Examples for gas sensor applications.
\r\n\tThe fifth topic is “complications and drug side effects in the treatment of pigmentation disorders”. These include drug allergies, hyper- and hypopigmentation, persistent skin depigmentation, scars, skin burns, and the potential for skin cancer and skin lymphoma. The last topic is called “coping and support along with skin pigmentation diseases”. Increase the quality of life, psychotherapy, team therapy, and asking for understanding and support from family members.
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The research of environmental gas sensors started since the 1960s with metal oxide films. In 1962, Seiyama et al. [3] reported thermally evaporated ZnO thin film sensor of thickness 1–100 nm for the detection of several volatile organics, hydrocarbon, and carbon dioxide at temperature above 400°C. Taguchi demonstrated SnO2-based semiconductor sensor. He patented his work [4] and formed the famous company named Figaro Engineering Inc. Due to the strict environmental pollution norms imposed for emission of various toxic gases, research on gas sensors and materials expanded exponentially in the last 50 years. Several 10,000 research papers were published to claim suitable gas sensors. In 1980, Advani et al. proposed a SnO2 thin film for H2 gas sensor [5]. The device based on SnO2 thick film gas sensor was reported by Heiland et al. [6] and thin film by Sberveglieri [7]. More efforts were given to develop sensors based on thin films to detect toxic gases mostly at room temperature. Several review articles on the progress of thin film sensors are available in the literature.
\nThe rapid growth of industrializations in modern life has enhanced the risk of pollution deteriorating the atmospheric environment around us. Thus it is necessary to control and monitor such pollutants to avoid health hazards.
\nTable 1 depicts potential gas sensor applications for various reasons. Several commercial sensors are available for gas detection in different environments. However, the demand of compact, reliable, cheap, selective, and low power consuming sensors is still not yet met. Therefore, extensive research is going on to satisfy the specific need of the situation.
\nApplications | \n
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Examples for gas sensor applications.
There is no accurate definition of thin film but it is limited by thickness. The film below 1 μm is considered as thin film, and film above it is considered as thick film. But, normally when a solid material is coated on solid support, called substrate, by either physical or chemical process, it is called as a thin film. It should be highlighted here that it is not only a small thickness (<1 μm) that endows the great and special distinguished characteristics but also the microstructure which is equally important. Thin films characteristically have different properties from the thick films [8]. Many researchers are investigating thick and thin film gas sensors using different materials like metal oxides, ceramic and polymer materials, etc. But, the problems associated with these sensors are limited by the measurement accuracy and long-term stability [9]. To solve this problem, nanotechnology plays a major role to rectify and provide huge opportunity to establish the next-generation gas sensor devices with enhanced sensing performance in terms of fast response and recovery, good reversibility, low power consumption, and excellent sensitivity at extremely low gas concentration by using nanostructured sensing materials [10, 11, 12].
\nFrom the literature it is seen that nanostructured materials have attracted keen attention for several applications including gas sensing. These include semiconductor metal oxide nanowires, nanoribbons, nanorods, carbon and other nanotubes, diamonds, graphene, and combination of these which make more interesting nanostructures. A major attraction of the nanomaterials in the gas sensor application is because of high surface area to volume ratio. This possibly deliberates high sensitivity due to the excellent adsorption of gas species on the available molecular binding site and thus often increases sensing capability [13]. Based on the materials, the following gas sensors can be considered for research and developments.
\nTo fabricate the nanostructured gas sensors, semiconducting metal oxides are the most widely used material. The schematic diagram of semiconducting metal oxide thin film gas sensor is shown in Figure 1. The electrical conductivity of semiconductor gets modified once the surface is exposed to sensing gas. Nanostructure metal oxide thin film produces very high sensitivity due to high surface activity and unique microstructure. High adsorption of gas species on the surface and subsequent catalytic activity with the adsorbed species enhance sensing performance and thus reducing response time compared to the conventional microstructure gas sensor.
\nSchematic of metal oxide thin film gas sensor.
Semiconducting metal oxides in the form of nanowire, nanobelt, and nanoparticles are also widely used for detecting various gases. The majority of the sensor work reported in the literature so far are based on various metal oxide semiconductors. These materials can be doped easily or sensitized by appropriate metal to tailor-made sensitivity, selectivity, and also operating temperature. Very recently, a comprehensive review article was published by Li et al. to document all different types of such gas sensors for detecting several toxic gases [14]. The metal oxide gas sensors have an advantage of working in the lower-temperature range with high sensitivity. However, metal oxide nanosensors are more expensive than the thick film or bulk material gas sensors because of the deposition of nanothin film using highly sophisticated techniques and also the use of advanced microscopic analysis for characterizing the materials to improve its sensing characteristics [15].
\nIn recent year, organic polymer-based nanosensors have been specially developed for detecting aromatic compounds, medicine, ionic species, amines, organic vapor, and gases [16]. Generally, the conducting polymers are coated on a substrate in the form of thin film. The sensor structures can either be with film with two electrodes or field-effect transistor with controlled electric field to monitor sensing current. Many such structures are also available in the literature. Figure 2 shows such structures. The sensitivity of the polymer-based gas sensor depends on the sensing area of the device and thickness of the film. Addition of metal oxides, carbon nanoparticles, or fibers in the polymer-based sensors leads to the increase of sensitivity. The deposition techniques of thin film are very simple and the process is cheap also. The main problems with polymer-based sensor are lower stability with temperature and time and their lack of selectivity. The studies have been carried out to improve the stability and selectivity of polymer-based sensors by adding the carbon nanoparticles and fibers, but still some problems are yet to be solved.
\n(a) Chemiresistor device structure; S, surface; I, interface with insulating substrate; C, contact. (b) Conducting polymer active layer in field-effect transistor (FET) (reproduced from Ref. [
Nanosensor with metal or normally metal nanoparticles dispersed on the substrate surface is also proposed [18]. In this case, very high surface exposure with respect to volume results more adsorption of gases. When these nanoparticles interact with gas molecules, change of electronic properties including that of substrate takes place rapidly. Vaporizing metal precursor deposition method produces metal film or metal nanoparticles, and subsequent annealing treatment produces these kinds of nanosensor. Maximum studies reported so far use metal oxide as a substrate with metal nanoparticle dispersed for such nanosensor device surface. Some of these sensors work at low temperature. Metal complex nanosensors have their unique property, i.e., ability to create reversible interaction with other atoms. Many studies, reported as metal complex, mostly act as a receptor for various types of molecules. This activity can increase the sensitivity and selectivity of different sensors [19]. The advantage of using metal complex as a sensing layer creates reversible interaction between the gas molecules and the device. The changing chemical environment or increasing the temperature affects the bonding formation during the gas sensing process. This type of sensors, based on the receptors, is designed to interact with specific gases to increase selectivity. However, synthesizing metal complex sensing layers for nanosensors is generally expensive.
