Classification of haemorrhage
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"8656",leadTitle:null,fullTitle:"Probability, Combinatorics and Control",title:"Probability, Combinatorics and Control",subtitle:null,reviewType:"peer-reviewed",abstract:"Probabilistic and combinatorial techniques are often used for solving advanced problems. This book describes different probabilistic modeling methods and their applications in various areas, such as artificial intelligence, offshore platforms, social networks, and others. It aims to educate how modern probabilistic and combinatorial models may be created to formalize uncertainties; to train how new probabilistic models can be generated for the systems of complex structures; to describe the correct use of the presented models for rational control in systems creation and operation; and to demonstrate analytical possibilities and practical effects for solving different system problems on each life cycle stage.",isbn:"978-1-83880-104-5",printIsbn:"978-1-83880-103-8",pdfIsbn:"978-1-78985-949-2",doi:"10.5772/intechopen.79802",price:139,priceEur:155,priceUsd:179,slug:"probability-combinatorics-and-control",numberOfPages:334,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"9993ec9b59bcb38d206f2e31125028b7",bookSignature:"Andrey Kostogryzov and Victor Korolev",publishedDate:"April 15th 2020",coverURL:"https://cdn.intechopen.com/books/images_new/8656.jpg",numberOfDownloads:9630,numberOfWosCitations:1,numberOfCrossrefCitations:8,numberOfCrossrefCitationsByBook:4,numberOfDimensionsCitations:14,numberOfDimensionsCitationsByBook:4,hasAltmetrics:0,numberOfTotalCitations:23,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 25th 2019",dateEndSecondStepPublish:"October 2nd 2019",dateEndThirdStepPublish:"December 1st 2019",dateEndFourthStepPublish:"February 19th 2020",dateEndFifthStepPublish:"April 19th 2020",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"148322",title:"Dr.",name:"Andrey",middleName:null,surname:"Kostogryzov",slug:"andrey-kostogryzov",fullName:"Andrey Kostogryzov",profilePictureURL:"https://mts.intechopen.com/storage/users/148322/images/system/148322.jpeg",biography:"Andrey Kostogryzov (1957.05.16) – Chief Researcher of the Federal Research Center 'Computer Science and Control” of the Russian Academy of Sciences (Moscow, Russia), Director and Scientific Leader of the Research Institute of Applied Mathematics and Certification. \nHonored Science Worker of the Russian Federation, Dr. of Engineering Science, Professor, Corresponding Member of the Russian Academy of Rockets and Artillery Sciences. The Winner of the Award of the Government of the Russian Federation in the Field of Science and Engineering. \nDeputy Chairman of the Committee \"Business Sequrity \" and Chairman of SC 'Information Technologies” of the Committee \"Industrial Safety” of the Chamber of Commerce and Industry of the Russian Federation. \nDeputy Chairman of the National TC 'Information Technologies”, Chairman of SC 'System and Software Engineering”. \nThe mamber of the Commission on Technogenic Safety of the Russian Academy of Sciences. \nCertified Expert of the Russian Academy of Sciences, the Ministry of Education of the Russian Federation, PJSC Gazprom. \nThe author of more than 100 mathematical models for analyzing and optimizing quality and risks and more than 210 scientific works, including 20 books",institutionString:"Russian Academy of Sciences",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Russian Academy of Sciences",institutionURL:null,country:{name:"Russia"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"298431",title:"Dr.",name:"Victor",middleName:null,surname:"Korolev",slug:"victor-korolev",fullName:"Victor Korolev",profilePictureURL:"https://mts.intechopen.com/storage/users/298431/images/system/298431.jpeg",biography:"Victor Korolev (1954.12.27) – Professor, Head of the Department of Mathematical Statistics, Faculty of Computational Mathematics and Cybernetics, Lomonosov Moscow State University; Leading researcher, Federal Research Center «Computer Science and Control»; visiting professor, Hangzhou Dianzi University, Hangzhou, China; Doctor of Sciences in Physics and Mathematics; Honorary professor of Lomonosov Moscow State University; Lomonosov prize winner for a series of works on analytical methods of risk theory based on mixed Gaussian models; awarded with Euler medal from the Perm State University for significant contribution to the development of mathematics in Russia; Chairman of the Organizing Committee of International Seminars on Stability Problems for Stochastic Models; member of the Editorial Boards of «Theory of Probability and its Applications» and several other journals; Editor-in-Chief of the series «Stability Problems for Stochastic Models» in «Journal of Mathematical Sciences» (Springer: New York—London); The author of more than 300 scientific works, including 21 books in Limit Theorems of Probability Theory and Their Applications, Mathematical Statistics, Reliability Theory, Mathematical Risk Theory, Financial Mathematics",institutionString:"Moscow State University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Moscow State University",institutionURL:null,country:{name:"Russia"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"968",title:"Mathematical Modeling",slug:"applied-mathematics-mathematical-modeling"}],chapters:[{id:"69286",title:"Probabilistic Methods for Cognitive Solving of Some Problems in Artificial Intelligence Systems",doi:"10.5772/intechopen.89168",slug:"probabilistic-methods-for-cognitive-solving-of-some-problems-in-artificial-intelligence-systems",totalDownloads:816,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"As a result of the analysis of dispatcher intelligence centers and aerial, land, underground, underwater, universal, and functionally focused artificial intelligence robotics systems, the problems of rational control, due to be performed under specific conditions of uncertainties, are chosen for probabilistic study. The choice covers the problems of planning the possibilities of functions performance on the base of monitored information about events and conditions and the problem of robot route optimization under limitations on risk of “failure” in conditions of uncertainties. These problems are resolved with a use of the proposed probabilistic approach. The proposed methods are based on selected probabilistic models (for “black box” and complex systems), which are implemented effectively in wide application areas. The cognitive solving of problems consists in improvements, accumulation, analysis, and use of appearing knowledge. The described analytical solutions are demonstrated by practical examples.",signatures:"Andrey Kostogryzov and Victor Korolev",downloadPdfUrl:"/chapter/pdf-download/69286",previewPdfUrl:"/chapter/pdf-preview/69286",authors:[{id:"148322",title:"Dr.",name:"Andrey",surname:"Kostogryzov",slug:"andrey-kostogryzov",fullName:"Andrey Kostogryzov"},{id:"298431",title:"Dr.",name:"Victor",surname:"Korolev",slug:"victor-korolev",fullName:"Victor Korolev"}],corrections:null},{id:"68436",title:"Laboratory, Bench, and Full-Scale Researches of Strength, Reliability, and Safety of High-Power Hydro Turbines",doi:"10.5772/intechopen.88306",slug:"laboratory-bench-and-full-scale-researches-of-strength-reliability-and-safety-of-high-power-hydro-tu",totalDownloads:669,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Large hydropower plants (HPPs) are categorized as critically and strategically important infrastructure facilities in industrialized countries. Therefore, the issues of ensuring HPPs safety are of paramount importance. In this chapter, the basic aspects of the safety analysis of HPPs, calculation and experimental substantiation of the strength, and resource and reliability of the main equipment are discussed. The scientific and technical measures to ensure safety of HPPs are presented. As a defining measure of safety, it is proposed to ensure the protection of HPPs from severe accidents and disasters according to risk criteria. The main provisions of the risk assessment are presented on the basis of a sequential analysis of loads, features of stress-strain states, characteristics of mechanical properties, and limit states of hydraulic equipment of HPPs. The issues of calculation and experimental evaluation of hydro turbine’s resource, which limit the safety of HPPs, are considered. The features of technical diagnosis of hydraulic turbines are considered; characteristic defects and damages are described. The main provisions of the estimated residual life of hydro turbines are presented. The results of the risk estimates of HPPs and hydro turbine resource are given.",signatures:"Nikolay Makhutov, Yury Petrenia, Anatoly Lepikhin, Vladimir Moskvichev, Mikhail Gadenin and Anatoly Tchernyaev",downloadPdfUrl:"/chapter/pdf-download/68436",previewPdfUrl:"/chapter/pdf-preview/68436",authors:[null],corrections:null},{id:"68644",title:"Mixture Transition Distribution Modelling of Multivariate Time Series of Discrete State Processes: With an Application to Modelling Flowering Synchronisation with Respect to Climate Dynamics",doi:"10.5772/intechopen.88554",slug:"mixture-transition-distribution-modelling-of-multivariate-time-series-of-discrete-state-processes-wi",totalDownloads:694,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"A new approach to assess synchronicity developed in this chapter is a novel bivariate extension of the generalised mixture transition distribution (MTDg) model (we coin this B-MTD). The aim of this chapter is to test MTDg an extended MTD with interactions model and its bivariate extension of MTD (B-MTD) to investigate synchrony of flowering of four Eucalypts species—E. leucoxylon, E. microcarpa, E. polyanthemos and E. tricarpa over a 31 year period. The mixture transition distribution (MTDg) is a method to estimate transition probabilities of high order Markov chains. Our B-MTD approach allows us the derive rules of thumb for synchrony and asynchrony between pairs of species, e.g. flowering of the four species. The latter B-MTD rules are based on transition probabilities between all possible on and off flowering states from previous to current time. We also apply MTDg modelling using lagged flowering states and climate covariates as predictors to model current flowering status (on/off) to assess synchronisation using residuals from the resultant models via our adaptation of Moran’s classic synchrony