, 131, 132, 133].
This intubation with the awake patient can be performed with a noninvasive technique or with an invasive technique (surgical or percutaneous), and among its advantages is that, by maintaining muscle tone, permeability of the airway and spontaneous ventilation, awake patients are easier to intubate because inducing general anesthesia tends to shift the larynx anterior.
The prerequisites for awake intubation in the ICU are:
Previously difficult airway scenario or positive predictive signs (MACOCHA score ≥ 3).
Patient cooperation.
Equipment familiar with awake intubation techniques.
Adequate AM preparation.
Contraindications:
Human team inexperience.
Negative of the patient.
Allergy to local anesthetics.
Hemorrhage in oropharyngeal cavity.
Before an intubation failure, we can find two possible scenarios:
There are different SAD that have been used to rescue ventilation with a difficult facial mask. The usual in ICU after ensuring oxygenation is that endotracheal intubation is necessary, so it is recommended to have some of the SAD that allow intubation through it [3].
In the case of failure, a CICO scenario will be declared, the worst of the possible scenarios.
CICO scenario is the end of the algorithms, and always constitutes a medical emergency that forces to explore an alternative plan based on transtracheal access, either through a percutaneous cricothyrotomy (choice for its speed), a surgical tracheotomy or through retrograde intubation.
This situation is reached when the attempt to AM had failed through tracheal intubation, facial mask ventilation, and a SAD. At this point, if the situation is not resolved quickly, hypoxic brain damage and death will occur.
The key points of the non-intubatable/non-oxygenable AM plan are:
The CICO scenario must be declared and proceed to anterior neck access.
A didactic technique has been described using a scalpel to promote standardized training.
Placing an endotracheal balloon tube through the cricothyroid membrane facilitates normal minute ventilation with a standard ventilation system.
High-pressure oxygenation through a fine cannula is associated with increased morbidity.
All operators must be trained in performing a surgical approach.
Training should be repeated at regular intervals to ensure that skills are not lost.
Through the training program of those specialists who develop their professional activity in ICU must be guaranteed the acquisition of skills in critical patient’s advanced airway management (Figure 8).
Teamwork, roles, goals and communication.
Those responsible for the training of each service should develop training programs based on simulation to maintain competencies with different devices: direct laryngoscopy, extraglottic devices, supraglottic devices, videolaryngoscopes, fiber optic bronchoscopes and cricothyrotomy set.
Also, each ICU should have immediate access 24 h a day to a difficult airway trolley that must include the same devices that the one usually available in the operating room.
Tracheal intubation in the critical patient is always potentially dangerous. Critically ill patients with acute respiratory, neurological, or cardiovascular failure requiring invasive mechanical ventilation are at high risk of difficult intubation and have organ dysfunctions associated with complications of intubation and anesthesia such as hypotension and hypoxemia. The complication rate increases with the number of intubation attempts. Videolaryngoscopy improves elective endotracheal intubation.
Every professional in ICU should have a basic knowledge about airway management, be familiar with algorithms to handle possible complications, and know correct use and interpretation of capnography. The algorithms that are usually handled by anesthesiologists in our routine clinical practice are not always useful in ICU because they contemplate alternatives such as awakening the patient or postponing the procedure that cannot be applied in a critical/emergency situation. The implementation of an intubation protocol in the ICU can contribute to significantly reduce the immediate severe complications associated with this procedure.
Airway management of patients admitted to the ICU is a challenge. New videolaryngoscopes have been proposed to improve management, but most studies comparing videolaryngoscopes with a standard direct laryngoscope (DL) have been performed in operating rooms. Therefore, the role of videolaryngoscopy in the ICU is still discussed, where there is a lack of scientific evidence and intubation conditions are worse than in the operating room. The Montpellier group has proposed and implemented a package for intubation care in its ICU which includes, among others, the use of two operators, fluid overload, preoxygenation, and, above all, the rapid detection of the position of the ETT by capnography. Including the use of videolaryngoscopy in this package, as described by De Jong et al. [51], the safety of tracheal intubation could be further improved.
The overall impact of VL on the anesthetic literature is weighed due to marked heterogeneity in the patient population, devices studied, operator experience, and confusion including manikin studies. While VL improves the ease of obtaining a view of the larynx, insertion of the ETT may be more difficult. VL may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a VL reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a VL affects the time required for intubation [134].
The study of VL in the ICU is difficult for similar reasons, although they are increasing in popularity [10, 36]. However, there is a need for randomized controlled trials (RCTs) of VL vs. DL in the ICU [31], the truth is that the use of VL in ICU is so widespread that such studies are impractical. A RCT could help determine which devices are most useful, and could study the impact of VL on both technical and human factors [135].
If randomized controlled trials demonstrating a benefit of videolaryngoscopy are designed in the future, it could become a new standard for tracheal intubation in the ICU, particularly in educational institutions, where tracheal intubations are often performed by residents in training.
Nevertheless, the introduction of videolaryngoscopy in the ICU should always be accompanied by formal training programs in the management of the DA and simulation using manikins with the specific device [47, 71, 121, 136, 137].
Best way to avoid the serious consequences associated with a DA is the constant preparation by all those who could be able to handle it, an adequate prior assessment of the patient and the capacity to face this situation with the different rescue alternatives, from the use of SAD, VL, and flexibility in the use of the FOB, to the management of cervical surgical neck access.
Finally, we must implement the capnography in the ICU, so that the capnograph will be used in every intubation maneuver in the critical patient. Capnography should be monitored continuously in all critical intubated patients requiring assisted ventilation, and all ICU staff should be trained in the interpretation and recognition of abnormal capnography tracings.
In summary, if we consider the latest data, exclusive use of VL in out-of-OR airway management, or disdain them, appears premature, and we agree with the authors that future research would be necessary to demonstrate the safe utility of videolaryngoscopy in the ICU context. Even though it is surely the future to follow.
Congenital malformations involving the gastrointestinal tract (GIT) can be broadly divided into upper and lower gut abnormalities (Table 1). Upper pathology involves the foregut tubes, which are proximal to the ligament of Treitz: the esophagus, stomach, duodenum, pancreas and hepatobiliary tract. Lower GIT anomalies include the mid and hindgut structures: the jejunum and ileum, which constitute the small bowel, the colon and anorectal malformations. Congenital anomalies can further be classified based on whether the defect is structural or functional. Structural anomalies result from either defective embryogenesis or intrauterine complications, such as ischemia. Functional defects have normal anatomy but disrupted flow of GIT contents. In most cases, structural defects adversely impact functional capability. This chapter reviews the clinical presentation, diagnostic work up and surgical management of upper and lower GIT congenital anomalies.
Anatomic relation | Embryonic source | Blood supply | Viscera | |
---|---|---|---|---|
Upper gastrointestinal tract | Proximal to ligament of Treitz | Foregut | Celiac axis | Esophagus Stomach Duodenum Biliary ducts Liver Pancreas |
Lower gastrointestinal tract | Distal to ligament of Treitz | Midgut | SMA | Jejunum Ileum Cecum Ascending colon Proximal 2/3 transverse colon |
Hindgut | IMA | Distal 1/3 transverse colon Descending colon Sigmoid colon Rectum Anal canal |
Embryologic derivates of the gastrointestinal tract.
SMA: superior mesenteric artery; IMA: inferior mesenteric artery.
During the fourth week of gestation, the embryonic ventral foregut differentiates into the esophagus and trachea. Muscular and neurovascular development of the esophagus is complete by the end of ninth week of gestation. It is likely that esophageal malformations result from errors during this developmental time period.
EA/TEF is categorized into five types and clinical presentation varies depending on the type of pathology (Figure 1). Type A is the most common (90% cases) and consists of proximal EA with a distal TEF. Type B consists solely of proximal EA (no fistula) whereas type C only has a TEF (no atresia). Type D has both a proximal and distal TEF in the setting of atresia. Type E consists of proximal EA with TEF and a distal esophageal pouch. Types D and E are exceedingly rare.
Types of tracheoesophageal fistulae depicted as figures A-E.
The infant will exhibit drooling and attempts at feeding will result in coughing, choking and regurgitation. Since types B and E have a proximal obstruction without distal fistulization, the infant will have a scaphoid abdomen and gas will not be seen in the bowel distally on radiograph. Type C may present with recurrent aspiration pneumonia and may not be diagnosed until later in life.
Prenatal ultrasound will demonstrate polyhydramnios and the blind end of the esophageal pouch may be visualized. After birth, unsuccessful attempt at passage of an oro- or nasogastric tube is diagnostic. The tip of the tube will be seen in the esophageal pouch on radiography.
Because of the VACTERL phenomenon (vertebral, anal, cardiac, tracheoesophageal, renal and limb deformities), renal and cardiac ultrasounds as well as plains films of the spine and limbs must be obtained to determine the presence of any other anomalies. An echocardiogram is particularly essential to ensure that the aortic arch is in its normal left-sided anatomic location because this impacts operative planning. Ventricular septal defect is the most common anomaly associated with EA/TEF.