\nAmong the nanostructured gas sensor, carbon-based materials are proven to be very promising gas sensors due to high surface area, excellent intrinsic electrical properties, and good thermal and chemical stability [20, 21, 22]. A typical carbon-based nanostructured (CNT-carbon nanotube) gas sensor is shown in Figure 3. In the twenty-first century, the carbon allotrope, graphene, has been found to be an extraordinary material for many applications due to its excellent electronic, optical, chemical, thermal, and mechanical properties [23]. Graphene is defined as one-atom-thick planar with sp2 hybridized 2D honeycomb crystal lattice of carbon. The stack of few atomic layers of graphene considered as a graphene sheets exhibits the semimetallic electronic behavior with zero bandgap energy state [24]. Graphene is differentiated as pristine graphene (PG), graphene oxide (GO), and reduced graphene oxide (RGO).
\nSchematic diagram of a FET device based on CNT(s) (adapted from Ref. [
In gas sensing application, graphene materials have unique sensing capability based on two-dimensional structural property of PG, GO, and RGO due to superior electron transport phenomena [25]. In 2007, the charge density of graphene was found to increase by the adsorbed gas molecules. Schedin developed the first graphene-based gas sensor [26]. The adsorption of gas molecules leads to the change of the electrical conductivity, i.e., local carrier concentration of graphene that attributed to the electron acting as donor/acceptor. All the varieties of graphene have different surface functional group and unique electrical properties, which play vital role in the sensing mechanism. In pristine graphene (PG), the adsorption of gas molecules can induce even very few charge carriers, resulting in a notable change in electrical conductivity.
\nGraphene oxide (GO) is different from pristine graphene due to its physical and chemical properties. GO is considered as promising material for gas sensing application because of highly rich oxygen functional group [27]. Prezioso et al. [28] using GO sensor device studied NO2 gas sensing performance by varying the gas concentration at different operating temperatures to optimize the sensing efficiency. The oxygen functional group on the surface is mainly attributed to the sensing activity, and also when the device tested in both oxidizing and reducing environment, a typical p-type sensing response is observed. GO-based gas sensors have been used to detect the low concentration of nitrogen dioxide, hydrogen, and other gases also. GO-based sensor device reveals the high and fast sensing performance as compared to the RGO-based device. However, reduced graphene oxide (RGO) is easily synthesized from graphene oxide. By removing oxygen-containing groups and without changing the conjugated structure from GO, reduced graphene oxide (RGO) sheet can be obtained. In gas sensing application, RGO has more advantages than pristine graphene (PG) like inexpensive to prepare, possible to modify structure, fine tuning of structure, etc. [29, 30]. Many reported as available on the use of RGO for detecting gas molecules like NH3, NO2, H2, etc. [31, 32, 33]. These sensors are tested in lower gas concentrations, and they exhibit high sensing response and reversibility at ambient temperature with low power consumptions. The limitation of RGO in practical application of low selectivity in gas sensor device is the same as the pristine graphene (PG). More detail of literature can be referred in the recent sensor review article based on carbon nanotube and graphene by Mao et al. [21].
\nThe first gas sensor reported in the literature is based on thin film semiconductor. Since sensitivity, selectivity, and long-term stability are the main parameters for sensor for mass applications, various methods have been used to prepare sensor devices. Developing ultrathin film sensor with enhanced sensitivity at low concentration is challenging. In the field of gas sensor applications based on semiconductor thin film, the morphology and thickness of film play a crucial role for sensing properties of the materials. Several standard techniques are available for the fabrication of thin film. Thermal evaporation, electron beam evaporation, laser-assisted evaporation and sputtering, molecular beam epitaxy, etc. are well-known physical deposition techniques.
\nOn the other hand, many useful techniques such as hydrothermal, sol-gel, chemical vapor deposition (CVD), spray CVD, microwave, dip coating, spin coating, etc. are used for depositing ultrathin films. The steps of making thin films using the above techniques are either standardized or as per the requirements; some modifications are done to achieve good quality films. Standard methods can be referred from various handbooks of thin film preparation [34, 35, 36]. The surface of thin film should be very active for gas sensing. Therefore, each of the techniques has some advantages and limitations. Grain size, film thickness, surface roughness (surface area) porosity, etc. significantly transform the film for effective detection of gas molecules down to ppm or sub-ppm level at room temperature.
\nIn most of the films, surface adsorption-desorption of gases modifies the electrical conductivity of the material. Very recently, using slow evaporation rate of 0.02–0.3 nm/s in thermal evaporation technique, copperphthalocyanine (CuPc) organic semiconductor was deposited with thickness 10–40 nm to fabricate organic thin film transistor for ppm level NH3 detection in room temperature [37]. The structure is shown in Figure 4. Using RF sputtering method, a 30-nm NiO film was deposited over sapphire and subsequently 1-nm platinum film was deposited over it by thermal evaporation for the detection of ammonia efficiently at low concentration at elevated temperature [38]. Several such works with ultrathin film have been reported in the literature. Since the demonstration of graphene-based sensor for detection of individual gas molecule almost a decade ago, several graphene-based sensors have been reported in the literature following newer techniques to improve the performance of the sensors [39, 40].
\n(a) Topography image of AFM of CuPc films with different thicknesses on PMMA dielectric. (b) Response curves for the four types of devices to NO2 pulses (reproduced with Ref. [
Generally, CVD, exfoliation, and other methods are used to prepare graphene for sensing. Wu et al. have recently developed graphene-based thin film using microwave plasma-enhanced chemical vapor deposition (MPCVD) followed by deposition of the fragmented 3D structure on substrate to develop nanoporous graphene (Gr) thin film [41]. Both NH3 and CO2 were detected efficiently using this film as conductance channel. Tian et al. have reviewed graphene-based gas sensor material preparation and characteristics [42].