statistic. We compare these MTDg (with covariates)-based synchrony measures with our B-MTD results in addition to those from extended Kalman filter (EKF)-based residuals.",signatures:"Irene Hudson, Susan Won Sun Kim and Marie Keatley",downloadPdfUrl:"/chapter/pdf-download/68644",previewPdfUrl:"/chapter/pdf-preview/68644",authors:[null],corrections:null},{id:"69938",title:"Hybrid Modeling of Offshore Platforms’ Stress-Deformed and Limit States Taking into Account Probabilistic Parameters",doi:"10.5772/intechopen.88894",slug:"hybrid-modeling-of-offshore-platforms-stress-deformed-and-limit-states-taking-into-account-probabili",totalDownloads:699,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Offshore platforms should be referred to critically and strategically important objects of a technosphere due to technological and operational challenges, on the one hand, and the danger potential level, on the other hand. Environmental, social and economic losses occurred over several decades of accidents and disasters in unique Great Britain, Norwegian. The Russian and the USA platforms were evaluated in death of dozens of operators, destruction of platforms, environment contamination and hence in multi-bullion losses. All of these indicate insufficiency of currently taken engineering solutions, providing structure strength, operational life and safety. The scientific, design, expert and supervising organizations in Russia and in the world are developing and improving mathematical and physical methods, implementing the probabilistic formulations for accidents and disasters, risk assessment and risks reduction on offshore platforms. The solutions of the following problems are included: extension of the comprehensive computational and experimental strength, operational life and survivability analysis to the cases of nonroutine events, accidental and catastrophic conditions; numerical justification of modelling of critical elements, zones and points with the maximum tension, deformations and damages occurring under impacts of external extreme seismic, ice, wind, low temperature; implementation of comprehensive diagnostic methods for damage states evaluation within nonlinear and probabilistic fracture mechanics; and use of new structural design and technological systems for reduction of negative extreme impacts as well as emergency protection systems. The solution of the specified problems is illustrated by case studies of the Russian specialists for each life cycle stage of the platforms offshore Caspian and Kara Seas and Sea of Okhotsk.",signatures:"Gennady Yu. Shmal, Vladimir A. Nadein, Nikolay A. Makhutov, Pavel A. Truskov and Viktor I. Osipov",downloadPdfUrl:"/chapter/pdf-download/69938",previewPdfUrl:"/chapter/pdf-preview/69938",authors:[{id:"231592",title:"Mr.",name:"Vladimir",surname:"Nadein",slug:"vladimir-nadein",fullName:"Vladimir Nadein"}],corrections:null},{id:"68106",title:"Probabilistic Modeling, Estimation and Control for CALS Organization-Technical-Economic Systems",doi:"10.5772/intechopen.88025",slug:"probabilistic-modeling-estimation-and-control-for-cals-organization-technical-economic-systems",totalDownloads:727,totalCrossrefCites:2,totalDimensionsCites:2,hasAltmetrics:0,abstract:"Theoretical propositions of new probabilistic methodology of analysis, modeling, estimation and control in stochastic organizational-technical-economic systems (OTES) based on stochastic CALS informational technologies are considered. Stochastic integrated logistic support (ILS) of OTES modeling life cycle (LC), stochastic optimal of current state estimation in stochastic media defined by internal and external noises (including specially organized OTES-NS (noise support) and stochastic OTES optimal control) according to social-technical-economic-support criteria in real time by informational-analytical tools (IAT) of global type are presented. OTES-CALS are nonlinear and continuous-discrete. So we use approximate methods of normal approximation of probabilistic densities both for modeling and estimation. Spectrum of possibilities may be broaden by solving problems of OTES-CALS integration for existing markets of finances, goods and services. Analytical modeling, analysis, parametric optimization and optimal stochastic processes regulation in limits of illustrate some technologies and IAT given plans.",signatures:"Igor Sinitsyn and Anatoly Shalamov",downloadPdfUrl:"/chapter/pdf-download/68106",previewPdfUrl:"/chapter/pdf-preview/68106",authors:[null],corrections:null},{id:"70004",title:"Combined Calculated, Experimental and Determinated and Probable Justifications for Strength of Trunk Crude Oil Pipelines",doi:"10.5772/intechopen.89036",slug:"combined-calculated-experimental-and-determinated-and-probable-justifications-for-strength-of-trunk-",totalDownloads:697,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Within the long-term Russian and foreign practice, deterministic methods of basic strength calculations have been developed and are being developed at the design stage of long-distance pipelines. Occurring operational damages, failures, accidents, and catastrophes show there are no direct substantiations for the prevention of such emergencies in the framework of existing calculations. In order to respond to these situations, the following are developed: additional precise deterministic, static, and probabilistic calculations with linear and nonlinear criteria of deformation and fracture mechanics, complex diagnostics of the state of the pipeline using in-line pigs, and laboratory, model, bench, and field tests of pipelines with technological and operational defects. The results of systematic scientific research and applied developments are presented.",signatures:"Dmitry Neganov and Nikolay Makhutov",downloadPdfUrl:"/chapter/pdf-download/70004",previewPdfUrl:"/chapter/pdf-preview/70004",authors:[{id:"256061",title:null,name:"Dmitriy A.",surname:"Neganov",slug:"dmitriy-a.-neganov",fullName:"Dmitriy A. Neganov"}],corrections:null},{id:"69677",title:"From Asymptotic Normality to Heavy-Tailedness via Limit Theorems for Random Sums and Statistics with Random Sample Sizes",doi:"10.5772/intechopen.89659",slug:"from-asymptotic-normality-to-heavy-tailedness-via-limit-theorems-for-random-sums-and-statistics-with",totalDownloads:594,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"This chapter contains a possible explanation of the emergence of heavy-tailed distributions observed in practice instead of the expected normal laws. The bases for this explanation are limit theorems for random sums and statistics constructed from samples with random sizes. As examples of the application of general theorems, conditions are presented for the convergence of the distributions of random sums of independent random vectors with finite covariance matrices to multivariate elliptically contoured stable and Linnik distributions. Also, conditions are presented for the convergence of the distributions of asymptotically normal (in the traditional sense) statistics to multivariate Student distributions. The joint asymptotic behavior of sample quantiles is also considered.",signatures:"Victor Korolev and Alexander Zeifman",downloadPdfUrl:"/chapter/pdf-download/69677",previewPdfUrl:"/chapter/pdf-preview/69677",authors:[null],corrections:null},{id:"68428",title:"Probability Modeling Taking into Account Nonlinear Processes of a Deformation and Fracture for the Equipment of Nuclear Power Plants",doi:"10.5772/intechopen.88233",slug:"probability-modeling-taking-into-account-nonlinear-processes-of-a-deformation-and-fracture-for-the-e",totalDownloads:816,totalCrossrefCites:2,totalDimensionsCites:2,hasAltmetrics:0,abstract:"At the solution of integrated tasks of strength, safe life and service safety maintenance for the nuclear power plants (NPP) equipment with slow reactors—water-moderated power reactors (WMPR) of VVER type and channel-type graphite-moderated power reactors (GMPR) of RBMK type arise necessity of physical and mathematical modeling of nonlinear processes of a deformation, fracture and damage at nonlinear probability statement. First of all, it concerns deriving determined, statistical and probabilistic characteristics of mechanical properties of reactor materials. Expectations and variation factors of mechanical properties’ characteristics obtained from experimental researches are inducted into the equations for the verification calculations at determination of static and cyclic strength margins with the use of nominal and local stresses and strains. For the improved determined and probability analysis of these margins modeling experimental researches of stress-strain states of the analyzed equipment are conducted. Special attention at such tests is given to concentration factors and variation factors of loading conditions. The final stage of estimation of basic normative and verification calculation accuracy at laboratory, modeling and test bench researches are full-scale pre-operational tests (cold-hot running-in) of pilot nuclear reactors with the use of the experimental mechanics methods. The conditions of safety service of the NPP equipment are estimated taking into account factors of reaching limiting states by criteria of risk of initiation of emergency situations.",signatures:"Nikolay Andreevich Makhutov, Mikhail Matveevich Gadenin, Igor Alexandrovich Razumovskiy, Sergey Valerievich Maslov and Dmitriy Olegovich Reznikov",downloadPdfUrl:"/chapter/pdf-download/68428",previewPdfUrl:"/chapter/pdf-preview/68428",authors:[null],corrections:null},{id:"68889",title:"Combinatorial Enumeration of Graphs",doi:"10.5772/intechopen.88805",slug:"combinatorial-enumeration-of-graphs",totalDownloads:745,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"In this chapter, I will talk about some of the enumerative combinatorics problems that have interested researchers during the last decades. For some of those enumeration problems, it is possible to obtain closed mathematical expressions, and for some other it is possible to obtain an estimation by the use of asymptotic methods. Some of the methods used in both cases will be covered in this chapter as well as some application of graph enumeration in different fields. An overview about the enumeration of trees will be given as an example of combinatorial problem solved in a closed mathematical form. Similarly, the problem of enumeration of regular graphs will be discussed as an example of combinatorial enumeration for which it is hard to obtain a