Ideally, EA/TEF is corrected in a single procedure. Staged procedure, beginning with decompressive gastrostomy and fistula takedown, followed by esophageal reconstruction at a later date, is reserved for those too unstable to tolerate general anesthesia due to respiratory or cardiac defects. Infants with long gap atresia also undergo delayed repair to allow elongation of the proximal and distal esophageal ends.
In current practice, the minimally invasive approach using video assisted thoracoscopy is preferred to open thoracotomy. If the open approach is employed, a right posterolateral thoracotomy incision is made at the fourth intercostal space, sparing the serratus anterior and latissimus dorsi muscles. Extrapleural dissection is carried until the azygous vein is encountered, which is then divided. In the case of type A, the lower esophageal pouch and its associated fistula are identified. The fistula is resected. The proximal esophageal pouch is then mobilized to establish tension free continuity between the two ends. If a proximal fistula is present, this is ligated prior to mobilization. The esophagus is reconstructed via a single layer end-to-end anastomosis. A chest tube is placed and remains until post-operative esophogram confirms patency of the anastomosis. Anastomotic leaks tend to heal without intervention and are managed by continuation of chest tube and antibiotics.
Thoracoscopic approach has led to improved outcomes and most infants grow to lead fairly normal lives, given the lack of concurrent anomalies such as cardiac defects. Most commonly, gastroesophageal reflux (GER) and esophageal strictures are lifelong issues endured by the patient. GER may be asymptomatic or lead to persistent cough, respiratory problems or esophageal stricturing. Primary management is medical with anti-reflux medications and prokinetics. Surgical correction of GER with fundoplication is last resort. Esophageal strictures may form many years after repair and are best managed by endoscopic dilation. Recurrent or refractory esophageal strictures require surgical resection and re-anastomosis.
It results due to the failure of duodenal recanalization and most commonly occurs in the second portion of the duodenum distal to ampulla of Vater but any segment can be affected.
Emesis and feeding intolerance occurs in the first 24–48 h of life. The type of emesis—bilious versus non—depends on the location of atresia relative to the major duodenal papilla. If obstruction is distal to it, infant will exhibit bilious emesis. Obstruction proximal to the ampulla causes non-bilious emesis. Abdomen will not be distended due to proximal nature of obstruction. A palpable mass in the epigastrium may be appreciated on physical exam.
The “double bubble” on abdominal x-ray indicates air in stomach and duodenum but not in distal small bowel and colon. An UGI series must be obtained to rule out malrotation, which can also present with bilious emesis early in life and is a surgical emergency. UGI may reveal a duodenal web, which is an intraluminal diverticulum that appears as an elongated, conical silhouette resembling a “windsock”. Echocardiogram and renal ultrasound are performed to rule out any other defects as there is an association with trisomy 21 and its related complications.
“The diamond D”, Diamond Duodenoduodenostomy—A transverse incision is made in the proximal widened duodenum and a longitudinal incision in the distal tapered portion of the duodenum (Figure 2). The anastomosis is created in a diamond shape to facilitate mucosal abutment between the two incongruent duodenal diameters. During repair, evaluation for duodenal web must be performed because they are not always identified on pre-operative UGI and can cause persistent obstruction if not corrected. If present, a longitudinal duodenotomy is performed over the area of the web and it is excised. Careful attention must be paid to its location relative to the major duodenal papilla so as to not disrupt the integrity of the ampulla of Vater. The duodenotomy is closed in a transverse fashion to avoid narrowing of the lumen.
Diamond duodenoduodenostomy for duodenal atresia repair.
There tend to be few, if any, long term complications following correction of duodenal atresia. Persistent obstruction may indicate missed duodenal web and requires re-operation. Delayed gastric emptying may occur in the early postoperative period and does not warrant any intervention; most cases resolve with time and enteral feedings can be advanced in small volumes as tolerated.
The exact etiology is unknown. Exposure to erythromycin has been implicated as a risk factor [1].
It is characterized with feeding intolerance and non-bilious emesis that becomes projectile over time; usually presenting around 2–4 weeks of life, however, may not present up until 6–12 weeks. Emesis is non-bilious because the site of obstruction, the pylorus, is proximal to the ampulla of Vater. It tends to occur in first born Caucasian males.
On physical exam, may be able to palpate an “olive like” firm, mobile mass in the right upper quadrant or epigastrium, however this is often difficult to appreciate on a restless infant. Abdomen is otherwise soft and non-distended. Ultrasound is diagnostic and demonstrates a pyloric channel length ≥ 16 mm, wall ≥4 mm in thickness.
Repeated vomiting of gastric acid (HCl) leads to hypochloremia, alkalosis and dehydration. Hypovolemia stimulates aldosterone secretion with resultant sodium resorption and potassium secretion. Thus, the infant’s laboratory panel will reveal hypochloremic, hypokalemic metabolic alkalosis. Hydrogen is shifted extracellularly in exchange for potassium to correct the acid–base imbalance, exacerbating hypokalemia. Eventually, worsening hypokalemia stimulates the renal hydrogen-potassium pump to resorb potassium and secrete hydrogen, resulting in acidic urine. This is termed “paradoxical aciduria” because bicarbonate secretion should take precedence in an alkalotic state, but the nephrons prioritize correction of potassium at the expense of hydrogen loss instead.
Pyloric stenosis is not a surgical emergency and operative intervention is deferred until electrolytes have normalized, ideally, chloride >95, bicarbonate <30. As the primary metabolic derangements are caused by volume and gastric juice loss, resuscitation should be initiated with 10-20 cc/kg normal saline boluses. Once volume status has been adequately restored and urine output robust, potassium containing fluids (D5 1/2NS + 10 K/L) are administered at maintenance rate.
The Ramstedt pyloromytomy was historically carried out through a right subcostal transverse incision however the laparoscopic approach is becoming preferred in current practice. A longitudinal incision along the anterior surface of the pylorus is carried down through the serosa and hypertrophied muscle until the submucosa protrudes, much like slicing the tough outer skin of a grape until the smooth inner flesh is encountered. The length of the myotomy extends from the antrum of the stomach proximally to the pyloric vein of Mayo distally, which designates the junction of the pylorus and proximal duodenum. Oral feeding may be initiated 6–8 h post-operatively and advanced as tolerated.
Long term results from pyloromyotomy are excellent and few infants, if any, have residual complications. Incomplete myotomy can present with persistent feeding intolerance in the peri-operative period and requires re-operation.
The pathophysiology is unknown. Between 4 and 10 weeks of gestation, the extrahepatic biliary tract develops from the hepatic diverticulum. This occurs normally. In the post-natal period, there appears to be an inflammatory process that causes fibrosis of the extrahepatic biliary ducts [2].
Worsening jaundice unamenable to phototherapy during the first 2 weeks of life, subsequently demonstrating unrelenting direct hyperbilirubinemia are characteristic. Laboratory values are consistent with biliary obstruction and demonstrate direct hyperbilirubinemia and elevated alkaline phosphatase. Signs of cholestasis, dark urine and light or gray colored stools are present.
Hepatobiliary technetium-99 iminodiacetic acid scan (99-Tc IDA) has highest sensitivity and specificity [2]. Normally, the radiotracer is taken up by hepatocytes and readily excreted into the intestines via the biliary ducts. In biliary atresia, technetium will be taken up by the liver normally, but obstruction of the extrahepatic ducts prevents outflow of radiotracer into the duodenum. Abdominal ultrasound may reveal a small or obliterated gallbladder. Magnetic resonance cholangiopancreatography (MRCP) is also be helpful in ruling out intrahepatic atresia or choledocal cysts.
Expeditious operative intervention is imperative as liver damage can be attenuated, even reversed, and chance of survival improved with early biliary decompression. Beyond 3–4 months, irreversible liver damage may preclude successful outcome. The Kasai portoenterostomy is the procedure of choice. First, an intraoperative cholangiogram is performed to delineate the anatomy of the biliary tree and confirm the diagnosis. A liver biopsy is obtained to document degree of liver damage. Next, the fibrotic common bile duct is dissected from the hepatoduodenal ligament up to the level of the porta hepatis and excised. An approximately 20 cm limb of jejunum is brought up in a retrocolic fashion and a Roux-en-Y hepaticojejunostomy is created.
Successful, long term establishment of bile flow correlates with earlier surgical intervention. Infants aged <60 days at time of surgery have best results. Approximately one-third of children undergoing portoenterostomy have a 10-year or greater survival, while the rest will ultimately succumb to liver failure and require transplant. Other indications for liver transplant include presence of intrahepatic atresia, fat soluble vitamin deficiencies causing failure to thrive and variceal bleeding secondary to portal hypertension. 5-year survival following liver transplant ranges from 75 to 95% [2].