\nThe popular environmental gas sensors operate on the principle of chemisorption. The adsorption and desorption processes of gas molecules on the active surface play a crucial role for sensing. Change in resistance or electrical current under an applied voltage in the presence of sensing gas is considered as the sensing signal response. Therefore, stability of the surface for long-term operation and also for repeatability of performance, the microstructure, and film thickness play a major role.
\nFor instance, in the case of CuPc ultrathin film [37] and SnO2 [43], the variation of microstructures of materials greatly improves the sensing performance for NO2 and formaldehyde (VOC), respectively. These microstructures and performance are shown in Figures 4 and 5.
\n(1) SEM images of tin oxide calcined at different temperatures (a, b) S400; (c, d) S650; (e, f) S800.
The metal oxide gas sensor works on chemi-resistance principle. When the gas molecule interacts with metal oxide surface, it acts as either an acceptor or donor. This changes the resistivity or electrical conductivity of thin film. The resistivity of the metal oxide semiconducting thin film depends on the majority carrier in the film and also gas molecule nature, i.e., whether it is oxidized or reduced in the ambient temperature [44]. Surface adsorption sites ensure appropriate interaction of gas molecules with the material. In the case of n-type (electron being majority carrier), the surface is generally get depleted with electrons by the appearance of oxygen ion species (O−, O2−, etc.), and upon exposure to sensing gas, these species react with gas molecules to revert back electron on the surface, thereby increasing conductivity. The creation of these oxygen species on the surface is material specific and broadly dependent of temperature. In the case of p-type (hole being majority carrier), similar situation arises. The sensing behavior of metal oxide thin film sensor is shown in Figure 6.
\nSchematic of metal oxide thin film gas sensor mechanism.
Among the various nano gas sensor materials particularly, carbon-based materials like carbon nanotube (CNT), graphene, graphene oxide, and reduced graphene oxide of nanosensors play an imperative role for sensing applications. A two-dimensional sp2 bonded allotropy of carbon called as graphene. A characteristic of high surface area to volume of carbon-based materials leads to a great potential for gas sensor applications. Especially, graphene acts as good device material due to its intrinsic properties. The graphene-based thin film sensor is shown in Figure 7. It has very large surface to volume ratio that can enhance adsorption of gas molecules, and hence response becomes fast and high. The working principle of graphene-based gas sensor depends on the catalytic and electronic properties of the active layers. For example, in the case of pristine graphene layer, it is electronically active but not sensing to detecting gas. In that case, surface modification or functionalization techniques are used to attain both electronic and sensing properties of graphene layer. But, this kind of surface modification technique should enhance the surface activity to adsorb the detecting gas molecules and quickly transfer the generated charges to the electrode.
\nSchematic of graphene-based thin film gas sensor (adapted from Ref. [
Furthermore, the electronic properties of graphene changed by metal nanoparticles influence the increase of selectivity and sensitivity in gas sensing characteristics. Figure 8 shows graphene decorated with metal nanoparticle-based sensor devices with interdigitated electrodes. Graphene with suitable sensitizer can improve the sensing performance and rectify the selectivity issues. Graphene-based functional nanohybrids can also facilitate fabrication of the nanosensor device [46].
\nSchematic image of graphene-based sensor devices with interdigitated electrodes and a graphene channel decorated with metal nanoparticles (adapted from Ref. [
The demand of reliable sensors for toxic gases and VOCs is increasing rapidly for the safe life. A lot of progress has been made to produce sensor especially in the form of thin film or nanostructure materials to exploit effectively sensing properties. The challenging parts of the devices are uniform fabrication of nanostructure in terms of thickness, shape, and morphology. The process is expensive also. Sensitivity, effect of temperature, stability of detection, selectivity, response and recovery time, repeatability, and durability are the concern for all these sensors for gas detection. Sensors during operation suffer from multiple limitations which require several optimization procedures meticulously. Commercial production of these ultrathin film or nanostructure sensors in large scale will depend on how all these properties of sensor materials are achieved uniformly. However, on the positive note, because of so much sophistication in technologies and materials engineering it, it will be possible to achieve high-quality and cheap sensor devices to be available in the market very soon.
\nThe importance of environmental sensors has been increasing exponentially due to the increase of toxic gas emission and at the same time imposition of several emission norms in the industries and permissible health hazard limits announced by health organizations. Looking at the historical aspects of the sensor development works, the chapter starts with the scope of various gas sensors to make environment risk free. Defining thin film, ultrathin film, and nanomaterials, efforts were made to categorize sensors and structures based on materials although there is always an overlapping research prospect. Various standard methods of preparation were mentioned. However, every sensor research based on nanotechnology is bringing some improvised method to fabricate sensor structures modifying available techniques. Sensing mechanisms were elaborated. Since to prepare nanostructure is tricky and expensive, more efforts should be given to achieve sensor fabrication viable, sustainable, and useful for mass production with acceptable quality.
\nThe authors declare no conflict of interest.
\nHysterectomy is one of the most commonly performed surgeries in the United States. In fact, Merrill et al. reported a 45% lifetime risk of hysterectomy [1] with an overall rate of 5.4 per 1000 women per year. The majority of hysterectomies are performed for benign gynecologic conditions—that is, the presence of fibroids. Other indications include abnormal uterine bleeding, uterovaginal prolapse, and pelvic pain. Hysterectomy can be performed via multiple routes—abdominally, laparoscopically (including robotic approach), or vaginally. Vaginal and laparoscopic procedures are considered minimally invasive surgical approaches based on the ability to avoid a large abdominal incision. These routes of hysterectomy are associated with shortened hospitalization and postoperative recovery when compared to the abdominal approach. As a result, analysis of U.S. surgical data demonstrates evolving practice patterns with an increase in minimally invasive hysterectomies and a decrease in abdominal hysterectomies [2, 3].
The Centers for Disease Control and Prevention defines surgical site infection (SSI) as an infection that occurs after surgery near the surgical site within 30 days following surgery or 90 days where an implant is involved. They can range from superficial infections involving skin, or more serious infections involving tissues underneath the skin, organs, or implanted materials. As such, SSI is classified as superficial, deep, or organ/space. The CDC monitors SSI via the National Healthcare Safety Network with reported SSI rates of 1.7% and 0.9% after abdominal and vaginal hysterectomy respectively [4].