closed mathematical form solution and apply the asymptotic estimation method used frequently in analytic combinatorics for this end. An example of application of the enumerative combinatorics for obtaining a result of applicability criteria of selection nodes in a virus spreading control problem will be given as well.",signatures:"Carlos Rodríguez Lucatero",downloadPdfUrl:"/chapter/pdf-download/68889",previewPdfUrl:"/chapter/pdf-preview/68889",authors:[null],corrections:null},{id:"68717",title:"New Variations of the Online k-Canadian Traveler Problem: Uncertain Costs at Known Locations",doi:"10.5772/intechopen.88741",slug:"new-variations-of-the-online-em-k-em-canadian-traveler-problem-uncertain-costs-at-known-locations",totalDownloads:570,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"In this chapter, we study new variations of the online k-Canadian Traveler Problem (k-CTP) in which there is an input graph with a given source node O and a destination node D. For a specified set consisting of k edges, the edge costs are unknown (we call these uncertain edges). Costs of the remaining edges are known and given. The objective is to find an online strategy such that the traveling agent finds a route from O to D with minimum total travel cost. The agent learns the cost of an uncertain edge, when she arrives at one of its end-nodes and decides on her travel path based on the discovered cost. We call this problem the online k-Canadian Traveler Problem with uncertain edges. We analyze both the single-agent and the multi-agent versions of the problem. We propose a tight lower bound on the competitive ratio of deterministic online strategies together with an optimal online strategy for the single-agent version. We consider the multi-agent version with two different objectives. We suggest lower bounds on the competitive ratio of deterministic online strategies to these two problems.",signatures:"Davood Shiri and F. Sibel Salman",downloadPdfUrl:"/chapter/pdf-download/68717",previewPdfUrl:"/chapter/pdf-preview/68717",authors:[null],corrections:null},{id:"70080",title:"A Geometrical Realisation of Quasi-Cyclic Codes",doi:"10.5772/intechopen.88288",slug:"a-geometrical-realisation-of-quasi-cyclic-codes",totalDownloads:651,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"We study and enumerate cyclic codes which include generalised Reed-Solomon codes as function field codes. This geometrical approach allows to construct longer codes and to get more information on the parameters defining the codes. We provide a closed formula in terms of Stirling numbers for the number of irreducible polynomials and we relate it with other formulas existing in the literature. Further, we study quasi-cyclic codes as orbit codes in the Grassmannian parameterizing constant dimension codes. In addition, we review Horn’s algorithm and apply it to construct classical codes by their defining ideals.",signatures:"Cristina Martinez Ramirez and Alberto Besana",downloadPdfUrl:"/chapter/pdf-download/70080",previewPdfUrl:"/chapter/pdf-preview/70080",authors:[null],corrections:null},{id:"68747",title:"Moments of the Discounted Aggregate Claims with Delay Inter-Occurrence Distribution and Dependence Introduced by a FGM Copula",doi:"10.5772/intechopen.88699",slug:"moments-of-the-discounted-aggregate-claims-with-delay-inter-occurrence-distribution-and-dependence-i",totalDownloads:577,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"In this chapter, with renewal argument, we derive higher simple moments of the Discounted Compound Delay Renewal Risk Process (DCDRRP) when introducing dependence between the inter-occurrence time and the subsequent claim size. To illustrate our results, we assume that the inter-occurrence time is following a delay-Poisson process and the claim amounts is following a mixture of Exponential distribution, we then provide numerical results for the first two moments. The dependence structure between the inter-occurrence time and the subsequent claim size is defined by a Farlie-Gumbel-Morgenstern copula. Assuming that the claim distribution has finite moments, we obtain a general formula for all the moments of the DCDRRP process.",signatures:"Franck Adékambi",downloadPdfUrl:"/chapter/pdf-download/68747",previewPdfUrl:"/chapter/pdf-preview/68747",authors:[null],corrections:null},{id:"68667",title:"Modelling the Information-Psychological Impact in Social Networks",doi:"10.5772/intechopen.88252",slug:"modelling-the-information-psychological-impact-in-social-networks",totalDownloads:729,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The paper considers the objects, subjects, purposes, tools, methods and implementation of information-psychological impact (IPI). It suggests a cellular automata model of the diffusion process of information-psychological impact in social networks, the hierarchy of the changes in the states of the subjects of information-psychological impact and the chart of transitions from state to state used in the cellular automaton algorithm. The suggested cellular automaton takes into account the effect of forgetting the information-psychological impact, as well as social and psychological parameters and probabilistic characteristics of the subjects of the social network. It therefore allows for the modelling of the diffusion of the information-psychological impact in the social network. The model can be used to determine the number of subjects affected by the information-psychological impact and the possibility of successful diffusion of the impact. The modelling of the suggested algorithm was performed. The results of the modelling are analysed in the paper.",signatures:"Igor Goncharov, Nikita Goncharov, Pavel Parinov, Sergey Kochedykov and Alexander Dushkin",downloadPdfUrl:"/chapter/pdf-download/68667",previewPdfUrl:"/chapter/pdf-preview/68667",authors:[{id:"231528",title:"Ph.D.",name:"Igor",surname:"Goncharov",slug:"igor-goncharov",fullName:"Igor Goncharov"},{id:"240727",title:"Mr.",name:"Nikita",surname:"Goncharov",slug:"nikita-goncharov",fullName:"Nikita Goncharov"},{id:"240728",title:"Mr.",name:"Pavel",surname:"Parinov",slug:"pavel-parinov",fullName:"Pavel Parinov"},{id:"240729",title:"Mr.",name:"Sergey",surname:"Kochedykov",slug:"sergey-kochedykov",fullName:"Sergey Kochedykov"},{id:"249097",title:"Dr.",name:"Alexander",surname:"Dushkin",slug:"alexander-dushkin",fullName:"Alexander Dushkin"}],corrections:null},{id:"70931",title:"Combinatorial Cosmology",doi:"10.5772/intechopen.90696",slug:"combinatorial-cosmology",totalDownloads:648,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"In this chapter, a combinatorial model for cosmology is analyzed. We consider each universe as a path in a graph, and the set of all such paths can be made into a finite probability space. We can then consider the probabilities for different kinds of behavior and under certain circumstances argue that a scenario where the behavior of the entropy is monotonic, either increasing or decreasing, should be much more likely than a scenario where the behavior is symmetric with respect to time. In this way we can attempt to construct a model for a multiverse which is completely time symmetric but where the individual universes tend to be time asymmetric, i.e., have an arrow of time. One of the main points with this approach is that this kind of broken symmetry can be studied in very small models using exact mathematical methods from, e.g., combinatorics. Even if the amount of computations needed increases very rapidly with the size of the model, we can still hope for valuable information about what properties more realistic models should have. 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The removal of the uterus at caesarean section is referred to as caesarean hysterectomy, while the removal after vaginal birth is called postpartum hysterectomy. The operation may be performed as an emergency or as a planned procedure [1,2].
Although uncommon in modern obstetrics, peripartum hysterectomy is one of the most devastating complications in obstetrics. It represents a catastrophic end to a pregnancy to all women in general and to those wanting to maintain their fertility in particular [3,4].
Despite advances in medicine and surgery, peripartum hysterectomy is associated with high rates of morbidity, near miss and mortality. It is mostly performed as an emergency procedure to control torrential life-threatening haemorrhage and remains a life-saving procedure [1,2,5].
Peripartum hysterectomy was proposed in 1768 by Joseph Cavallini in animal experiments. In 1823, James Blundell approved caesarean hysterectomy on a work based on rabbits. The first documented caesarean hysterectomy was performed by Horatio Storer in 1869. The patient died 68 h after surgery. In 1876, Eduardo Porro performed the first caesarean hysterectomy in which both the mother and baby survived. His patient was a 25-year-old primiparous dwarf. A constricting wire was passed around the cervix to control haemorrhage, and the uterus was excised. The abdominal wound was closed with silver wire. Various modifications followed, such as those of Godson in 1884 and Lawson in 1890 [6].
In modern obstetrics, there are considerable differences in the incidence of emergency peripartum hysterectomy in different parts of the world, with higher figures in low-resource countries, while developed countries generally report lower rates [7,8]. The variations may be related to the standard of antenatal care, unbooked emergencies, obstetric care, differing rates of caesarean delivery, different patterns of parity, maternal age and the earlier recourse to hysterectomy due to the lack of adequate blood and blood banking facilities. In addition, certain conservative procedures involving interventional radiology may not be available in most developing countries [9].
In a recent review of relevant articles in English literature, the incidence of emergency peripartum hysterectomy ranged from 0.24 to 8.7 per 1000 deliveries [10].
Emergency peripartum hysterectomy was found to be more common following caesarean section than vaginal deliveries. In addition, there is a significant association between emergency peripartum hysterectomy and previous caesarean section and placenta praevia. The risk of emergency peripartum hysterectomy increases with the number of previous caesarean sections. There is an increased incidence of previous caesarean section in patients with placenta praevia and in patients with adherent placenta [11-23].