Apart from progressive liver failure, cholangitis is another major post-operative complication occurring in as much as 50% of patients who undergo portoenterostomy [2]. Decreased bile flow indicated by elevated total bilirubin in the setting of fever and leukocytosis is essentially diagnostic of cholangitis until proven otherwise. It is managed with IV antibiotics and fluid resuscitation.
Etiology is unknown. Aberrant pancreaticobiliary junction near the duodenal wall has been suggested [3].
Infants present with symptoms of biliary obstruction: progressive jaundice, dark urine, light colored stools. A tender abdominal mass may be palpated in the right upper quadrant. Laboratory values will be consistent with biliary obstruction and demonstrate elevated direct bilirubin and alkaline phosphatase. Patients may also present with cholangitis or pancreatitis.
While abdominal ultrasound and hepatobiliary 99-Tc IDA scan are useful, MRCP best delineates the anatomy of the biliary tree and is the diagnostic test of choice. There are five types (Figure 3). Type 1 is the most common and presents as saccular or fusiform dilation of the common bile duct (CBD; Figure 3A). Intrahepatic ducts are normal. Type 2 is an isolated CBD diverticulum (Figure 3B). Type 3 is a choledochocele, in which there is cystic dilation of the supra-duodenal CBD, prior to its junction with the pancreatic duct (Figure 3C). In type 4 disease, intra- and extra-hepatic bile ducts are dilated whereas in type 5 disease only intra-hepatic ducts are dilated (Figures 3D,E).
Normal anatomy of the hepatobiliary tree and its relationship to the pancreas and duodenum. (A) Choledocal cyst type 1: fusiform dilation of the extrahepatic duct common bile duct. (B) Choledocal cyst type 2: isolated diverticulum off the common bile duct. (C) Choledocal cyst type 3: supraduodenal choledococele. (D) Choledocal cyst type 4: cystic dilation of intra- and extra-hepatic bile ducts. (E) Choledocal cyst type 5, dilation of intra-hepatic ducts only.
Given the risk of cholangiocarcinoma, highest in types I and IV, surgical intervention is indicated at the time of diagnosis of any type of choledochal cyst. The approach depends on type of lesion. For type 1 cysts, primary cyst excision with cholecystectomy and roux-en-Y hepaticojejunostomy reconstruction is procedure of choice. Type 2 disease is managed by simple diverticulectomy. Type 3 is managed by transduodenal cyst excision or marsupialization and sphincteroplasty. Types 4 and 5 may be treated by anatomic hepatic resection based on the extent and location of disease, however, liver transplantation is ultimately required in most cases.
Excision of choledocal cysts result in excellent long-term outcomes with few major complications. Biliary tract malignancy, the most feared complication, may occur with incomplete excision. Cholangitis, stricture formation and choledocolithiasis are lesser significant complications that are managed medically and endoscopically, respectively.
Midgut development begins around the fifth week of gestation. The midgut starts as a vertical tube and has two connections: a ventral connection to the yolk sac via the omphalomesenteric (vitelline) duct and a dorsal attachment to the posterior abdominal wall, the mesentery [4, 5, 6]. The dorsal mesentery is the conduit for the superior mesenteric artery (SMA), which buds from the aorta, and delivers blood to the midgut. The lengthening gut tube outgrows the confines of the abdominal cavity and consequently herniates into the umbilical cord. As it elongates, it rotates 90° in a clockwise direction relative to the embryo (counterclockwise if visualized from the front). The midgut tube continues to grow extra-abdominally during gestational weeks 6–10. Around week 10, it retracts back into the abdominal cavity, rotating another 180° while doing so. Final intra-abdominal growth and fixation ensue, placing the cecum in the right lower quadrant and the duodeno-jejunal junction to the left of the upper midline, inferior to the SMA. The mesentery broadens, fanning out from its root in the posterior abdominal wall, to support the blood vessels and lymphatics that serve the jejunum, ileum, cecum/appendix, ascending colon and proximal 2/3 of the transverse colon. It is believed that ischemic events during this period cause jejunoileal atresia.
Atresia causes a structural obstruction that prevents passage of meconium in the first 24–48 h of life and results in bilious emesis. On physical exam, the abdomen will be distended.
Jejunoileal atresia is classified into four types (Figures 4A–E). Type 1 is an intraluminal web with intact mesentery (Figure 4A). The seromuscular layers of bowel remain in continuity. Type 2 also has an intact mesentery, but the two ends of bowel are disconnected by a fibrous cord (Figure 4B). Type 3a has a small v-shaped mesenteric defect that separates two blind ends of bowel (Figure 4C). In type 3b disease, known as an “apple-peel” or “Christmas-tree” deformity, a large mesenteric defect separates the proximal and distal ends of bowel. The proximal pouch is very dilated, and the distal collapsed bowel is supplied by a small vessel around which it repeatedly winds (Figure 4D). Type 4 consists of numerous blind ended segments of bowel with discontinuous mesentery, appearing as a “string of sausages” (Figure 4E).
(A) Type 1 jejunoileal atresia. (B) Type 2 jejunoileal atresia. (C) Type 3a jejunoileal atresia. (D) Type 3b jejunoileal atresia. (E) Type 4 jejunoileal atresia.
Abdominal x-ray will reveal dilated portions of bowel proximal to the site of obstruction with collapsed loops and paucity of air in the distal bowel. Contrast enema will demonstrate an abrupt transition from the filling to non-filling segments of small bowel and the colon will be appear small, <1 cm diameter, due to lack of use. In all cases of bilious emesis, an UGI series is warranted to rule out malrotation, a surgical emergency. UGI will reveal contrast filling in the stomach and proximal bowel, with abrupt cessation of contrast filling at the point of atresia.
Initial management begins with insertion of an oro- or nasogastric tube for bowel decompression and fluid resuscitation. Resection of atretic segments with end-to-end anastomoses is the procedure of choice; however, this can prove quite difficult in cases where ends of bowel are greatly mismatched in diameter. In such circumstances, the anastomosis is created in a fashion similar to duodenoduodenostomy in which the smaller end of bowel is incised longitudinally along its anti-mesenteric border to fit the end of the larger caliber bowel. Prior to completing the anastomosis, the entire length of the bowel must be inspected to ensure there are no intraluminal webs or fenestrations that may cause persistent obstruction. The goal is to resect all defunct bowel segments while maintaining enough length to ensure adequate resorptive capacity. If the ileocecal valve is spared, enteral nutrition can be tolerated with as little as 15–20 cm of small bowel. Otherwise, a length of approximately 40 cm is required [4]. Mesenteric defects are closed, taking care not to disrupt the feeding blood vessels.
Intestinal dysmotility, even in infants that have adequate remaining bowel length, may occur for many weeks following repair. Infants with short bowel syndrome, those with less than 40 cm, often require long term parenteral nutrition, which itself carries risks of sepsis and liver damage. Nonetheless, overall mortality is low and related to co-morbidities, such as low birth weight and/or cardiac defects.
As described above, normal 270° rotation and fixation of the midgut fails to occur [4, 5, 6, 7]. This lack of rotation positions the duodenum and small bowel to the right of the midline and the large bowel to the left. The cecum remains anterior to the duodenum and is tethered to the abdominal wall by lateral peritoneal attachments. These lateral peritoneal attachments, known as Ladd’s bands, compress the duodenum, thereby causing obstruction and resultant bilious emesis. The root of the mesentery is narrowed and may potentially act as fulcrum around which the bowel can twist (“volvulize”), thereby kinking the SMA and causing ischemia (Figure 5).
Intestinal malrotation showing abnormal position of cecum and Ladd’s bands
Acute malrotation with midgut volvulus presents with feeding intolerance and bilious emesis, usually around the first week of life. Abdominal rigidity, overlying erythema are signs of peritonitis and indicate ischemic bowel. Abdominal distention will not be present given the very proximal nature of pathology. As feeding intolerance and bilious emesis are symptoms of multiple pathologies, a high index of suspicion is required to make this diagnosis.
An abdominal X-ray is typically first obtained, though rarely helpful in establishing the diagnosis. Any concern for malrotation mandates a prompt UGI. A normal study will reveal contrast exiting the pylorus, descending through the second portion of the duodenum and crossing the midline through the third portion of the duodenum into the small bowel. Thus, a normal “C-loop” will be visualized. An abnormal study will demonstrate contrast exiting the pylorus and descending straight down to the right of the midline into the small bowel.
Once the diagnosis of acute malrotation is made, the patient is taken emergently to the operating room for detorsion and evaluation of bowel viability. Fluid resuscitation, insertion of oro- or nasogastric tube for decompression and administration of intravenous antibiotics have ideally been implemented prior to surgical intervention. The bowel is eviscerated and detorsed in a counterclockwise direction, fanning out its mesentery. Ladd’s bands are incised to release the obstruction. Any frankly necrotic appearing bowel is resected, while dusky bowel can be re-evaluated and usually salvaged in a second look operation 24–48 h later. Ends of healthy, viable bowel can be anastomosed, otherwise stomas are placed. A prophylactic appendectomy is performed to eliminate the possibility of appendicitis in the future. If a second look operation is required, the abdomen is left open and covered with a temporary sterile dressing; if not, it is closed.