In a retrospective cohort study of 23,366 patients undergoing laparoscopic and abdominal hysterectomy between the years 2005 and 2011, 783 (3%) developed a surgical site infection. The majority of these were wound infections with approximately ¼ of cases being infections of the organ space which represents 0.7% of the entire cohort [5]. A more recent large cohort study examining patients between the years 2012 and 2015 demonstrated a 2% incidence of postoperative infection after hysterectomy [6]. When stratified between abdominal versus minimally invasive approaches, the incidence of SSI in the abdominal hysterectomy group exceeded 1%, while the incidences in the other groups were 0.2–0.3% [7, 8, 9].
It is well known that postoperative infections are associated with increased patient morbidity and mortality, and may result in additional costs, extended hospital stays, and prolonged antibiotic use. On average, patients who had an SSI following hysterectomy incur twice the cost of care of their counterparts who did not have an SSI. In a study examining the clinical and economic burden of surgical site infection following hysterectomy, the highest cost owing to SSI ($19,203; 95% CI 17,260–21,365) was for abdominal hysterectomy. In addition, those who had SSI had a mean length of stay (LOS) that was between three and fivefold the LOS of those who did not have an SSI irrespective of surgical approach [10]. SSI following index surgery is also associated with a significantly greater percentage of hospital readmissions. Surgical site infections after hysterectomy have serious implications on patient care and healthcare as a whole. This chapter will review the current literature on surgical site infection (SSI) after hysterectomy for benign indications and address various methods of prevention and treatment.
There are a variety of factors that influence the route of hysterectomy including informed patient preference, accessibility of the uterus, extent of extrauterine disease, size and shape of the vagina and uterus, concurrent procedures, available hospital technology and support, the nature of the case
Evidence supports that the vaginal approach is associated with better outcomes when compared with other approaches to hysterectomy. A Cochrane review analyzing 47 randomized control trials with a total of 5,102 women determined that vaginal hysterectomy resulted in quicker return to normal activity when compared to abdominal hysterectomy. There was no difference in satisfaction, quality of life, and surgical complications. Similarly, laparoscopic hysterectomy also resulted in more rapid recovery, fewer febrile episodes, and lower incidence of SSI when compared to the abdominal approach [12]. In this systematic review, there were no advantages of laparoscopic over vaginal hysterectomy. In addition, the laparoscopic approach was associated with longer operating times and increased rates of urinary tract injuries [13]. As a result, a vaginal approach continues to be the preferred route of hysterectomy.
When it is not feasible to perform a vaginal hysterectomy, a surgeon must choose between a laparoscopic or an open abdominal approach. A Cochrane review demonstrated faster return to normal activity, shorter hospital stay, fewer infections, and improved quality of life in patients undergoing laparoscopic versus abdominal hysterectomy. However, operating times were longer with higher rates of lower urinary tract (bladder and ureter) injuries in the laparoscopy group [13].
When stratified by the type of hysterectomy
When stratified into various forms of laparoscopic hysterectomy including robotic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and single-port hysterectomy, the authors concluded that more research was needed to determine if there is in fact, a benefit over conventional laparoscopic approaches. The largest study available on single port laparoscopy in gynecology was a retrospective study from Cleveland Clinic reviewing a total of 908 cases. The authors concluded that single port access was safe and feasible in gynecologic surgery inclusive of both malignant and premalignant conditions with a low rate of adverse outcomes. Perhaps the most prevalent adverse outcome is an increased risk of incisional hernia with a rate of 5.5% [15, 16]. Well-designed studies that compare outcomes of alternative hysterectomy routes (robotic, laparoscopic assisted vaginal, and single-port) are needed to determine if patients may benefit from these other approaches.
Although minimally invasive routes to hysterectomy remain the preferred approach, open abdominal hysterectomy is still an important surgical option for some patients. Open abdominal hysterectomy may become necessary in a variety of clinical scenarios including failure of to maintain a minimally invasive approach.
Preoperative medical optimization is critically important in risk reduction for SSI prior to hysterectomy. Eliminating particular risk factors for SSI contributes vastly to perioperative care. This includes taking an in-depth medical history, performing a comprehensive physical exam, and addressing the patient’s medical comorbidities. Patients should be counseled on modifiable and nonmodifiable risk factors such as smoking status, diabetes stabilization, anatomic anomalies, renal comorbidities, hydrosalpinx, endometrioma, prior laparotomy, and untreated pelvic inflammatory disease (PID) or bacterial vaginosis [17, 18, 19, 20]. Optimal diabetes control is critical in preventing postoperative SSI with both spot glucose levels ≤200 mg/dl and hemoglobin A1C levels below 8.5–9.0% [21, 22].
Preoperative screening for genital tract infections is generally not necessary; however, certain types of infections are clinically important prior to hysterectomy. It has been well established that bacterial vaginosis (BV) is associated with an increased risk of postoperative cuff cellulitis and subsequent pelvic abscess formation after hysterectomy [23]. Treatment of BV prior to scheduled hysterectomy will decrease this risk.
Practicing safe, high-quality, evidence-based operating room care begins first with accurate identification of the patient, surgical site, and procedure.
In an AAGL white paper, “Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery”, infection prophylaxis can be achieved via the implementation of SSI prevention bundles [24]. Quality or safety bundles provide a framework for the implementation of evidence-based practices. They have been validated across multiple disciplines to actually decrease SSI [25, 26, 27, 28]. The ACOG Council on Patient Safety in Women’s Health Care has published a consensus bundle on prevention of SSI prior to gynecologic surgery. This provides a framework for hospitals to develop, implement, and practice evidence-based prevention of SSIs [29].