To estimate the magnitude of increased maternal morbidity associated with increasing number of caesarean deliveries, Silver et al. in a prospective observational cohort of 30,132 women who had caesarean delivery without labour in 19 academic centres over 4 years found that placenta accreta was present in 15 (0.24 %), 49 (0.31%), 36 (0.57 %), 31 (2.13 %), 6 (2.33 %) and 6 (6.74 %) women undergoing their first, second, third, fourth, fifth and sixth or more caesarean deliveries, respectively. Hysterectomy was required in 40 (0.65 %) first, 67 (0.42 %) second, 57 (0.90 %) third, 35 (2.41 %) fourth, 9 (3.49 %) fifth and 8 (8.99 %) sixth or more caesarean deliveries. Furthermore, in women with praevia, the risk for placenta accreta was 3 %, 11 %, 40 %, 61 % and 67 % for first, second, third, fourth and fifth or more repeat caesarean deliveries, respectively [24].
The incidence of emergency peripartum hysterectomy is rising worldwide in view of the rising caesarean section rate and the concomitant rise in placenta praevia and placenta praevia accreta and multiple births [25].
Besides the predominant reported indications for emergency peripartum hysterectomy that include uterine atony, placenta praevia, placenta praevia accreta and uterine rupture, other reported risk factors include precipitate labour, induction, prolonged labour, dystocia, cephalopelvic disproportion, augmentation, foetal macrosomia, multiple pregnancy, retained products of conception, previous endometrial curettage, coagulopathy, thrombocytopenia, maternal obesity, advanced maternal age, previous primary postpartum haemorrhage, gestational diabetes and abruptio placentae, particularly the concealed variety that is associated with Couvelaire uterus. All were identified as independent risk factors for uterine atony [11-23].
Elective peripartum hysterectomy may be performed in patients with an antepartum diagnosis of placenta accreta or stage IA2 and IB1 cervical carcinoma [2]. Severe postpartum infection unresponsive to medical therapy and placental site vessel subinvolution are other potential indications for the procedure [26,27].
Severe post partum haemorrhage remains a significant cause of maternal morbidity and mortality in both developed and developing countries [28,29]. The rate of postpartum haemorrhage requiring blood transfusion was reported to occur in 1.7% deliveries [30]. Maternal complications of postpartum haemorrhage include hypovolaemic shock, disseminated intravascular coagulopathy (DIC), renal failure, hepatic failure and acute respiratory distress syndrome (ARDS) [31,32]. The most severe complication of haemorrhage is maternal death.
Haemorrhage, in general, is classified into four categories [33] (Table 1). Postpartum haemorrhage is measured by the loss of greater than 500 ml of blood following vaginal birth or 1000 ml of blood following caesarean section [34]. Postpartum haemorrhage can be minor (500–1000 ml) or major (more than 1000 ml). Major postpartum haemorrhage could be divided to moderate (1000–2000 ml) or severe (more than 2000 ml). A blood loss of more than 2000 ml is regarded as ‘life threatening’.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
Blood loss (ml) | \n\t\t\t<750 | \n\t\t\t750–1500 | \n\t\t\t1500–2000 | \n\t\t\t>2000 | \n
Blood loss (%) | \n\t<15 % | \n\t15–30 % | \n\t30–40 % | \n\t>40 % | \n
Pulse rate/min | \n\t<100 | \n\t>100 | \n>120 | \n>140 | \n
Blood pressure | \n\tNormal | \n\tHypo | \n\tHypo | \n\tHypo | \n
Respiratory rate/min | \n\t14–20 | \n\t20–30 | \n\t30–40 | \n\t>35 | \n
Urine output (ml/hour) | \n\t>30 | \n20–30 | \n5–15 | \n<5 | \n
Signs and symptoms | \n\tNone | \n\tFatigue, pallor | \n\tConfusion | \n\tLife threatening | \n
Action: stop loss | \n\tObserve | \n\tIV fluid | \n\tBlood transfusion | \n\tBlood transfusion | \n
Classification of haemorrhage
Haemorrhagic shock is a life-threatening condition that results when more than 20 % of the body’s blood is lost. Symptoms include anxiety, blue lips and fingernails, low or no urine output, profuse sweating, tachypnoea, dizziness, confusion, chest pain, loss of consciousness, hypotension, tachycardia and weak pulse [35].
A Cochrane review addressed the use of uterotonics in the third stage of labour. It indicated that, for women delivering vaginally, oxytocin 5 IU by intramuscular injection is the regimen of choice for routine prophylaxis against postpartum haemorrhage. In the context of caesarean delivery, oxytocin 5 IU by intravenous injection is the recommended routine for prophylaxis against postpartum haemorrhage; the drug should be given slowly to avoid the risk of profound hypotension [36].
\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t
Oxytocin | \n\t\tIV | \n\t\t10–40 U in 1 L N saline | \n\t\tContinuous | \n\t
Oxytocin | \n\t\tIM | \n\t\t10 U | \n\t\t\n\t |
Ergometrine* | \n\t\tIM | \n\t\t0.5 mg | \n\t\tEvery 2–4 h | \n\t
PGF2α** | \n\t\tIM or intra-myometrially | \n\t\t0.25 mg | \n\t\tEvery 15–90 min. Max. 8 | \n\t
PGE2 | \n\t\tVaginal or rectal | \n\t\t20 mg | \n\t\tEvery 2 h | \n\t
PGE1 | \n\t\tRectal | \n\t\t1 mg | \n\t\t\n\t |
Pharmacological management of postpartum haemorrhage
* Contraindicated in women with hypertension
** Contraindicated in women with asthma
To arrest postpartum haemorrhage, algorithms have been proposed to aid its systematic management. Procedures for immediate management of postpartum haemorrhage include the use of pharmacological uterotonic drugs (Table 2), uterine massage or bimanual uterine compression on an empty bladder, the initiation of blood and blood components therapy (Table 3), repair of genital tract lacerations, evacuation of retained products of conception, the implementation of uterine or internal iliac arteries or anterior division of internal iliac arteries embolisation (Figure 1), uterine tamponade techniques (Table 4) (Figure 2), uterine compression sutures (Figure 3), systematic pelvic devascularisation (Figure 4), internal iliac artery ligation (Figure 5) and recombinant-activated factor VII for category III and IV postpartum haemorrhage [37-44] . Consideration should be given to the possibility that placenta praevia percreta may extend into the bladder and other pelvic organs. Clinicians need to be aware of the appropriateness and the timing of instituting interventions.
\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t
Packed red cells | \n\t\t240 ml | \n\t\tRBC, WBC, plasma | \n\t\tIncrease PCV 3 % points, Hb 1 g/dl | \n\t
Platelets | \n\t\t50 ml | \n\t\tPlatelets, RBC, WBC, plasma | \n\t\tIncrease platelet 5,000–10,000/µl | \n\t
Fresh frozen plasma | \n\t\t250 ml | \n\t\tFibrinogen, antithrombin III, V, VIII | \n\t\tIncrease fibrinogen by 10 mg/dl | \n\t
Cryoprecipitate | \n\t\t40 ml | \n\t\tFibrinogen, VIII, XIII, VWF | \n\t\tIncrease fibrinogen by 10 mg/dl | \n\t
Blood component therapy
\n\t\t\t | \n\t\t\n\t\t\t | \n\t
Packing | \n\t\t4-inch gauze in 5 ml of sterile saline | \n\t
Foley catheter | \n\t\tInsert one or more bulbs, instil 60–80 ml of saline | \n\t
Sengstaken–Blakemore tube | \n\t\t\n\t |
Tamponade balloon | \n\t\tInstil 300–500 ml of saline | \n\t
Uterine tamponade techniques for postpartum haemorrhage
Internal iliac artery, anterior division angiogram. An enlarged uterine artery is present post-caesarean section. Courtesy of The Pump and the Tubes. A journal of all things vascular
Uterine tamponade. Courtesy of Bt-Cath® With Easyfill™ Inflation System. Utah Medical Products, Inc.
Uterine compression sutures. Courtesy of B-Lynch
Stepwise devascularisation. Courtesy of B-Lynch
Systematic pelvic devascularisation and internal iliac artery ligation. Courtesy of B-Lynch
Postpartum haemorrhage is a leading indication for emergency peripartum hysterectomy. Peripartum hysterectomy is generally performed in the setting of category IV life-threatening haemorrhage during or after abdominal and vaginal deliveries that cannot be controlled by the above medical and conservative surgical measures.
Uterine rupture is associated with maternal and perinatal mortality and morbidity worldwide, particularly in developing countries. The most common cause of uterine rupture is tear of a previous caesarean section scar after a trial of labour in a patient with a previous caesarean section. Rupture of an unscarred uterus is rare. It may occur in obstructed, multiparous labour and in response to inappropriate use of oxytocic agents. Its incidence decreases with improvement in obstetric practice [45].