Without significant intestinal necrosis requiring resection, outcomes following correction of malrotation are quite favorable. Infants grow normally and do not have any major adverse sequelae. Rarely, adhesive small bowel obstruction may occur years later, however any operation carries this risk.
This condition occurs as a result of the failure of the omphalomesenteric (vitelline) duct to completely involute between weeks 5–7 of gestation (Figure 6).
Omphalocele (left) and gastroschisis (right). The herniated intestine is covered with a sac with umbilical cord attached to it in omphalocele, while the intestinal loops in gastroschisis herniate through a defect on the right side of umbilicus and are not covered.
Meckel’s diverticulum is the most common congenital GIT malformation and the most common cause of painless lower intestinal bleeding in children. It usually presents by the age of 2 years, but presentation can be delayed into the teenage years. There is a male predominance. The bleeding is typically brisk and bright red. Laboratory values will demonstrate anemia. A fibrous cord connecting the diverticulum to the abdominal wall may be present and can act as a point around which bowel can obstruct, twist or intussuscept. In such cases, the child will present with abdominal pain and distention, inability to pass flatus or move their bowels.
Technetium-99 pertechnate scintigraphy (“Meckel’s scan”) localizes the bleeding ulcer. The diverticulum is typically found within 2 feet proximal to the ileocecal valve, on the anti-mesenteric side of the ileum and contains heterotopic mucosa, usually that of gastric or pancreatic in origin. Ulceration and bleeding occur secondary to acid secretion from the heterotopic mucosa. It is a true diverticulum involving all four layers of the bowel.
If bleeding is the presenting symptom, ileal resection with primary anastomosis is the procedure of choice. Segmental resection is also indicated in cases complicated by diverticulitis, perforation, obstruction, volvulus or if the base of the diverticulum is very wide. Simple diverticulectomy may be performed if the neck of the diverticulum is narrow, or if diverticulitis does not involve the base.
Resection of Meckel’s diverticulum has an excellent prognosis without major long term post-operative complications.
These are congenital defects of the abdominal wall, not of the gastrointestinal tract itself, but are discussed because they are associated with malrotation (Figure 6).
Numerous physical characteristics differentiate omphalocele from gastroschisis. The abdominal wall defect in omphalocele is midline, versus to the right of the umbilicus in gastroschisis. Defects tend to be smaller in gastroschisis, typically ≤3 cm. In comparison, omphaloceles can vary widely in diameter, ranging in size from 2 to 15 cm. Larger defects allow for herniation of more organs, namely the liver and spleen. This rarely, if at all, occurs in gastroschisis. Herniated contents are covered by an amniotic sac in omphalocele but not in gastroschisis. Exposure of the bowel to amniotic fluid during gestation causes the bowel to become thickened and the mesentery fibrotic whereas bowel is normal in omphalocele since it is protected by the overlying sac. Lastly, omphalocele has a higher association with chromosomal abnormalities and other congenital anomalies compared gastroschisis. Intestinal atresia may be seen in gastroschisis.
These defects may be appreciated on pre-natal ultrasound and are therefore expected upon delivery. Chest radiography, echocardiogram and renal ultrasound are performed to rule out associated anomalies in the case of omphalocele, as is karyotyping though this may have been performed prenatally.
Exposure of intestinal contents to the environment can result in significant insensible losses. Initial management aims to maintain adequate volume status and body temperature. The infant is placed under a warmer, fluid resuscitation commenced, and urinary catheter inserted to strictly monitor volume status. Oro- or naso-gastric tube is placed for bowel decompression. Intestinal contents are wrapped in a moist, sterile plastic dressing to prevent evaporative losses. In the case of omphalocele, care must be taken to prevent rupture of the protective sac. The goals of operation are to return the herniated contents into the abdominal cavity and close the defect. If this is unable to be accomplished either because the infant is too unstable to be taken to the operating room or because there is high risk of abdominal compartment syndrome, a silo can be sutured in place over the herniated viscera and contents gradually reduced. Daily manual reduction can be performed bedside, gently as tolerated, with complete reduction usually achieved over 3–7 days. The resultant ventral hernia is repaired once all viscera have been reduced and the infant deemed fit to tolerate general anesthesia.
Given the protective nature of the overlying sac in omphalocele, infants typically have normal bowel function following reduction and abdominal wall repair. Long term complications are related to concomitant congenital defects. In contrast, patients with gastroschisis, especially if they also have intestinal atresia, are subject to dysmotility, malabsorption and are at increased risk of developing necrotizing enterocolitis. These infants often require long term parenteral nutrition following surgical correction.
Aganglionosis of the myenteric plexus due to failure of neural crest cell migration during weeks 6–12 of embryonic development. Most often occurs in the rectum though any portion and, rarely, the entire bowel can be affected. The myenteric plexus lies in between the outer longitudinal and inner circular muscle layers of the colon and is responsible for peristalsis.
Aganglionosis results in a functional obstruction manifesting as failure to pass meconium within first 24 h of life. Abdominal distention may be present. Rectal stimulation causes explosive passage of air and stool. Because disease is distal, infant will likely be able to tolerate oral intake though may have intermittent episodes of bilious emesis. Less severe disease may not manifest until later in childhood, up to 2–3 years of age, with chronic constipation. There is an association with trisomy 21. Therefore, work up includes echocardiogram to rule out concomitant cardiac defects.
Gold standard is suction rectal biopsy, which demonstrates aganglionosis of the myenteric plexus. Biopsy should be obtained 1–1.5 cm proximal from the dentate line to ensure rectal specimen is obtained. Pathology will reveal unmyelinated nerve fibers with hypertrophied endings that stain darkly with acetylcholinesterase. Abdominal X-ray shows dilated proximal bowel with collapsed distal colon. Contrast enema is helpful in distinguishing transition zone between affected and normal colon however, gross anatomic distinction does not always correlate with histopathology [8].
Although various operative methods have been described, the fundamental principle of each procedure is the same: to establish continuity between the normal, ganglionic segments of bowel. In the past, multi-stage operations beginning with decompressive colostomy followed by definitive repair was common. Nowadays, single-stage laparoscopic approach is preferred. Regardless of procedure, however, intra-operative frozen section must be performed to confirm the presence of normal ganglionic colon prior to anastomosis, otherwise dysfunction will continue post-operatively.
The rectum/aganglionic segment is dissected circumferentially, everted through the anus and resected. Normal colon is pulled down and a low end-to-end colorectal anastomosis is created.
The aganglionic portion of bowel is bypassed and a posterior end to side anastomosis is created between the innervated segments of colon and distal rectum. The rectum is stapled at the proximal margin of disease. An incision is made in the distal posterior wall of the rectal stump approximately 1 cm superior to the dentate line. The innervated colon is pulled down through the presacral space and then anastomosed in an end-to-side fashion to the distal posterior rectal wall. The defunct rectal stump is left in place.
Circumferential endorectal dissection of rectal mucosa and submucosa, followed by evagination of these layers through the anus for resection. A rectal muscular channel remains, and innervated colon is intussuscepted through the remaining rectal muscular channel. A colorectal anastomosis is performed at the distal end of the muscular channel [9].
No single procedure has been shown to be superior to other in terms of long-term outcomes, and up to 90% patients will have relatively normal bowel function following repair. Although results tend to be quite favorable, one significant cause of significant morbidity and mortality is Hirschsprung’s enterocolitis. While the exact etiology of this entity is unknown, bacterial overgrowth and translocation appear to be implicated. Patients present with fever, abdominal distention and diarrhea. Management consists of fluid resuscitation, IV antibiotics and rectal irrigation. Refractory cases require surgical decompression with a proximal ostomy. Other complications such as anastomotic leak, stricture, abscess, wound infection and obstruction occur in up to 10% cases [1].
During the 5th week of gestation, the midline urorectal septum descends in a caudal direction toward the cloaca and divides into ventral and dorsal portions. The ventral bud becomes the urogenital sinus, which develops into the urethra and bladder. The dorsal bud becomes the rectum and anal membrane. The anal membrane involutes around week 8, thereby forming the anus. Dysgenesis can occur at any time point, allowing for variability in clinical presentation.
An anatomical distinction based on the pathology’s relation to the levator ani muscle complex was first described by Pena. The levator ani complex supports the pelvic floor and is composed of three striated muscles: the puborectalis, the pubococcygeus and the iliococcygeus. The puborectalis encircles the base of the rectum, helps to form the external anal sphincter and thereby plays an integral role in regulating defecation. Anorectal dysgenesis above the levator ani muscles is considered a “high” lesion. Conversely, lesions inferior to the levator ani complex are termed “low” malformations. Generally speaking, higher malformations tend to cause more severe issues with controlling defecation as the neuromuscular development between the levator ani complex and growing recto-anus is compromised to a greater degree.