An example of a hysterectomy bundle is as follows:
The degree of contamination at the time of surgery is classified using the National Healthcare Safety Network (NHSN) wound class. Hysterectomy is a clean-contaminated procedure and as a result, is unavoidably associated with a relatively higher risk of infection as the procedure breaches the genital tract. Common sites of infection after hysterectomy include the abdominal wall, the vaginal cuff, bladder, and pelvic floor. Related complications include pelvic abscess or infected hematoma and sepsis. A patient’s individual susceptibility to infection depends on a variety of factors including bacterial virulence, extent of surgery-related tissue trauma and fluid collection, the effectiveness of the patient’s immune system, age, nutritional status, presence of diabetes, smoking, coexistent infection or colonization with microorganisms. Perhaps the most important factors in SSI prevention in hysterectomy are timely administration of appropriate preoperative antibiotics and meticulous surgical technique. Use of β-lactam alternatives in patients who do not report an anaphylactic reaction can lead to increased antimicrobial resistance. In fact, a retrospective cohort study involving over 21,000 women undergoing hysterectomy demonstrated that the use of standard β-lactam antibiotics had a lower risk of SSI compared to those who received an alternative regimen [23]. Thus, we advise judicious use of β-lactam alternatives for patients with a history of IgE-mediated penicillin hypersensitivity. The most common organisms isolated from vaginal cuff infections are anaerobes. In a large retrospective cohort study with over 18,000 patients undergoing hysterectomy of any type, those receiving cefazolin or a second-generation cephalosporin have more than double the SSI risk compared with those receiving combined treatment with cefazolin and metronidazole [25]. This is likely related to enhanced anaerobic coverage with the addition of metronidazole. We recommend that all patients undergoing hysterectomy receive metronidazole in addition to the standard intraoperative antibiotics.
The CDC also advises that the entire body be cleansed with either soap or antiseptic the night prior to the procedure. Intraoperatively, alcohol-based chlorhexidine is more effective for skin preparation when compared to iodine solutions [30, 31]. With regards to vaginal preparation, either povidone-iodine or chlorhexidine gluconate (4%) with a low concentration of isopropyl alcohol is acceptable, as both significantly reduce rates of postoperative infectious morbidity [32].
In general, our practice will have patients return for short-term postoperative evaluation within 2 weeks following their hysterectomy. Patients are counseled to maintain pelvic rest for a minimum of 8 weeks. Postoperative blood and other secretions from the vaginal cuff may raise the vaginal pH and as a result, increase the risk of bacterial vaginosis. Many patients with vaginal cuff infections present more than 2 weeks following hysterectomy, which suggests a late ascending spread of vaginal microorganisms. As a result, our patients return for a second postoperative appointment and vaginal cuff check approximately 4–6 weeks after their hysterectomy.
Gynecological surgical site infections are polymicrobial with a mix of both anaerobic and aerobic infections. Common pathogens contain gram-negative bacilli, enterococci, streptococci, and anaerobes
Wound exploration and debridement are pillars in the management of superficial and deep-incisional SSIs. This includes not only opening the wound, debridement of necrotic and devitalized tissue, but also involves the culture of the wound to allow for speciation of potential pathogens to assist in antibiotic therapy.
The mortality and morbidity of organ/space SSI tend to be higher than superficial or deep SSI. The primary objective in management is to achieve source control. Computed tomography and ultrasound are employed to guide placement of closed suction percutaneous drains into abscess collections when feasible. The initial approach in treatment of post-hysterectomy pelvic abscess depends on three factors: (1) hemodynamic stability, (2) abscess size, and (3) abscess location. Hemodynamically unstable patients require prompt surgical intervention and intensive care monitoring.
Patients who are hemodynamically stable with a post-hysterectomy pelvic abscess should be treated empirically with parenteral broad-spectrum antibiotics. Initial antimicrobial regimens can be tailored to subsequent culture and sensitivity results. If the patient does not respond within 48–72 hours, percutaneous drainage or infectious disease consultation may be warranted. An argument can be made for earlier percutaneous drainage. In fact, a systematic review comparing the success rates of 3 modalities of minimally invasive management of tubo-ovarian abscesses—laparoscopy, ultrasound-guided drainage and computed tomography-guided drainage
Treatment failure is defined as persistent fever, leukocytosis, pain or lack of abscess resolution. Risk factors include residual fluid collection after drainage and increasing patient age. Surgical management is recommended at this time.
The most common reason for unplanned readmission after surgery is surgical site infection. SSIs are associated with increased morbidity, mortality, transfer to an intensive care setting, prolonged hospitalization, hospital readmission, and increased healthcare costs. In addition, the development of SSI negatively impacts patient experience.
The majority of postoperative issues can be anticipated and prevented preoperatively. Systematically addressing these issues at the preoperative evaluation may result in greater patient satisfaction and fewer complications. Thus, prevention of SSI after hysterectomy begins with a calculation of perioperative risk followed by addressing those risk factors prior to the procedure. Intraoperative measures aimed at SSI prevention include the implementation of evidence-based SSI prevention bundles, proper administration of intraoperative antibiotic prophylaxis, and proper skin/vaginal preparation. Postoperatively, hysterectomy patients should be followed closely.
Thanks to the faculty, residents, fellows, and medical students of the Zucker School of Medicine.