Traumatic rupture can occur with internal version, classical application of the anterior blade of Kielland’s forceps, manual removal of the placenta, manual exploration of the uterus and during curettage for secondary postpartum haemorrhage. Other causes of traumatic ruptures of the uterus are relatively rare and tend to occur at the fundus and usually result only from the most violent accidents [46].
Caesarean hysterectomy may be necessary in cases of lateral extension of the lower uterine segment incision, when the caesarean section is performed with the foetal head deeply impacted in the pelvis in the second stage of labour. The tear may extend to branches of the uterine arteries. Haemostasis may be challenging; injuries to the ureters are possible. Broad ligament haematoma is not uncommon.
Emergency peripartum hysterectomy may be necessary in cases of extensive uterine sepsis where antibiotic treatment is not effective and in the rare cases of placental site vessel subinvolution [27], in which uterine bleeding is protracted.
The problems of uterine atony and uterine rupture have been greatly reduced through the use of potent uterotonic agents and the utilisation of modern obstetric care [47]. With the rising caesarean section rate and the rising incidence of placenta praevia and accreta and the more severe forms of increta and percreta, associated with previous caesarean sections, recent studies have indicated a change in the trend towards abnormal placentation (Figure 6) as the most common indication for emergency and planned peripartum hysterectomy [48-50]. In the absence of risk factors, early diagnosis of placental abnormalities is difficult. Unfortunately, the diagnosis is frequently established only after unsuccessful removal of the placenta at delivery.
Diagram illustrating placenta accreta, increta and percreta. Courtesy of Callen P
For the antenatal diagnosis of placenta accreta, transvaginal and transabdominal ultrasonography are complementary diagnostic techniques. Transvaginal ultrasound is safe for patients with placenta praevia. Normal placentation is characterised by a hypoechoic boundary between the placenta and the bladder. Features suggestive of placenta accreta include thinning of the myometrium overlying the placenta (Figure 7), protrusion of the placenta into the bladder and irregularly shaped placental lacunae. The presence of lacunae ‘moth-eaten or Swiss cheese appearance’ within the placenta is predictive of placenta accreta (Figure 8). The use of colour Doppler, power Doppler or three-dimensional imaging may improve the diagnostic sensitivity (Figure 9), compared with that achieved by grayscale ultrasonography alone [51].
Sonogram demonstrating absence (arrows) of the intervening myometrium between the placenta and uterine serosa. Courtesy of Callen P
Sonogram demonstrating numerous vascular lacunae (arrows) within the placenta in a patient with placenta accreta Ultrasound of placenta and bladder wall interface indicating placenta accreta. Courtesy of Riteau et al.
Colour Doppler image demonstrating absence of intervening myometrium (short arrow) and abnormal bladder–uterine wall vascularisation (long arrow). Courtesy of Callen P
Overall, one study demonstrated that grayscale ultrasonography may be sufficient to diagnose placenta accreta, with a sensitivity of 91.4 % (95 % CI, 77.6–97.0 %), specificity of 95.9 % (95 % CI, 92.2–97.9 %), a positive predictive value of 80.0 % (95 % CI, 65.2–89.5 %) and a negative predictive value of 98.4 % (95 % CI, 95.5–99.5 %) [52]. Another study concluded that ultrasound for the prediction of placenta accreta may not be as accurate as previously described, with reported sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 53.5 %, 88.0 %, 82.1 %, 64.8 % and 64.8 %, respectively [53].
Magnetic resonance imaging (MRI) is considered to add little to the diagnostic accuracy of ultrasonography. However, when there are ambiguous ultrasound findings or a suspicion of a posterior placenta accreta, with or without placenta praevia, ultrasonography may be insufficient. In general, MRI may better outline the anatomy and degree of invasion (Figure 10) [54].
Sagittal magnetic resonance images indicated a bulge at the bladder wall indicating a major anterior placenta praevia accreta with bladder wall involvement. Courtesy of unsw.edu.au
Controversy surrounds the use of gadolinium-based contrast enhancement even though it adds to the specificity of the placenta accreta diagnosis by MRI. The use of gadolinium contrast enables MRI to more clearly delineate the outer placental surface relative to the myometrium. However, it is recommended that intravenous gadolinium should be used only if absolutely essential [55].
Recently, prophylactic arterial occlusion has been described as a strategy to reduce bleeding during planned hysterectomy (Figure 11). The efficacy and safety of this procedure is unknown. One small-scale study suggested that the successful use of a staged embolisation hysterectomy procedure for placenta accreta is associated with decreased maternal morbidity [56]. Another study using prophylactic intravascular balloon catheters did not benefit women with placenta accreta undergoing caesarean hysterectomy [57]. The use of these procedures should not delay recourse to surgery.
Placing arterial catheters (C) and ureteral catheters (U) preoperatively; E is the external foetal monitor. Courtesy of Ochsner 201
Surgical planning is necessary. Once the decision is made to embark on surgical haemostasis, the most appropriate choice of procedure will depend on available resources and the expertise of available staff. Obstetricians should be prepared for the potential need to perform emergent peripartum hysterectomy. There is a high chance that a patient with uterine rupture, placenta accreta, increta or percreta will undergo hysterectomy [58]. At least 4 U of blood and blood products must be made available in suspected cases of accreta.
The acute loss of blood and the unplanned nature of surgery render the conditions for postpartum haemorrhage less than ideal to perform the procedure. Peripartum hysterectomy is associated with increased rates of both intraoperative and postoperative complications. Compared with nonobstetric hysterectomy, peripartum hysterectomy is associated with higher rates of morbidity and mortality. The mortality of peripartum hysterectomy is more than 25 times that of hysterectomy performed outside of pregnancy, with the higher rates in regions with limited medical and hospital resources [15]. Therefore, peripartum hysterectomy is considered a major dramatic life-saving surgical venture and represents the most challenging complication that an obstetrician will face.
Adequate resuscitation and prompt decision-making for hysterectomy would contribute to decreasing maternal morbidity and mortality, as timing is critical to an optimal outcome. It has been established that there is a relationship between the duration of time that passes prior to deciding to perform an emergency hysterectomy and the likelihood of coagulopathy, severe hypovolaemia, hypothermia and acidosis. Early recourse to hysterectomy is recommended, especially where bleeding is associated with placenta accreta or uterine rupture [59].
For peripartum hysterectomy, an experienced senior obstetrician with an experience in obstetric hysterectomy should be present at surgery. Of concern however is the limited experience of performing emergency hysterectomy among some obstetricians. Emergency peripartum hysterectomy being performed by an experienced surgeon is reported to significantly reduce maternal morbidity in general, operating time, number of units of blood transfusion and hospital stay in particular [60,61].
Although hysterectomy has traditionally been advised for the management of placenta accreta, it is associated with considerable maternal morbidity and mortality. Therefore, new strategies have been attempted to manage this condition conservatively, so that fertility can be preserved and some of the complications of peripartum hysterectomy averted. Such strategies include leaving the placenta in situ, combined with uterine artery embolisation or uterine compression sutures, and the use of methotrexate to inhibit trophoblast growth. However, these conservative approaches may be limited by the high risk of bleeding, infection and poor placental absorption [62-64].
Transfusion-related acute lung injury (TRALI) is a rare but potentially fatal complication of blood product transfusion, manifesting as acute respiratory distress syndrome (ARDS). It is characterised by acute respiratory distress following transfusion. All plasma-containing blood products have been implicated including rare reports of IVIG and cryoprecipitate. The symptoms typically develop during or within 6 h of a transfusion [32].
Transfusion-related acute lung injury patients present with the rapid onset of dyspnoea and tachypnoea. There may be associated fever, cyanosis and hypotension. Chest x-rays show bilateral patchy infiltrates, which may progress to the complete ‘white out’ oedema of acute respiratory distress syndrome.
It is hypothesised that transfusion-related acute lung injury may be precipitated by the infusion of donor antibodies directed against recipient leucocytes. The infusion of donor anti-HLA or anti-HNA antibodies is thought to directly cause complement activation, release of cytotoxic agents, endothelial damage and capillary leak. The majority of patients require ventilatory support [32].
Patients at high risk of caesarean hysterectomy should be scheduled for delivery at a time when appropriate ancillary staff with high-risk anaesthetists, interventional radiologists, urologists and resources is readily available. It is preferable to avoid emergency deliveries after the onset of labour, as the ancillary staff may not be available at a very short notice. Transfer of care to a tertiary care centre may be necessary if these resources are not locally available [65].
Patients at risk for peripartum hysterectomy should be counselled about the likelihood of the procedure, what the procedure involves, complications, issues related to ovarian conservation and possible need for recovery in an intensive care unit. Forward planning for delivery highlights the importance of antenatal checks and screening to minimise blood loss, morbidity and mortality. After the initial postoperative recovery, women should receive a comprehensive outline of events from experienced obstetricians [66].
The fertility-ending nature of emergency obstetric hysterectomy can be devastating as some women that receive an emergency peripartum hysterectomy are primigravid. After the initial postoperative recovery, those women should be comprehensively counselled.