Failure to pass meconium in the first 24–48 h of life. Physical exam will reveal abdominal distention and absence of anus. A subtle opening in the perineum through which small amounts of meconium pass may be present and indicates an anoperineal fistula in the setting of a low imperforate anus. This is the most common pathology seen. In females, low lesions may also be associated with a rectovestibular fistula, and meconium may be expressed through the vagina. Elimination of meconium during urination indicates rectourethral or rectovesicular fistula and a high rectal pouch.
Diagnosis is made upon physical examination of the perineum. Historically, an invertogram was performed to evaluate the length of atresia. In this study, a radiopaque marker is placed on the infant’s bottom, where the anus would normally be located, and the infant is placed in a head down position to allow air to ascend at the most inferior point in the rectum. Lateral films of the pelvis are then obtained. The distance between the marker and distal rectum indicate the level of pathology—high vs. low. Now, ultrasound is preferred.
Anorectal malformations are part of the VACTERL syndrome and most commonly associated with concomitant genitourinary defects. In addition to a renal ultrasound, a voiding cystourethrogram should be obtained, especially if a rectourethral/rectovesicular fistula is suspected as this can help delineate the tract. Plains films of the chest, limbs and spine as well as an echocardiogram help identify the presence of other anomalies. Any other life-threatening co-morbidities take precedence, and a temporary diverting ostomy can be placed until definitive repair can be safely performed, usually between 8 and 12 months of age.
Posterior sagittal anorectoplasty (PSARP) is the surgical procedure performed. The infant is placed in a prone jack-knife position. If a perineal fistula is present, an incision is made around the fistula and carried posteriorly toward the coccyx. If no perineal fistula is present, the incision starts inferior to the coccyx and is carried down to the perineum. It is imperative to remain midline. This is ensured by visualizing striated muscle fibers, which run perpendicular to the incision. If fat is encountered during the dissection, this indicates that the operator has deviated from midline and entered the lateral ischioanal/ischiorectal space. The rectum is identified by its overlying glistening fascia and then freed circumferentially, beginning posteriorly and advancing anteriorly until the fistula is encountered. The fistula is resected. After the fistula is taken down, the anterior rectal wall is freed from its surrounding structures. In females, the anterior rectum lies in close proximity to the posterior vaginal wall and in males, the prostate and bladder. The anterior rectal wall is gently dissected off these structures up to the peritoneal reflection. Complete, circumferential dissection of the rectum will allow for tension-free pull down and anastomosis. The rectum is situated in its anatomic position in the muscle complex. The muscle complex is repaired around the properly positioned rectum and the neoanus is created by suturing mucosa to the perineum.
Long terms outcomes are dependent on the level of pathology—high versus low anorectal dysgenesis—and the extent of neuromuscular development of the levator ani complex and rectum. Almost all children will require some degree of lifestyle modifications to manage fecal incontinence or, conversely, chronic constipation. This is achieved by strict bowel regimens with enemas or cathartics. In more severe cases, a cecostomy or appendicostomy may be required to allow for daily antegrade enemas. Worst case scenarios may necessitate a diverting ostomy.
The contribution of Natalia Louise Smith is greatly appreciated for drawing the figures numbered as 1-to-6.
The Internet has irrevocably changed the dynamics of scholarly communication and publishing. Consequently, we find it necessary to indicate, unambiguously, our definition of what we consider to be a published scientific work.
",metaTitle:"Prior Publication Policy",metaDescription:"Prior Publication Policy",metaKeywords:null,canonicalURL:"/page/prior-publication-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"A significant number of working papers, early drafts, and similar work in progress are openly shared online between members of the scientific community. It has become common to announce one’s own research on a personal website or a blog to gather comments and suggestions from other researchers. Such works and online postings are, indeed, published in the sense that they are made publicly available. However, this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
\\n\\nThe significance of Peer Review cannot be overstated when it comes to defining, in our terms, what constitutes a published scientific work. Peer Review is widely considered to be the cornerstone of modern publishing processes and the key value-adding contribution to a scholarly manuscript that a publisher can make.
\\n\\nOther than the issue of originality, research misconduct is another major issue that all publishers have to address. IntechOpen’s Retraction & Correction Policy and various publication ethics guidelines identify both redundant publication and (self)plagiarism to fall within the definition of research misconduct, thus constituting grounds for rejection or the issue of a Retraction if the work has already been published.
\\n\\nIn order to facilitate the tracking of a manuscript’s publishing history and its development from its earliest draft to the manuscript submitted, we encourage Authors to disclose any instances of a manuscript’s prior publication, whether it be through a conference presentation, a newspaper article, a working paper publicly available in a repository or a blog post.
\\n\\nA note to the Academic Editor containing detailed information about a submitted manuscript’s previous public availability is the preferred means of reporting prior publication. This helps us determine if there are any earlier versions of a manuscript that should be disclosed to our readers or if any of those earlier versions should be cited and listed in a manuscript’s references.
\\n\\nSome basic information about the editorial treatment of different varieties of prior publication is laid out below:
\\n\\n1. CONFERENCE PAPERS & PRESENTATIONS
\\n\\nGiven that conference papers and presentations generally pass through some sort of peer or editorial review, we consider them to be published in the accepted scholarly sense, particularly if they are published as a part of conference proceedings.
\\n\\nAll submitted manuscripts originating from a previously published conference paper must contain at least 50% of new original content to be accepted for review and considered for publication.
\\n\\nAuthors are required to report any links their manuscript might have with their earlier conference papers and presentations in a note to the Academic Editor, as well as in the manuscript itself. Additionally, Authors should obtain any necessary permissions from the publisher of their conference paper if copyright transfer occurred during the publishing process. Failure to do so may prevent Us from publishing an otherwise worthy work.
\\n\\n2. NEWSPAPER & MAGAZINE ARTICLES
\\n\\nNewspaper and magazine articles usually do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense. Articles appearing in newspapers and magazines rarely possess the depth and structure characteristic of scholarly articles.
\\n\\nSubmitted manuscripts stemming from a previous newspaper or magazine article will be accepted for review and considered for publication. However, Authors are strongly advised to report any such publication in an accompanying note to the External Editor.
\\n\\nAs with the conference papers and presentations, Authors should obtain any necessary permissions from the newspaper or magazine that published the work, and indicate that they have done so in a note to the External Editor.
\\n\\n3. GREY LITERATURE
\\n\\nWhite papers, working papers, technical reports and all other forms of papers which fall within the scope of the ‘Luxembourg definition’ of grey literature do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense.
\\n\\nAlthough such papers are regularly made publicly available via personal websites and institutional repositories, their general purpose is to gather comments and feedback from Authors’ colleagues in order to further improve a manuscript intended for future publication.
\\n\\nWhen submitting their work, Authors are required to disclose the existence of any publicly available earlier drafts in a note to the Academic Editor. In cases where earlier drafts of the submitted version of the manuscript are publicly available, any overlap between the versions will generally not be considered an instance of self-plagiarism.
\\n\\n4. SOCIAL MEDIA, BLOG & MESSAGE BOARD POSTINGS
\\n\\nWe feel that social media, blogs and message boards are generally used with the same intention as grey literature, to formulate ideas for a manuscript and gather early feedback from like-minded researchers in order to improve a particular piece of work before submitting it for publication. Therefore, we do not consider such internet postings to be publication in the scholarly sense.
\\n\\nNevertheless, Authors are encouraged to disclose the existence of any internet postings in which they outline and describe their research or posted passages of their manuscripts in a note to the Academic Editor. Please note that we will not strictly enforce this request in the same way that we would instructions we consider to be part of our conditions of acceptance for publication. We understand that it may be difficult to keep track of all one’s internet postings in which the researcher´s current work might be mentioned.
\\n\\nIn cases where there is any overlap between the Author´s submitted manuscript and related internet postings, we will generally not consider it to be an instance of self-plagiarism. This also holds true for any co-Author as well.
\\n\\nFor more information on this policy please contact permissions@intechopen.com.
\\n\\nPolicy last updated: 2017-03-20
\\n"}]'},components:[{type:"htmlEditorComponent",content:'A significant number of working papers, early drafts, and similar work in progress are openly shared online between members of the scientific community. It has become common to announce one’s own research on a personal website or a blog to gather comments and suggestions from other researchers. Such works and online postings are, indeed, published in the sense that they are made publicly available. However, this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
\n\nThe significance of Peer Review cannot be overstated when it comes to defining, in our terms, what constitutes a published scientific work. Peer Review is widely considered to be the cornerstone of modern publishing processes and the key value-adding contribution to a scholarly manuscript that a publisher can make.