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However, some of these heavy metals in high doses can be harmful to the body while others such as cadmium, mercury, lead, chromium, silver, and arsenic in minute quantities have delirious effects in the body causing acute and chronic toxicities in humans. The focus of this chapter is to describe the various mechanism of intoxication of some selected heavy metals in humans along with their health effects. Therefore it aims to highlight on biochemical mechanisms of heavy metal intoxication which involves binding to proteins and enzymes, altering their activity and causing damage. More so, the mechanism by which heavy metals cause neurotoxicity, generate free radical which promotes oxidative stress damaging lipids, proteins and DNA molecules and how these free radicals propagate carcinogenesis are discussed. Alongside these mechanisms, the noxious health effects of these heavy metals are discussed.",book:{id:"7111",slug:"poisoning-in-the-modern-world-new-tricks-for-an-old-dog-",title:"Poisoning in the Modern World",fullTitle:"Poisoning in the Modern World - New Tricks for an Old Dog?"},signatures:"Godwill Azeh Engwa, Paschaline Udoka Ferdinand, Friday Nweke Nwalo and Marian N. Unachukwu",authors:[{id:"241837",title:"Mr.",name:"Godwill Azeh",middleName:null,surname:"Engwa",slug:"godwill-azeh-engwa",fullName:"Godwill Azeh Engwa"},{id:"274194",title:"BSc.",name:"Paschaline Ferdinand",middleName:null,surname:"Okeke",slug:"paschaline-ferdinand-okeke",fullName:"Paschaline Ferdinand Okeke"},{id:"286975",title:"Dr.",name:"Friday",middleName:null,surname:"Nweke Nwalo",slug:"friday-nweke-nwalo",fullName:"Friday Nweke Nwalo"},{id:"286976",title:"Dr.",name:"Marian",middleName:null,surname:"Unachukwu",slug:"marian-unachukwu",fullName:"Marian Unachukwu"}]},{id:"57717",doi:"10.5772/intechopen.71923",title:"In Vitro Cytotoxicity and Cell Viability Assays: Principles, Advantages, and Disadvantages",slug:"in-vitro-cytotoxicity-and-cell-viability-assays-principles-advantages-and-disadvantages",totalDownloads:14818,totalCrossrefCites:78,totalDimensionsCites:157,abstract:"Cytotoxicity is one of the most important indicators for biological evaluation in vitro studies. In vitro, chemicals such as drugs and pesticides have different cytotoxicity mechanisms such as destruction of cell membranes, prevention of protein synthesis, irreversible binding to receptors etc. In order to determine the cell death caused by these damages, there is a need for cheap, reliable and reproducible short-term cytotoxicity and cell viability assays. Cytotoxicity and cell viability assays are based on various cell functions. A broad spectrum of cytotoxicity assays is currently used in the fields of toxicology and pharmacology. There are different classifications for these assays: (i) dye exclusion assays; (ii) colorimetric assays; (iii) fluorometric assays; and (iv) luminometric assays. Choosing the appropriate method among these assays is important for obtaining accurate and reliable results. When selecting the cytotoxicity and cell viability assays to be used in the study, different parameters have to be considered such as the availability in the laboratory where the study is to be performed, test compounds, detection mechanism, specificity, and sensitivity. In this chapter, information will be given about in vitro cytotoxicity and viability assays, these assays will be classified and their advantages and disadvantages will be emphasized. The aim of this chapter is to guide the researcher interested in this subject to select the appropriate assay for their study.",book:{id:"6310",slug:"genotoxicity-a-predictable-risk-to-our-actual-world",title:"Genotoxicity",fullTitle:"Genotoxicity - A Predictable Risk to Our Actual World"},signatures:"Özlem Sultan Aslantürk",authors:[{id:"211212",title:"Dr.",name:"Özlem Sultan",middleName:null,surname:"Aslantürk",slug:"ozlem-sultan-aslanturk",fullName:"Özlem Sultan Aslantürk"}]},{id:"66259",doi:"10.5772/intechopen.85270",title:"Antioxidant Compounds and Their Antioxidant Mechanism",slug:"antioxidant-compounds-and-their-antioxidant-mechanism",totalDownloads:7594,totalCrossrefCites:58,totalDimensionsCites:152,abstract:"An antioxidant is a substance that at low concentrations delays or prevents oxidation of a substrate. Antioxidant compounds act through several chemical mechanisms: hydrogen atom transfer (HAT), single electron transfer (SET), and the ability to chelate transition metals. The importance of antioxidant mechanisms is to understand the biological meaning of antioxidants, their possible uses, their production by organic synthesis or biotechnological methods, or for the standardization of the determination of antioxidant activity. In general, antioxidant molecules can react either by multiple mechanisms or by a predominant mechanism. The chemical structure of the antioxidant substance allows understanding of the antioxidant reaction mechanism. This chapter reviews the in vitro antioxidant reaction mechanisms of organic compounds polyphenols, carotenoids, and vitamins C against free radicals (FR) and prooxidant compounds under diverse conditions, as well as the most commonly used methods to evaluate the antioxidant activity of these compounds according to the mechanism involved in the reaction with free radicals and the methods of in vitro antioxidant evaluation that are used frequently depending on the reaction mechanism of the antioxidant.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Norma Francenia Santos-Sánchez, Raúl Salas-Coronado, Claudia Villanueva-Cañongo and Beatriz Hernández-Carlos",authors:[{id:"143354",title:"Dr.",name:"Raúl",middleName:null,surname:"Salas-Coronado",slug:"raul-salas-coronado",fullName:"Raúl Salas-Coronado"},{id:"148546",title:"Dr.",name:"Norma Francenia",middleName:null,surname:"Santos-Sánchez",slug:"norma-francenia-santos-sanchez",fullName:"Norma Francenia Santos-Sánchez"},{id:"193718",title:"Dr.",name:"Beatriz",middleName:null,surname:"Hernández-Carlos",slug:"beatriz-hernandez-carlos",fullName:"Beatriz Hernández-Carlos"},{id:"278133",title:"Dr.",name:"Claudia",middleName:null,surname:"Villanueva-Cañongo",slug:"claudia-villanueva-canongo",fullName:"Claudia Villanueva-Cañongo"}]},{id:"40253",doi:"10.5772/50486",title:"Lipid Nanoparticulate Drug Delivery Systems: A Revolution in Dosage Form Design and Development",slug:"lipid-nanoparticulate-drug-delivery-systems-a-revolution-in-dosage-form-design-and-development",totalDownloads:11293,totalCrossrefCites:22,totalDimensionsCites:105,abstract:null,book:{id:"2509",slug:"recent-advances-in-novel-drug-carrier-systems",title:"Recent Advances in Novel Drug Carrier Systems",fullTitle:"Recent Advances in Novel Drug Carrier Systems"},signatures:"Anthony A. 