Peripartum hysterectomy may be either subtotal or total. It has been recommended that the decision on the type of hysterectomy should be individualised. Subtotal hysterectomy may be preferable because it may be technically easier with shorter operating time, less blood loss, less urological injury and low morbidity, added to the fact that the cervix may be difficult to identify, especially if the patient has laboured and whose cervix is fully effaced, dilated and soft. This is important in the setting of severe acute haemorrhage [67,68].
In cases of placenta praevia, where the entire placental bed has to be removed, and if the lower segment, cervix and paracolpos are involved in the haemorrhage, total hysterectomy will be necessary for haemostasis. Similar approach is adopted for cases of placenta praevia accreta that is invading the cervical stroma.
In the preoperative preparation for peripartum hysterectomy, in suspected cases of accreta, 4 U of both packed red blood cells and plasma have to be cross-matched. Cryoprecipitate and platelets should be available. General anaesthesia is considered to be more appropriate when there is continuing bleeding and the cardiovascular stability is compromised.
When the cardiovascular is stable and there is no evidence of coagulation failure, regional anaesthesia can be used. This may be particularly appropriate where a working epidural has been in place during labour. A vertical skin incision should be considered to provide better exposure.
The technique of peripartum hysterectomy is similar in principle to that of abdominal hysterectomy in gynaecology, except for the anatomical and physiological changes in pregnancy that render the uterine and ovarian vessels enlarged and distended and the pelvic tissues oedematous and friable.
In some cases of peripartum hysterectomy, traumatised tissues at the base of the pelvis may continue to bleed following surgery despite ligation of obvious bleeding pedicles. This bleeding is usually associated with disseminated intravascular coagulation (DIC). In such cases, the application of pelvic pressure packs may provide haemostasis until haematological stability is achieved. Vascular embolisation may be considered in the interim [69].
In general, emergency procedures are associated with a higher rate of postoperative complications than planned procedures. Furthermore, compared with nonobstetric hysterectomy, peripartum hysterectomy is accompanied by substantial morbidity and mortality. The principal complications are febrile episodes, haemorrhage, urinary tract injuries, coagulopathy, paralytic ileus or bowel obstruction, wound sepsis/dehiscence, vaginal cuff bleeding, pulmonary embolism and the need for re-exploration because of persistent bleeding.
In a population-based analysis to examine the morbidity and mortality of peripartum hysterectomy in comparison with nonobstetric hysterectomy, bladder and ureteral injuries were more common for peripartum hysterectomy, 9 % compared with 1 % and 0.7 % compared with 0.1 % respectively, (P<.001). Rates of reoperation (4 % compared with 0.5 %), postoperative haemorrhage (5 % compared with 2 %), wound complications (10 % compared with 3 %) and venous thromboembolism (1 % compared with 0.7 %) were all higher in women who underwent peripartum hysterectomy. In multivariable analysis, the odds ratio for death from peripartum compared to nonobstetric hysterectomy was 14.4 (95 % confidence interval 9.84–20.98) [38].
During peripartum hysterectomy, scarring from previous caesarean sections may obliterate the utero-vesical pouch and make the dissection of the bladder from the uterus injury prone. Furthermore, the ureters may be sectioned, clamped or stitched because of heavy bleeding that interferes with proper exposure. The reported incidence of urological injuries with peripartum hysterectomy is high [38]. Within the context of the emergency situation and the available resources, it is best to diagnose and deal with any bladder or ureteric injury at the time of the hysterectomy. Any tear in the bladder should be repaired with two layers of 3/0 polyglactin (Vicryl) or equivalent suture. After repair of any bladder injury, the bladder can be filled with methylene blue or sterile milk to ascertain that this has been accomplished successfully. Perioperative cystoscopy with ureteral stent placement may be considered.
In the intraoperative stage of peripartum hysterectomy, the application of tourniquet around the uterine cervix can be attempted to reduce blood loss. This is facilitated by the use of transillumination, where the avascular spaces in the broad ligament, roughly opposite the level of a transverse lower caesarean incision, are identified and a catheter passed through on each side to encircle the lower uterine segment just above the cervix. The catheter should be twisted and tightly clamped. This would compress the uterine arteries. In addition, the application of straight clamps adjacent to the uterus to include the round ligaments, the Fallopian tubes and the utero-ovarian ligaments will serve to control the collateral blood flow to the uterus from the ovarian arteries. These two manoeuvres should occlude the main collateral ovarian and uterine artery supply to the uterus.
It is recommended that all pedicles should be doubly ligated in all types of hysterectomy. In peripartum hysterectomy, the vascular pedicles are particularly thick and oedematous. At first, a transfixing suture is applied, followed by an all encompassing ligature. Check should be made to ensure that there is no haematoma formation at the base of the pedicle.
In cases of hysterectomy for placenta praevia accreta, increta and percreta, the foetus is delivered through a classical uterine incision, and the intact placenta is left in situ while the hysterectomy is completed (Figure 12).
Hysterectomy specimen opened. Note placenta praevia percreta left in situ. © 2015 Callen P. Courtesy of Tikkanen, J Med Case Rep
At caesarean hysterectomy, a finger can be placed through the uterine incision and the cervical rim palpated. It is the safest to enter the vagina posteriorly, identify the rim of the cervix and then proceed anteriorly.
In general, No. 1 polyglactin (Vicryl) or equivalent is used throughout the peripartum hysterectomy procedures. Perioperative antibiotic prophylaxis should be continued for 24–48 h. Both mechanical and pharmacologic prophylaxis for deep venous thrombosis should be instituted. Thromboprophylaxis with heparin should be started as soon as one is satisfied that haemostasis is secure, at least 4 h postoperatively. The ovaries are almost always conserved. Peripartum hysterectomy is not a contraindication to breastfeeding. Women may use a breast pump temporarily until they are fit enough to breastfeed [70].
For an optimal management strategy for placenta accreta, it has been suggested that avoiding attempted placental removal at caesarean hysterectomy in women with suspected placenta accreta is associated with reduced maternal morbidity. Furthermore, some studies have recommended that patients with placenta accreta, increta or percreta who have no attempt to remove any of their placentae, with the aim of conserving their uterus, have reduced levels of haemorrhage and a reduced need for blood transfusion [62-64].
To provide a standardised approach to patients with postpartum haemorrhage, it is recommended that each labour unit should have a protocol for cases with estimated blood loss exceeding 1000 ml. Management involves four components that must be initiated simultaneously: communication, resuscitation, arresting the bleeding and monitoring and investigation, for optimal patient care. The following is a general guide for the management of major postpartum haemorrhage of more than 1000 ml and continuing to bleed OR clinical shock.
Notify the senior obstetrician in charge, the department of anaesthesia, blood bank and laboratory.
Establish two 14-gauge intravenous canula access; 20 ml blood sample should be taken for full blood count, coagulation screen, urea and electrolytes and cross match (4 U).
For atony, administer oxytocin 10 IU by slow intravenous injection, followed by 40 IU in 500 ml of Hartmann’s solution or normal saline at 125 ml/hour. If no intravenous access, give 10 IU intramuscularly. Oxytocin may be combined with other pharmacological agents; ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension); carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 min to a maximum of eight doses (contraindicated in women with asthma); direct intramyometrial injection of carboprost 0.5 mg; misoprostol 1000 µg rectally (Table 2).
Initiate uterine massage and/or manual uterine compression.
Administer oxygen (10–15 l/min) by face mask or intubation, regardless of maternal oxygen concentration.
Transfuse blood as soon as possible. If cross-matched blood is still unavailable, give uncross-matched group-specific blood or ‘O RhD negative’ blood. Four units of fresh frozen plasma is given for every 6 U of red cells or prothrombin time/activated partial thromboplastin time more than 1.5 x normal (total 1 l). Platelet concentrates is administered if platelet count is less than 50 x 109/L and cryoprecipitate if fibrinogen is less than 1 g/L. The clinical picture should be the main determinant for the need for blood transfusion. Time should not be wasted waiting for laboratory results (Table 3).
Until blood is available, infuse up to 3.5 L of warmed crystalloid Hartmann’s solution (2 l) and/or colloid (1–2 l) as rapidly as required.
Inspect the vagina and cervix for lacerations and repair them as necessary; evacuate any retained products of conception.
If pharmacological measures fail to control the haemorrhage, initiate surgical haemostasis sooner rather than later. The following surgical interventions may be attempted, depending on clinical circumstances and available expertise:
For the constant and close monitoring and support, unstable patients may need to be catered for in an intensive care unit.
Common tests and their normal values include coagulation screen, electrolytes, liver function tests, acid-base and blood gases and kidney function tests (Table 5-9).