\n\nOther than the issue of originality, research misconduct is another major issue that all publishers have to address. IntechOpen’s Retraction & Correction Policy and various publication ethics guidelines identify both redundant publication and (self)plagiarism to fall within the definition of research misconduct, thus constituting grounds for rejection or the issue of a Retraction if the work has already been published.
\n\nIn order to facilitate the tracking of a manuscript’s publishing history and its development from its earliest draft to the manuscript submitted, we encourage Authors to disclose any instances of a manuscript’s prior publication, whether it be through a conference presentation, a newspaper article, a working paper publicly available in a repository or a blog post.
\n\nA note to the Academic Editor containing detailed information about a submitted manuscript’s previous public availability is the preferred means of reporting prior publication. This helps us determine if there are any earlier versions of a manuscript that should be disclosed to our readers or if any of those earlier versions should be cited and listed in a manuscript’s references.
\n\nSome basic information about the editorial treatment of different varieties of prior publication is laid out below:
\n\n1. CONFERENCE PAPERS & PRESENTATIONS
\n\nGiven that conference papers and presentations generally pass through some sort of peer or editorial review, we consider them to be published in the accepted scholarly sense, particularly if they are published as a part of conference proceedings.
\n\nAll submitted manuscripts originating from a previously published conference paper must contain at least 50% of new original content to be accepted for review and considered for publication.
\n\nAuthors are required to report any links their manuscript might have with their earlier conference papers and presentations in a note to the Academic Editor, as well as in the manuscript itself. Additionally, Authors should obtain any necessary permissions from the publisher of their conference paper if copyright transfer occurred during the publishing process. Failure to do so may prevent Us from publishing an otherwise worthy work.
\n\n2. NEWSPAPER & MAGAZINE ARTICLES
\n\nNewspaper and magazine articles usually do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense. Articles appearing in newspapers and magazines rarely possess the depth and structure characteristic of scholarly articles.
\n\nSubmitted manuscripts stemming from a previous newspaper or magazine article will be accepted for review and considered for publication. However, Authors are strongly advised to report any such publication in an accompanying note to the External Editor.
\n\nAs with the conference papers and presentations, Authors should obtain any necessary permissions from the newspaper or magazine that published the work, and indicate that they have done so in a note to the External Editor.
\n\n3. GREY LITERATURE
\n\nWhite papers, working papers, technical reports and all other forms of papers which fall within the scope of the ‘Luxembourg definition’ of grey literature do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense.
\n\nAlthough such papers are regularly made publicly available via personal websites and institutional repositories, their general purpose is to gather comments and feedback from Authors’ colleagues in order to further improve a manuscript intended for future publication.
\n\nWhen submitting their work, Authors are required to disclose the existence of any publicly available earlier drafts in a note to the Academic Editor. In cases where earlier drafts of the submitted version of the manuscript are publicly available, any overlap between the versions will generally not be considered an instance of self-plagiarism.
\n\n4. SOCIAL MEDIA, BLOG & MESSAGE BOARD POSTINGS
\n\nWe feel that social media, blogs and message boards are generally used with the same intention as grey literature, to formulate ideas for a manuscript and gather early feedback from like-minded researchers in order to improve a particular piece of work before submitting it for publication. Therefore, we do not consider such internet postings to be publication in the scholarly sense.
\n\nNevertheless, Authors are encouraged to disclose the existence of any internet postings in which they outline and describe their research or posted passages of their manuscripts in a note to the Academic Editor. Please note that we will not strictly enforce this request in the same way that we would instructions we consider to be part of our conditions of acceptance for publication. We understand that it may be difficult to keep track of all one’s internet postings in which the researcher´s current work might be mentioned.
\n\nIn cases where there is any overlap between the Author´s submitted manuscript and related internet postings, we will generally not consider it to be an instance of self-plagiarism. This also holds true for any co-Author as well.
\n\nFor more information on this policy please contact permissions@intechopen.com.
\n\nPolicy last updated: 2017-03-20
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr.",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Rheinmetall (Germany)",country:{name:"Germany"}}},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. His research interests include the application of agent technology for achieving agile control in the manufacturing environment.",institutionString:null,institution:null},{id:"605",title:"Prof",name:"Dil",middleName:null,surname:"Hussain",slug:"dil-hussain",fullName:"Dil Hussain",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/605/images/system/605.jpg",biography:"Dr. Dil Muhammad Akbar Hussain is a professor of Electronics Engineering & Computer Science at the Department of Energy Technology, Aalborg University Denmark. Professor Akbar has a Master degree in Digital Electronics from Govt. College University, Lahore Pakistan and a P-hD degree in Control Engineering from the School of Engineering and Applied Sciences, University of Sussex United Kingdom. Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. He has contributed in stochastic estimation of control area especially, in the Multiple Target Tracking and Interactive Multiple Model (IMM) research, Ball & Beam Control Problem, Robotics, Levitation Control. He has contributed in developing Algorithms for Fingerprint Matching, Computer Vision and Face Recognition. He has been supervising Pattern Recognition, Formal Languages and Distributed Processing projects for several years. He has reviewed many books on Management, Computer Science. Currently, he is an active and permanent reviewer for many international conferences and symposia and the program committee member for many international conferences.\nIn teaching he has taught the core computer science subjects like, Digital Design, Real Time Embedded System Programming, Operating Systems, Software Engineering, Data Structures, Databases, Compiler Construction. 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This introductory chapter explains how a new tool can be added to this toolkit: robots. The use of robotic assets in search and rescue operations is explained and an overview is given of the worldwide efforts to incorporate robotic tools in search and rescue operations. Furthermore, the European Union ICARUS project on this subject is introduced. The ICARUS project proposes to equip first responders with a comprehensive and integrated set of unmanned search and rescue tools, to increase the situational awareness of human crisis managers, such that more work can be done in a shorter amount of time. The ICARUS tools consist of assistive unmanned air, ground, and sea vehicles, equipped with victim-detection sensors. The unmanned vehicles collaborate as a coordinated team, communicating via ad hoc cognitive radio networking. To ensure optimal human-robot collaboration, these tools are seamlessly integrated into the command and control equipment of the human crisis managers and a set of training and support tools is provided to them to learn to use the ICARUS system.",book:{id:"6181",slug:"search-and-rescue-robotics-from-theory-to-practice",title:"Search and Rescue Robotics",fullTitle:"Search and Rescue Robotics - From Theory to Practice"},signatures:"Geert De Cubber, Daniela Doroftei, Konrad Rudin, Karsten Berns,\nAnibal Matos, Daniel Serrano, Jose Sanchez, Shashank Govindaraj,\nJanusz Bedkowski, Rui Roda, Eduardo Silva and Stephane Ourevitch",authors:[{id:"206420",title:"Dr.",name:"Geert",middleName:null,surname:"De Cubber",slug:"geert-de-cubber",fullName:"Geert De Cubber"}]},{id:"56737",doi:"10.5772/intechopen.69738",title:"UAV for Landmine Detection Using SDR-Based GPR Technology",slug:"uav-for-landmine-detection-using-sdr-based-gpr-technology",totalDownloads:3444,totalCrossrefCites:14,totalDimensionsCites:17,abstract:"This chapter presents an approach for explosive-landmine detection on-board an autonomous aerial drone. The chapter describes the design, implementation and integration of a ground penetrating radar (GPR) using a software defined radio (SDR) platform into the aerial drone. The chapter?s goal is first to tackle in detail the development of a custom-designed lightweight GPR by approaching interplay between hardware and software radio on an SDR platform. The SDR-based GPR system results on a much lighter sensing device compared against the conventional GPR systems found in the literature and with the capability of re-configuration in real-time for different landmines and terrains, with the capability of detecting landmines under terrains with different dielectric characteristics. Secondly, the chapter introduce the integration of the SDR-based GPR into an autonomous drone by describing the mechanical integration, communication system, the graphical user interface (GUI) together with the landmine detection and geo-mapping. This chapter approach completely the hardware and software implementation topics of the on-board GPR system given first a comprehensive background of the software-defined radar technology and second presenting the main features of the Tx and Rx modules. Additional details are presented related with the mechanical and functional integration of the GPR into the UAV system.",book:{id:"5905",slug:"robots-operating-in-hazardous-environments",title:"Robots Operating in Hazardous Environments",fullTitle:"Robots Operating in Hazardous Environments"},signatures:"Manuel Ricardo Pérez Cerquera, Julian David