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Among these heavy metals, a few have direct or indirect impact on the human body. Some of these heavy metals such as copper, cobalt, iron, nickel, magnesium, molybdenum, chromium, selenium, manganese and zinc have functional roles which are essential for various diverse physiological and biochemical activities in the body. However, some of these heavy metals in high doses can be harmful to the body while others such as cadmium, mercury, lead, chromium, silver, and arsenic in minute quantities have delirious effects in the body causing acute and chronic toxicities in humans. The focus of this chapter is to describe the various mechanism of intoxication of some selected heavy metals in humans along with their health effects. Therefore it aims to highlight on biochemical mechanisms of heavy metal intoxication which involves binding to proteins and enzymes, altering their activity and causing damage. More so, the mechanism by which heavy metals cause neurotoxicity, generate free radical which promotes oxidative stress damaging lipids, proteins and DNA molecules and how these free radicals propagate carcinogenesis are discussed. Alongside these mechanisms, the noxious health effects of these heavy metals are discussed.",book:{id:"7111",slug:"poisoning-in-the-modern-world-new-tricks-for-an-old-dog-",title:"Poisoning in the Modern World",fullTitle:"Poisoning in the Modern World - New Tricks for an Old Dog?"},signatures:"Godwill Azeh Engwa, Paschaline Udoka Ferdinand, Friday Nweke Nwalo and Marian N. Unachukwu",authors:[{id:"241837",title:"Mr.",name:"Godwill Azeh",middleName:null,surname:"Engwa",slug:"godwill-azeh-engwa",fullName:"Godwill Azeh Engwa"},{id:"274194",title:"BSc.",name:"Paschaline Ferdinand",middleName:null,surname:"Okeke",slug:"paschaline-ferdinand-okeke",fullName:"Paschaline Ferdinand Okeke"},{id:"286975",title:"Dr.",name:"Friday",middleName:null,surname:"Nweke Nwalo",slug:"friday-nweke-nwalo",fullName:"Friday Nweke Nwalo"},{id:"286976",title:"Dr.",name:"Marian",middleName:null,surname:"Unachukwu",slug:"marian-unachukwu",fullName:"Marian Unachukwu"}]},{id:"49459",title:"Pharmacokinetics of Drugs Following IV Bolus, IV Infusion, and Oral Administration",slug:"pharmacokinetics-of-drugs-following-iv-bolus-iv-infusion-and-oral-administration",totalDownloads:15480,totalCrossrefCites:16,totalDimensionsCites:24,abstract:null,book:{id:"4491",slug:"basic-pharmacokinetic-concepts-and-some-clinical-applications",title:"Basic Pharmacokinetic Concepts and Some Clinical Applications",fullTitle:"Basic Pharmacokinetic Concepts and Some Clinical Applications"},signatures:"Tarek A. Ahmed",authors:[{id:"175649",title:"Dr.",name:"Tarek A",middleName:null,surname:"Ahmed",slug:"tarek-a-ahmed",fullName:"Tarek A Ahmed"}]},{id:"29240",title:"Oral Absorption, Intestinal Metabolism and Human Oral Bioavailability",slug:"oral-absorption-intestinal-metabolism-and-human-oral-bioavailability-",totalDownloads:27175,totalCrossrefCites:28,totalDimensionsCites:58,abstract:null,book:{id:"672",slug:"topics-on-drug-metabolism",title:"Topics on Drug Metabolism",fullTitle:"Topics on Drug Metabolism"},signatures:"Ayman El-Kattan and Manthena Varma",authors:[{id:"85539",title:"Dr.",name:"Ayman",middleName:null,surname:"El-Kattan",slug:"ayman-el-kattan",fullName:"Ayman El-Kattan"},{id:"88221",title:"Dr.",name:"Manthena",middleName:null,surname:"Varma",slug:"manthena-varma",fullName:"Manthena Varma"}]},{id:"66259",title:"Antioxidant Compounds and Their Antioxidant Mechanism",slug:"antioxidant-compounds-and-their-antioxidant-mechanism",totalDownloads:7587,totalCrossrefCites:58,totalDimensionsCites:152,abstract:"An antioxidant is a substance that at low concentrations delays or prevents oxidation of a substrate. Antioxidant compounds act through several chemical mechanisms: hydrogen atom transfer (HAT), single electron transfer (SET), and the ability to chelate transition metals. The importance of antioxidant mechanisms is to understand the biological meaning of antioxidants, their possible uses, their production by organic synthesis or biotechnological methods, or for the standardization of the determination of antioxidant activity. In general, antioxidant molecules can react either by multiple mechanisms or by a predominant mechanism. The chemical structure of the antioxidant substance allows understanding of the antioxidant reaction mechanism. This chapter reviews the in vitro antioxidant reaction mechanisms of organic compounds polyphenols, carotenoids, and vitamins C against free radicals (FR) and prooxidant compounds under diverse conditions, as well as the most commonly used methods to evaluate the antioxidant activity of these compounds according to the mechanism involved in the reaction with free radicals and the methods of in vitro antioxidant evaluation that are used frequently depending on the reaction mechanism of the antioxidant.",book:{id:"8008",slug:"antioxidants",title:"Antioxidants",fullTitle:"Antioxidants"},signatures:"Norma Francenia Santos-Sánchez, Raúl Salas-Coronado, Claudia Villanueva-Cañongo and Beatriz Hernández-Carlos",authors:[{id:"143354",title:"Dr.",name:"Raúl",middleName:null,surname:"Salas-Coronado",slug:"raul-salas-coronado",fullName:"Raúl Salas-Coronado"},{id:"148546",title:"Dr.",name:"Norma Francenia",middleName:null,surname:"Santos-Sánchez",slug:"norma-francenia-santos-sanchez",fullName:"Norma Francenia Santos-Sánchez"},{id:"193718",title:"Dr.",name:"Beatriz",middleName:null,surname:"Hernández-Carlos",slug:"beatriz-hernandez-carlos",fullName:"Beatriz Hernández-Carlos"},{id:"278133",title:"Dr.",name:"Claudia",middleName:null,surname:"Villanueva-Cañongo",slug:"claudia-villanueva-canongo",fullName:"Claudia Villanueva-Cañongo"}]},{id:"66742",title:"Introductory Chapter: Alkaloids - Their Importance in Nature and for Human Life",slug:"introductory-chapter-alkaloids-their-importance-in-nature-and-for-human-life",totalDownloads:4130,totalCrossrefCites:16,totalDimensionsCites:32,abstract:null,book:{id:"6828",slug:"alkaloids-their-importance-in-nature-and-human-life",title:"Alkaloids",fullTitle:"Alkaloids - Their Importance in Nature and Human Life"},signatures:"Joanna Kurek",authors:[{id:"214632",title:"Dr.",name:"Joanna",middleName:null,surname:"Kurek",slug:"joanna-kurek",fullName:"Joanna Kurek"}]}],onlineFirstChaptersFilter:{topicId:"19",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"83076",title:"Treatments for the Infection by SARS-CoV-2",slug:"treatments-for-the-infection-by-sars-cov-2",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.106232",abstract:"In late 2019, pneumonia cases from unknown origin were detected in Wuhan, China. The cause was a new coronavirus. The World Health Organization (WHO) named the virus SARS-CoV-2 and COVID-19 the associated disease. In the first months of 2020, this disease became a pandemic with a high lethality reported. Since then, the search for treatments