\n\t\t\t | \n\t\t\n\t\t\t | \n\t
Platelet count (Plt) | \n\t\t140–450 x 103/µL | \n\t
Mean platelet volume (MPV) | \n\t\t7.4–10.4 fL | \n\t
Prothrombin time (PT) | \n\t\t1–15 s | \n\t
International normalised ratio (INR) | \n\t\t0.9–1.2 | \n\t
Activated partial thromboplastin time (APTT) | \n\t\t18–45 s | \n\t
Thrombin clotting time (TCT) | \n\t\t11–18 s | \n\t
Fibrinogen | \n\t\t1.7–4.2 g/L | \n\t
Antithrombin | \n\t\t0.15–0.39 mg/mL | \n\t
Bleeding time | \n\t\t2–9 min | \n\t
Viscosity | \n\t\t1.5–1.7 cP | \n\t
Coagulation-bleeding screen
\n\t\t\t | \n\t\t\n\t\t\t | \n\t
Sodium (Na) | \n\t\t135–147 mEq | \n\t
Potassium (K) | \n\t\t3.5–5 mEq | \n\t
Bicarbonate (HCO3) | \n\t\t24–30 mEq | \n\t
Chloride (Cl) | \n\t\t100–106 mEq | \n\t
Electrolytes
\n\t\t\t | \n\t\t\n\t\t\t | \n\t
ALT | \n\t\t5 to 56 U/L | \n\t
AST | \n\t\t6 to 40 U/L | \n\t
ALP | \n\t\t42 to 128 U/L | \n\t
Total protein | \n\t\t35 to 84 g/L | \n\t
Albumin | \n\t\t35 to 50 g/L | \n\t
Globulins | \n\t\t25 to 35 g/L | \n\t
Total bilirubin | \n\t\t0.1 to 1.0 mg/dL | \n\t
Direct/conjugated bilirubin | \n\t\t0.0 to 0.4 mg/dL | \n\t
GGT | \n\t\t9 to 48 U/L | \n\t
LD | \n\t\t122 to 222 U/L | \n\t
PT | \n\t\t9.5 to 13.8 s | \n\t
Liver function tests
Reports of balloon tamponade describe the intervention as the ‘tamponade test’. Control of postpartum haemorrhage following inflation of the balloon indicates that laparotomy is not required. Continued postpartum haemorrhage following inflation of the balloon is an indication to proceed to laparotomy. This serves to affirm place of balloon tamponade as first-line procedure in the ‘surgical’ management of postpartum haemorrhage. The balloon should be left in place for 4–6 h, and, preferably, it should be removed during daytime hours. The balloon should be deflated and left in place for few minutes to ensure that bleeding does not reoccur [71,72].
The logistics for performing arterial occlusion or embolisation may not be readily available. This makes uterine balloon tamponade a more appropriate first-line treatment. Nevertheless, interventional radiology may be considered in cases of antenatal diagnosis of malplacentation, in the form of placenta praevia and placenta accreta, increta or percreta, where intra-arterial catheters, with the view of either occlusion or embolisation, can be placed prior to the performance of caesarean section. Follow-up studies of women who had undergone arterial embolisation or internal iliac artery ligation for control of postpartum haemorrhage suggest that these interventions do not impair subsequent menstruation, fertility and pregnancy outcomes [73,74].
\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t
pH | \n\t\tArterial | \n\t\t7.35 to 7.45 | \n\t
Venous | \n\t\t7.31 to 7.41 | \n\t|
(H+) | \n\t\tArterial | \n\t\t36 to 44 nmol/L | \n\t
3.6 to 4.4 ng/dl | \n\t||
Base excess | \n\t\tArterial and venous | \n\t\t-3 to +3 mEq/L | \n\t
Oxygen partial pressure (pO2) | \n\t\tArterial | \n\t\t10 to 14 kPa | \n\t
75 to 105 mmHg | \n\t||
Venous | \n\t\t4.0 to 5.3 kPa | \n\t|
30 to 40 mmHg | \n\t||
Oxygen saturation (SpO2) | \n\t\tArterial | \n\t\t94 to 100 % | \n\t
Venous | \n\t\tApproximately 75 % | \n\t|
Carbon dioxide partial pressure (pCO2) | \n\t\tArterial | \n\t\t4.4 to 6.0 kPa | \n\t
33 to 45 mmHg | \n\t||
Venous | \n\t\t5.5 to 6.8 kPa | \n\t|
41 to 51 mmHg | \n\t||
Absolute content of CO2\n\t\t | \n\t\tArterial | \n\t\t23 to 30 mmol/L | \n\t
100 to 132 mg/dl | \n\t||
Bicarbonate (HCO3) | \n\t\tArterial and venous | \n\t\t18 to 23 mmol/L | \n\t
110 to 140 mg/dL | \n\t||
Standard bicarbonate (SBC) | \n\t\tArterial and venous | \n\t\t21 to 28 mmol/L or mEq/L | \n\t
134 to 170 mg/dL | \n\t
Acid–base and blood gases
\n\t\t\t | \n\t\t\n\t\t\t | \n\t
Blood urea nitrogen (BUN) | \n\t\t6 to 20 mg/dL | \n\t
Creatinine | \n\t\t0.6 to 1.3 mg/dL | \n\t
Urine creatinine (24-hour sample) | \n\t\t500 to 2000 mg/day. 11 to 26 mg/kg weight | \n\t
Creatinine clearance | \n\t\t88 to 137 ml/min | \n\t
Kidney function tests
It recommended that these postpartum guidelines should be implemented at an estimated blood loss well below approx 2000 ml as the aim is to prevent haemorrhage escalating to the point where it is life threatening. In the face of relentless bleeding, up to 1 L of fresh frozen plasma and 10 U of cryoprecipitate (two packs) may be given while awaiting the results of coagulation studies. Factor VIIa therapy may be used as an adjuvant to standard pharmacological and surgical treatments, in a dose of 90 µg/kg, which may be repeated within 15–30 min in the absence of clinical response. Fibrinogen should be above 1 g/L and platelets greater than 20 x 109/L before Factor VIIa is given.
These recommendations are primarily for clinicians working in specialist-led obstetric departments; they are less appropriate for settings where resources are limited. It is recommended that the main therapeutic goals of management of massive blood loss are to maintain:
Haemoglobin more than 8 g/dl
Platelet count more than 75 x 109/L
Prothrombin less than 1.5 x mean control
Fibrinogen more than 1.0 g/L
Intraoperative cell salvage for autologous red cell transfusion is being investigated for use in obstetrics. The insertion of a central line will provide a means of accurate central venous pressure (CVP) monitoring and act as a route for rapid fluid replacement. In addition to central venous pressure line, a direct arterial pressure line should be used for cardiovascular monitoring in cases of major haemorrhage.
Increasing caesarean rates would lead to an increase in the number of peripartum hysterectomies for abnormal placentation. Because serious maternal morbidity and mortality increases progressively with increasing number of caesarean deliveries, the number of intended family size should be considered when counselling regarding elective primary caesarean delivery and elective repeat caesarean operation versus a trial of labour [73-76].
Peripartum hysterectomy is a challenging procedure. Its role in modern obstetrics is evolving. Improving management of postpartum haemorrhage should decrease peripartum hysterectomy for uterine atony. Peripartum hysterectomy merits a multidisciplinary approach.
The stiff knee (SKN) is considered as a clinical situation that the range of motion (ROM) is less than a 50° arc of movement [1, 2]. SKN causes a variable level of functional disability, painful discomfort during scarce knee mobility, limp in the gait cycle, and hamper with activities of daily living [3]. Normal walking requires 70°–80° of ROM, stairs require 80°–90° of ROM, and squatting requires at least 130° of ROM [4].
The main causes of SKN are previous surgery on the knee, advanced primary knee ostearthritis, secondary posttraumatic ostearthrosis, reflex sympathetic dystrophy (RSD), neuromuscular disorder, sequelae of previous infection, inflammatory diseases (rheumatoid and psoriatic arthritis), arthrofibrosis, and hemofilic arthropathy. Ankylosis is more common in patients who had their knee immobilized or who are wheelchair bound. The common clinical characteristics in patients with SKN are patela baja, quadriceps contracture, intra-articular adhesions, posterior capsule contracture, poor patellar gliding, and heterotopic ossification [5, 6]. Total knee arthroplasty (TKA) in SKN is a challenging procedure. One of the goals of TKA is to improve knee mobility, including ambulatory ability in the gait [7, 8]. Other goals of TKA in patients with SKN are to relieve pain, improve the alignment to correct the knee deformity, and provide knee stability.
The most relevant factor that predicts knee mobility after TKA is preoperative range of motion [9, 10]. Young age, female sex, and obese patients are more susceptible to achieve less mobility after TKA [11, 12]. In patients with SKNs, the predominant symptom is not mechanical pain. Functional disabilities like impairments in stair climbing, unable to sit on a chair, and inability to walk a long distance are common complaints. Psychological and cosmetic harms are associated with decline in the quality life. TKA is considered a valuable option to improve functional capacity and obtain a mobile knee.
The SKN can be presented clinically in loss of extension (LOE), loss of flexion (LOF), mixed or ankylosed. The major troubles in LOE are adhesions in suprapatellar pouch and in medial and lateral gutters, contracture of extensor mechanism, patellofemoral joint fusion, and loss of tibiofemoral joint space. The SKN in LOF, the extensor mechanism that is elongated with posterior capsule, posterior cruciate ligament (PCL), and collaterals ligaments are contractured. The posterior osteophytes causes a mechanical barrier to achieve complete ROM. Ankylosed knee can be associated with knee arthrodesis, infection, reconstruction after tumor ressection, after severe trauma with distal femur, and tibial plateau fractures. The classification proposed by Sharma [13] is based on the degree of loss of ROM in the knee joint, as shown in Table 1.
|
|
|
|
|
|
Classification for stiff/ankylosed knees proposed by Sharmal [13].