Colorado Montaño\nand Iván Mondragón",authors:[{id:"177422",title:"Dr.",name:"Julian",middleName:null,surname:"Colorado",slug:"julian-colorado",fullName:"Julian Colorado"},{id:"197884",title:"Prof.",name:"Ivan",middleName:null,surname:"Mondragon",slug:"ivan-mondragon",fullName:"Ivan Mondragon"},{id:"199958",title:"Prof.",name:"Manuel",middleName:null,surname:"Perez",slug:"manuel-perez",fullName:"Manuel Perez"}]}],mostDownloadedChaptersLast30Days:[{id:"56737",title:"UAV for Landmine Detection Using SDR-Based GPR Technology",slug:"uav-for-landmine-detection-using-sdr-based-gpr-technology",totalDownloads:3443,totalCrossrefCites:14,totalDimensionsCites:17,abstract:"This chapter presents an approach for explosive-landmine detection on-board an autonomous aerial drone. The chapter describes the design, implementation and integration of a ground penetrating radar (GPR) using a software defined radio (SDR) platform into the aerial drone. The chapter?s goal is first to tackle in detail the development of a custom-designed lightweight GPR by approaching interplay between hardware and software radio on an SDR platform. The SDR-based GPR system results on a much lighter sensing device compared against the conventional GPR systems found in the literature and with the capability of re-configuration in real-time for different landmines and terrains, with the capability of detecting landmines under terrains with different dielectric characteristics. Secondly, the chapter introduce the integration of the SDR-based GPR into an autonomous drone by describing the mechanical integration, communication system, the graphical user interface (GUI) together with the landmine detection and geo-mapping. This chapter approach completely the hardware and software implementation topics of the on-board GPR system given first a comprehensive background of the software-defined radar technology and second presenting the main features of the Tx and Rx modules. Additional details are presented related with the mechanical and functional integration of the GPR into the UAV system.",book:{id:"5905",slug:"robots-operating-in-hazardous-environments",title:"Robots Operating in Hazardous Environments",fullTitle:"Robots Operating in Hazardous Environments"},signatures:"Manuel Ricardo Pérez Cerquera, Julian David Colorado Montaño\nand Iván Mondragón",authors:[{id:"177422",title:"Dr.",name:"Julian",middleName:null,surname:"Colorado",slug:"julian-colorado",fullName:"Julian Colorado"},{id:"197884",title:"Prof.",name:"Ivan",middleName:null,surname:"Mondragon",slug:"ivan-mondragon",fullName:"Ivan Mondragon"},{id:"199958",title:"Prof.",name:"Manuel",middleName:null,surname:"Perez",slug:"manuel-perez",fullName:"Manuel Perez"}]},{id:"67705",title:"Advanced UAVs Nonlinear Control Systems and Applications",slug:"advanced-uavs-nonlinear-control-systems-and-applications",totalDownloads:1971,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"Recent development of different control systems for UAVs has caught the attention of academic and industry, due to the wide range of their applications such as in surveillance, delivery, work assistant, and photography. In addition, arms, grippers, or tethers could be installed to UAVs so that they can assist in constructing, transporting, and carrying payloads. In this book chapter, the control laws of the attitude and position of a quadcopter UAV have been derived basically utilizing three methods including backstepping, sliding mode control, and feedback linearization incorporated with LQI optimal controller. The main contribution of this book chapter would be concluded in the strategy of deriving the control laws of the translational positions of a quadcopter UAV. The control laws for trajectory tracking using the proposed strategies have been validated by simulation using MATLAB®/Simulink and experimental results obtained from a quadcopter test bench. Simulation results show a comparison between the performances of each of the proposed techniques depending on the nonlinear model of the quadcopter system under investigation; the trajectory tracking has been achieved properly for different types of trajectories, i.e., spiral trajectory, in the presence of unknown disturbances. Moreover, the practical results coincided with the results of the simulation results.",book:{id:"7792",slug:"unmanned-robotic-systems-and-applications",title:"Unmanned Robotic Systems and Applications",fullTitle:"Unmanned Robotic Systems and Applications"},signatures:"Abdulkader Joukhadar, Mohammad Alchehabi and Adnan Jejeh",authors:null},{id:"60953",title:"Small to Medium UAVs for Civilian Applications in Indonesia",slug:"small-to-medium-uavs-for-civilian-applications-in-indonesia",totalDownloads:1339,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Indonesian government needs a well-built, easy to operate unmanned aircraft systems (UAS) to perform various civilian missions as UAS are a well-known platform for dirty, dull, and dangerous missions. Hence, the Indonesian government has an organization that performs research and development of UAS, named as Aeronautic Technology Center. This organization is placed underneath Indonesian National Institute of Aeronautics and Space. The UAS developments in this institute are primarily driven by civilian uses; therefore, the UAS size, sensor types, and mission payload are optimized for civilian missions. In order to produce the decent to the best quality of the aerial image, which is the essential product for various civilian missions, the UAS regularly flies under the cloud. For this reason, the Aeronautic Technology Center is only developing the LASE (low altitude, short-endurance) and the LALE (low altitude, long endurance) UAS type as of now. The UAS development was begun with LSU-01, followed by LSU-02, LSU-03, and LSU-05. The LSU-01, LSU-02, and LSU-03 are in the operational phase, while the LSU-05 is in the experimental Phase. In this chapter, the specification of the platforms and the sensor capabilities that are relevant with the demands of users in the civilian sector are described.",book:{id:"6465",slug:"drones-applications",title:"Drones",fullTitle:"Drones - Applications"},signatures:"Fuad Surastyo Pranoto, Ari Sugeng Budiyanta and Gunawan Setyo\nPrabowo",authors:[{id:"223333",title:"M.Sc.",name:"Fuad",middleName:"Surastyo",surname:"Pranoto",slug:"fuad-pranoto",fullName:"Fuad Pranoto"},{id:"223356",title:"MSc.",name:"Ari Sugeng",middleName:null,surname:"Budiyanta",slug:"ari-sugeng-budiyanta",fullName:"Ari Sugeng Budiyanta"},{id:"223357",title:"MSc.",name:"Gunawan Setyo",middleName:null,surname:"Prabowo",slug:"gunawan-setyo-prabowo",fullName:"Gunawan Setyo Prabowo"}]},{id:"67003",title:"Vision-Based Autonomous Control Schemes for Quadrotor Unmanned Aerial Vehicle",slug:"vision-based-autonomous-control-schemes-for-quadrotor-unmanned-aerial-vehicle",totalDownloads:978,totalCrossrefCites:0,totalDimensionsCites:4,abstract:"This chapter deals with the development of vision-based sliding mode control strategies for a quadrotor system that would enable it to perform autonomous tasks such as take-off, landing and visual inspection of structures. The aim of this work is to provide a basic understanding of the quadrotor dynamical model, key concepts in image processing and a detailed description of the sliding mode control, a widely used robust non-linear control scheme. Extensive MATLAB simulations are presented to enhance the understanding of the controller on the quadrotor system subjected to bounded disturbances and uncertainties. The vision algorithms developed in this chapter would provide the necessary reference trajectory to the controller enabling it to exercise control over the system. This work also describes, in brief, the implementation of the developed control and vision algorithms on the DJI Matrice 100 to present real-time experimental data to the readers of this chapter.",book:{id:"7792",slug:"unmanned-robotic-systems-and-applications",title:"Unmanned Robotic Systems and Applications",fullTitle:"Unmanned Robotic Systems and Applications"},signatures:"Archit Krishna Kamath, Vibhu Kumar Tripathi and Laxmidhar Behera",authors:null},{id:"59130",title:"The Use of Unmanned Aerial Vehicles by Urban Search and Rescue Groups",slug:"the-use-of-unmanned-aerial-vehicles-by-urban-search-and-rescue-groups",totalDownloads:1294,totalCrossrefCites:5,totalDimensionsCites:6,abstract:"In the case of natural or man-made disaster, the top priority of urban search and rescue (USAR) groups is to localise the victim as quickly as possible. Even minutes might play a crucial role in the victim’s survival. A number of standard operating procedures may be applied to achieve best performance. Rescue dogs are trained to search for alive victims; special inspection cameras are used, before heavy equipment is being implemented. To improve the effectiveness of USAR group operations, innovative technologies might be implemented. The most recent solution is currently designed in MOBNET project, founded by EU under the Horizon 2020 programme. The scope of the project is to combine both cellular technology and early Galileo services to localise the smartphones of potential victims. Integration tests give some promising outcomes. 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Ribeiro-Barros",profilePictureURL:"https://mts.intechopen.com/storage/users/171036/images/system/171036.jpg",institutionString:"University of Lisbon",institution:{name:"University of Lisbon",institutionURL:null,country:{name:"Portugal"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},subseriesFiltersForPublishedBooks:[{group:"subseries",caption:"Sustainable Economy and Fair Society",value:91,count:1}],publicationYearFilters:[{group:"publicationYear",caption:"2022",value:2022,count:1}],authors:{paginationCount:250,paginationItems:[{id:"274452",title:"Dr.",name:"Yousif",middleName:"Mohamed",surname:"Abdallah",slug:"yousif-abdallah",fullName:"Yousif Abdallah",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274452/images/8324_n.jpg",biography:"I certainly enjoyed my experience in Radiotherapy and Nuclear Medicine, particularly it has been in different institutions and hospitals with different Medical Cultures and allocated resources. Radiotherapy and Nuclear Medicine Technology has always been my aspiration and my life. As years passed I accumulated a tremendous amount of skills and knowledge in Radiotherapy and Nuclear Medicine, Conventional Radiology, Radiation Protection, Bioinformatics Technology, PACS, Image processing, clinically and lecturing that will enable me to provide a valuable service to the community as a Researcher and Consultant in this field. My method of translating this into day to day in clinical practice is non-exhaustible and my habit of exchanging knowledge and expertise with others in those fields is the code and secret of success.",institutionString:null,institution:{name:"Majmaah University",country:{name:"Saudi Arabia"}}},{id:"313277",title:"Dr.",name:"Bartłomiej",middleName:null,surname:"Płaczek",slug:"bartlomiej-placzek",fullName:"Bartłomiej Płaczek",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/313277/images/system/313277.jpg",biography:"Bartłomiej Płaczek, MSc (2002), Ph.D. (2005), Habilitation (2016), is a professor at the University of Silesia, Institute of Computer Science, Poland, and an expert from the National Centre for Research and Development. His research interests include sensor networks, smart sensors, intelligent systems, and image processing with applications in healthcare and medicine. 