began. We started by searching among treatments previously approved for human use that were not designed for COVID-19 and were considered to treat this condition. We continued searching on the therapeutics guidelines published by the WHO for the management of infection by SARS-CoV-2. Based on these results, we searched for the literature in PubMed to obtain further evidence on the drugs against SARS-CoV-2. The treatments presented in this chapter are Ivermectin, Hydroxychloroquine, Nitazoxanide, Azithromycin, Molnupiravir, Casirivimab-Imdevimab, Ritonavir-Nirmatrelvir, Ritonavir-Lopinavir, Remdesivir, and Favipiravir. Two years ahead of the start of the COVID-19 pandemic, a plenty of options for treatment have been investigated. Only a few of them have been shown to be efficient and safe. According to the WHO, Ritonavir-Nirmatrelvir outperforms other proposed therapeutics.",book:{id:"11690",title:"COVID-19 Drug Development - Recent Advances, New Perspectives, and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/11690.jpg"},signatures:"Nicolás Padilla-Raygoza, Gilberto Flores-Vargas, María de Jesús Gallardo-Luna, Efraín Navarro-Olivos, Francisco Javier Magos-Vázquez and Daniel Alberto Díaz-Martínez"},{id:"83054",title:"Pulsatory Liposome: A Possible Biotechnological Device",slug:"pulsatory-liposome-a-possible-biotechnological-device",totalDownloads:1,totalDimensionsCites:0,doi:"10.5772/intechopen.106347",abstract:"A unilamellar liposome filled with an osmotic solution is introduced into a hypotonic aqueous environment. Because of the mechanical tension induced by the osmotic flow, the vesicle swells up to a critical size, when suddenly a transbilayer pore appears and the vesicle relaxing stage starts. A part of the intracellular material leaks out through this pore, and the liposome membrane relaxes and finally recovers. The swelling begins again and the liposome experiences a periodical process. For this reason, we have named it a pulsatory liposome. The swelling of the liposome is described by a differential equation. All the processes which contribute to the vesicle relaxing and its coming back to the initial size are described by three differential equations. The pulsatory liposome can be programmed to work a number of cycles, established before. The activity of a pulsatory liposome can be characterized by the following parameters: (a) number of cycles, the length time of each cycle, and liposome activity life; (b) the length time of the swelling stage and the relaxation stage for each cycle; (c) the amount of solute leaked out through the pore in each cycle. The pulsatory liposome may be regarded as a two-stroke engine.",book:{id:"11814",title:"Liposomes - Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/11814.jpg"},signatures:"Dumitru Popescu and Alin Gabriel Popescu"},{id:"82962",title:"Pluralism Medical Treatment, Prevention, and Control of COVID-19 Infection and Its Long-Sufferings among the Older Adults in the Northeast of Thailand from 2019 to 2022",slug:"pluralism-medical-treatment-prevention-and-control-of-covid-19-infection-and-its-long-sufferings-amo",totalDownloads:48,totalDimensionsCites:0,doi:"10.5772/intechopen.106339",abstract:"COVID-19 in 2019 has brought both changes and challenges to the world. This global pandemic has an impact on people of all age levels, especially older adults. In Thailand, older persons are at high risk of COVID-19 infection. They are included in the so-called 608 groups. The objective of this review article was to synthesize and present medical pluralism, the development of drugs from herbs, and projects conducted to treat, prevent, and control the infection and long sufferings of COVID-19. The review covers 10 studies, three projects produced at Mahasarakham University, Chaiyaphum Rajabhat University, and Khon Kaen University that were reviewed, synthesized, and analyzed. The results of the synthesis indicate that modern and Thai traditional medicine can help reduce the severity of the infection and long sufferings of COVID-19. The medical pluralism between modern and Thai traditional medicine is needed to remedy COVID-19 cases among the older adults in the Northeast of Thailand.",book:{id:"11690",title:"COVID-19 Drug Development - Recent Advances, New Perspectives, and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/11690.jpg"},signatures:"Pissamai Homchampa, Khemika Napattaradechanon, Parichat Yatniyom, Thawalrat Ratanasiri, Piyaporn Sansila, Thanawan Sirisuk, Thawalwong Ratanasiri and Amornrat Ratanasiri"},{id:"82353",title:"Pharmacovigilance of Biological Drugs",slug:"pharmacovigilance-of-biological-drugs",totalDownloads:5,totalDimensionsCites:0,doi:"10.5772/intechopen.105520",abstract:"The use of biological drugs has significantly increased over the past decades and has allowed for the treatment of many life-threatening and chronic diseases. The patent expiration of biological innovative medicines enables copies of these drugs called biosimilars. The availability of biosimilars enhances competition, with the potential to improve patient access to biological medications and contribute to the financial sustainability of the healthcare systems. Unlike equivalent drugs, biosimilars are not identical but similar to their innovator products because of the differences in the manufacturing process, which is a biological process. However, they are considered comparable to their originators in safety, quality characteristics, biological activity, and efficacy. The regulatory procedures used for generic drugs cannot be applied for biosimilars, so they are subjected to rigorous characterization as well as comparative clinical studies. Since they are highly complex molecules produced from living cells, even small change in the production process can have major implications on their safety and effectiveness profile, causing a potential risk of immune-based adverse reactions. For all these reasons, for biological drugs, a robust long-term pharmacovigilance system is necessary. It is desirable that in the future, there are further guidance and resolution of the ongoing discussions on biosimilar labeling, naming, pharmacovigilance and interchangeability/substitution, to ensure the appropriate use of these drugs in clinical practice.",book:{id:"11679",title:"Pharmacovigilance and Regulations",coverURL:"https://cdn.intechopen.com/books/images_new/11679.jpg"},signatures:"Simona Guerzoni, Flavia Lo Castro, Carlo Baraldi, Giuliana Colella and Luca Pani"},{id:"82868",title:"Recent Strategies for Ocular Drug Delivery: Promises and Challenges",slug:"recent-strategies-for-ocular-drug-delivery-promises-and-challenges",totalDownloads:9,totalDimensionsCites:0,doi:"10.5772/intechopen.106335",abstract:"Ocular diseases include various anterior and posterior segment diseases. 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