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. His research interests include computer graphics, computer vision, image processing, machine learning, pattern recognition, soft computing, data science, intelligent systems, information technology, and information systems. Prof. Sarfraz has been a keynote/invited speaker on various platforms around the globe. He has advised various students for their MSc and Ph.D. theses. He has published more than 400 publications as books, journal articles, and conference papers. He is a member of various professional societies and a chair and member of the International Advisory Committees and Organizing Committees of various international conferences. Prof. Sarfraz is also an editor-in-chief and editor of 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:"267434",title:"Dr.",name:"Rohit",middleName:null,surname:"Raja",slug:"rohit-raja",fullName:"Rohit Raja",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/267434/images/system/267434.jpg",biography:"Dr. Rohit Raja received Ph.D. in Computer Science and Engineering from Dr. CVRAMAN University in 2016. His main research interest includes Face recognition and Identification, Digital Image Processing, Signal Processing, and Networking. Presently he is working as Associate Professor in IT Department, Guru Ghasidas Vishwavidyalaya (A Central University), Bilaspur (CG), India. He has authored several Journal and Conference Papers. He has good Academics & Research experience in various areas of CSE and IT. He has filed and successfully published 27 Patents. He has received many time invitations to be a Guest at IEEE Conferences. He has published 100 research papers in various International/National Journals (including IEEE, Springer, etc.) and Proceedings of the reputed International/ National Conferences (including Springer and IEEE). He has been nominated to the board of editors/reviewers of many peer-reviewed and refereed Journals (including IEEE, Springer).",institutionString:"Guru Ghasidas Vishwavidyalaya",institution:{name:"Guru Ghasidas Vishwavidyalaya",country:{name:"India"}}},{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:{name:"University of Silesia",country:{name:"Poland"}}},{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:null,institution:{name:"Beijing University of Technology",country:{name:"China"}}},{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:"265335",title:"Mr.",name:"Stefan",middleName:"Radnev",surname:"Stefanov",slug:"stefan-stefanov",fullName:"Stefan Stefanov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/265335/images/7562_n.jpg",biography:null,institutionString:null,institution:{name:"Medical University Plovdiv",country:{name:"Bulgaria"}}},{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:"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:"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:"Igor Victorovich Lakhno 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.\nPh.D. – 1999, Kharkiv National Medical Univesity.\nDSC – 2019, PL Shupik National Academy of Postgraduate Education \nProfessor – 2021, Department of Obstetrics and Gynecology of VN Karazin Kharkiv National University\nHead of Department – 2021, Department of Perinatology, Obstetrics and gynecology of Kharkiv Medical Academy of Postgraduate Education\nIgor Lakhno has been graduated from international training courses on reproductive medicine and family planning held at Debrecen University (Hungary) in 1997. Since 1998 Lakhno Igor has worked as an associate professor in 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 been a professor in the department of obstetrics and gynecology of VN Karazin National University and a professor of the perinatology, obstetrics, and gynecology department. He’s affiliated with Kharkiv Medical Academy of Postgraduate Education as a Head of Department from November 2021. Igor Lakhno has participated in several international projects on fetal non-invasive electrocardiography (with Dr. J. A. Behar (Technion), Prof. D. Hoyer (Jena University), and José Alejandro Díaz Méndez (National Institute of Astrophysics, Optics, and Electronics, Mexico). He’s an author of about 200 printed works and there are 31 of them in Scopus or Web of Science databases. Igor Lakhno is a member of the Editorial Board of Reproductive Health of Woman, Emergency Medicine, and Technology Transfer Innovative Solutions in Medicine (Estonia). He is a medical Editor of “Z turbotoyu pro zhinku”. Igor Lakhno is a reviewer of the Journal of Obstetrics and Gynaecology (Taylor and Francis), British Journal of Obstetrics and Gynecology (Wiley), 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 a DSc degree “Pre-eclampsia: prediction, prevention, and treatment”. Three years ago Igor Lakhno has participated in a training course on innovative technologies in medical education at Lublin Medical University (Poland). 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: are obstetrics, women’s health, fetal medicine, and cardiovascular medicine. \nIgor Lakhno is a consultant at Kharkiv municipal perinatal center. He’s graduated from training courses on endoscopy in gynecology. He has 28 years of practical experience in the field.",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. RELACION DE PONENCIAS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGIA. 10/2014.",institutionString:null,institution:null},{id:"243698",title:"Dr.",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:null,institution:null},{id:"7227",title:"Dr.",name:"Hiroaki",middleName:null,surname:"Matsui",slug:"hiroaki-matsui",fullName:"Hiroaki Matsui",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Tokyo",country:{name:"Japan"}}},{id:"312999",title:"Dr.",name:"Bernard O.",middleName:null,surname:"Asimeng",slug:"bernard-o.-asimeng",fullName:"Bernard O. Asimeng",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Ghana",country:{name:"Ghana"}}},{id:"318905",title:"Prof.",name:"Elvis",middleName:"Kwason",surname:"Tiburu",slug:"elvis-tiburu",fullName:"Elvis Tiburu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Ghana",country:{name:"Ghana"}}},{id:"336193",title:"Dr.",name:"Abdullah",middleName:null,surname:"Alamoudi",slug:"abdullah-alamoudi",fullName:"Abdullah Alamoudi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Majmaah University",country:{name:"Saudi Arabia"}}},{id:"318657",title:"MSc.",name:"Isabell",middleName:null,surname:"Steuding",slug:"isabell-steuding",fullName:"Isabell Steuding",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Harz University of Applied Sciences",country:{name:"Germany"}}},{id:"318656",title:"BSc.",name:"Peter",middleName:null,surname:"Kußmann",slug:"peter-kussmann",fullName:"Peter Kußmann",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Harz University of Applied Sciences",country:{name:"Germany"}}}]}},subseries:{item:{id:"18",type:"subseries",title:"Proteomics",keywords:"Mono- and Two-Dimensional Gel Electrophoresis (1-and 2-DE), Liquid Chromatography (LC), Mass Spectrometry/Tandem Mass Spectrometry (MS; MS/MS), Proteins",scope:"With the recognition that the human genome cannot provide answers to the etiology of a disorder, changes in the proteins expressed by a genome became a focus in research. Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. The Proteomics topic aims to attract contributions on all aspects of MS-based proteomics that, by pushing the boundaries of MS capabilities, may address biological problems that have not been resolved yet.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11414,editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",slug:"paolo-iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",biography:"Paolo Iadarola graduated with a degree in Chemistry from the University of Pavia (Italy) in July 1972. He then worked as an Assistant Professor at the Faculty of Science of the same University until 1984. In 1985, Prof. Iadarola became Associate Professor at the Department of Biology and Biotechnologies of the University of Pavia and retired in October 2017. Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. He is a Consultant Reviewer for several journals, including the Journal of Chromatography A, Journal of Chromatography B, Plos ONE, Proteomes, International Journal of Molecular Science, Biotech, Electrophoresis, and others. He is also Associate Editor of Biotech.",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",slug:"simona-viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",biography:"Simona Viglio is an Associate Professor of Biochemistry at the Department of Molecular Medicine at the University of Pavia. She has been working since 1995 on the determination of proteolytic enzymes involved in the degradation process of connective tissue matrix and on the identification of biological markers of lung diseases. She gained considerable experience in developing and validating new methodologies whose applications allowed her to determine both the amount of biomarkers (Desmosine and Isodesmosine) in the urine of patients affected by COPD, and the activity of proteolytic enzymes (HNE, Cathepsin G, Pseudomonas aeruginosa elastase) in the sputa of these patients. Simona Viglio was also involved in research dealing with the supplementation of amino acids in patients with brain injury and chronic heart failure. She is presently engaged in the development of 2-DE and LC-MS techniques for the study of proteomics in biological fluids. The aim of this research is the identification of potential biomarkers of lung diseases. 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