This classification provides a guidance for surgeons related to surgical approach, type of prosthetic implants, and helps to presume functional outcome after TKA.
Advanced primary knee osteoarthritis (Kellgren-Lawrence 3 or 4);
Posttraumatic knee osteoarthitis and/or previous knee surgery;
After knee osteotomy (distal femur and/or proximal tibia);
Arthrofibrosis (post-surgery and/or prolonged immobilization);
Inflammatory osteoarthritis (rheumatoid arthritis and psoriasis);
Hemophilic arthropathy;
Ankylosis (after knee arthrodesis);
Heterotopic ossification (HO);
Reflex sympathetic dystrophy (RSD);
Neurologic arthropathy;
Postinfection arthropathy.
Neuromuscular disease (s) with RSD;
Paralysis after brain vascular stroke;
Patient inability to follow the postoperative rehabilitation protocol;
Active infection without clinical control.
A through clinical history must include questions about previous conservative treatment and surgeries, period of time that stiffness started, comorbidities, medications, and psychological profile. The physical examination must comprise the preoperative passive and active ROM (flexion and extension), patellar gliding, the amount of flexion contracture, scars, type and flexibility of the angular deformity, gait pattern, and extensor mechanism status (elongated or contractured). Osteoporosis is frequent in SKNs. Complete motor, sensory, and vascular assessment should be performed. Ankle/brachial index and Doppler ultrasound can be useful to estimate the function of blood circulation in the legs.
The imaging exams of the knee should include radiographic evaluation in anteroposterior (AP) and lateral at 30° of flexion (Figures 1 and 2). Special views with maximal and minimal flexion in the sagittal plane should be documented. Long-axis anteroposterior (AP) view can be useful to determine the mechanical and anatomical axis of the lower limbs. The sunrise patellar view at 45° of flexion can demonstrate a severe arthritic involvement, where the patella usually is fused with the anterior femur [2, 5]. A stress view in the coronal plane can be helpful to determine if the angular deformity is rigid or correctable. Presence of hardware is not uncommon in STK patients. Computed tomography (CT) scan may be used to assess bone stock and rule out infections [3].
Radiography in anteroposterior view with stiff knee.
Radiography in lateral view with 30° of flexion.
The surgeon must select which type of knee prosthesis will be required. A broad assortment of modular systems are disposable according to each patient. More constrained implants can be considered in cases with bone loss, ligamentous insufficiency, or after extensive soft tissues releases. A custom prosthesis must be fabricated for a particular situation as a very small or large knees and ankylosed knees in rheumatoid patients. In a previous infected STK, a staged procedure can be recommended to decrease the risk of serious complications [14, 15].
The type of anesthesia should emphasize the muscle relaxation and minimize blood loss. Usually, the epidural anesthesia associated with peripheral nerve block as adductor canal provide decrease of narcotic usage and postoperative pain. The tranexamic acid (20–60 mg/kg) can be administrated intravenous during the anesthetic induction in attempt to reduce the blood loss. The use of tourniquet is questionable and can be avoidable in STK patients [16, 17]. The use of sterile drape is recommended, and the leg should be free to move during the TKA. The range of motion (ROM) and ligamentous stability should be addressed prior the incision and documented.
A straight midline incision should be used, if there is not prior surgical scar. If an anterior longitudinal knee scar is found, the skin incision starts more proximally. Usually, the skin is adherent to the subcutaneous tissue and careful dissection may be required to mobilize the skin. This step assists the deep subfascial dissection and facilitates the dermis and epidermis closure. A medial parapatellar arthrotomy is performed with capsule opening and releases the adhesions in the suprapatellar pouch and plane between anterior distal femur underneath the quadriceps tendon. After this step, cleaning the medial and lateral gutters may be required to gain adequate exposure. All the fibrotic tissues should be removed. The patellar tendon is identified and protected during the TKA, and the space posterior to the tendon freed by sharp dissection with the scalpel or eletrocautery.
The next step is the patellar eversion. The difficulty to dislocate the patella laterally, in SKN, remains a problem. The lateral retinacular release can be performed, if the knee remains stiff with flexion less than 40° and the lateral patellofemoral ligament is cut to assist the patellar eversion. An extensive transquadricipital approach, the rectus snip, can be performed to improve and provide good exposure with low risk related to the extensor mechanism damage. The rectus tendon is transected in an oblique fashion, around 45°, in a superior and lateral direction [18]. Orienting the rectus snip distally allows for conversion to a V-Y quadricepsplasty that the surgeon incises the rectus tendon and vastus lateralis, but not the lateral retinaculum [19, 20]. This approach preserves the superior lateral geniculate artery, which provides the major blood supply to the patella, when a medial arthrotomy has been performed. However, this technique is not recommended in the presence of subluxated or dislocated patella laterally. In this scenario, an extensive lateral retinacular release can be performed and the patella is everted and knee is flexed gently. It is recommended to be cautious during this maneuver to avoid patellar tendon avulsion from the tibia tubercle, bone avulsion, and medial collateral ligament (MCL) tear in the progression for the knee flexion [21]. The placement of a metallic pin through the tibial tubercle can decrease the stress over the patellar tendon and hinder the avulsion. The combination of a quadriceps snip and lateral release provides an adequate exposure for most SKNs. The rectus tendon and vastus lateralis muscle are repaired, but the lateral retinacular incision is left open. This approach has the advantage of not requiring modification of postoperative rehabilitation [22].
In the varus deformity, the subperiosteal medial release is then continued, with a sharp scalpel, an electrocautery or an osteotome, as the knee is further flexed and the tibia externally rotated. Dissection should begin in extension on the bone surfaces in attempt to mobilize the soft tissues. Then, skeletonization of the tibia and femur has been performed to allow knee flexion for adequate exposure. For severe varus SKNs, a medial transepicondylar femoral osteotomy may be required. In the valgus deformity with SKNs, a decision must be made to choose an anterior longitudinal traditional incision or lateral approach described by Keblish [23].
The tibial tubercle osteotomy (TTO) can be performed to extend the incision distally for the most difficult SKNs. The osteotomy should encompass at least 8 centimeters (cm) distal to the top of the tibial tubercle. The bone cut is made with an oscillating saw from medial to lateral, and then the lateral cortex is transected with an osteotome. Muscle attachments to the lateral tibial crest with a periosteal soft tissues hinge are left preserved. Two or three wires are passed to encompass the tubercle during closure [24]. Furthermore, two or three screws can be used to stabilize the TTO, in patients with good bone quality. In osteoporotic bone, TTO is not recommended. Before wound closure, the knee was taken through a passive ROM to assure osteotomy fixation and patellofemoral tracking. Postoperatively, the patients wore a protective knee immobilizer while up and walking for the first 6 weeks.
For the ligament balancing, sequential soft tissue release can be performed to correct the angular deformity; if posterior cruciate ligament (PCL) appears to be functional and balanced, cruciate retaining (CR) prosthesis can be used, but this is an uncommon scenario. For a rigid or severe flexion, contracture may be necessary to cut more distal femur (2 mm) to achieve a straight knee in extension. It is not a feasible solution to cut more distal femur than 2 mm due to the high risk to raise the joint line. Then, the tibial and femoral bone cuts are recommended to place the laminar spreaders in extension and flexion in 90°. A curved osteotome is used to remove the posterior osteophytes and release the posterior capsule (Figure 3). This maneuver is essential to open the flexion gap [25](Figures 4 and 5).
Removal of posterior osteophytes in the femoral condyles.
Narrow flexion gap prior the posterior release.
Opening of the flexion gap with laminar spreaders.
Moreover, more constrained implants as posterior stabilized (PS) models with an elevated polyethylene post are considered as the implant of choice due to the PCL contracture in SKNs. If during insertion of trial components, the knee is unstable in both coronal and sagittal plane, and a more constrained modular component with augments and stems or hinged prosthesis can be chosen. It is recommended to place the femoral component more posterior to decrease the flexion gap, mainly in PS implants. The level of constriction will depend the extent of the ligamentous releases and the amount of bone loss encountered during the TKA. A tumor prosthesis or custom implants may be needed in extremely SKNs, especially in extension. The prosthesis chosen should have options available for femoral and tibial implants in attempt to re-establish the anatomic joint line with available metallic augments (Figures 6 and 7). Care should be taken to avoid overstuff in the patellofemoral articulation that can lead to a flexion contracture and anterior knee pain.
Postoperative radiography in anteroposterior view after TKA in stiff knee.
Postoperative radiography in lateral view after TKA in stiff knee.
In ankylosed and after knee arthrodesis, the patellar and proximal tibial cut can be performed in the beginning to obtain more space and promote a better exposure during the TKA. A posterior capsule release with the electrocautery and the laminar spreaders positioned in extension can help after the bone cuts to achieve zero degrees. For a more severe contracture above 30°, the quadricepsplasty may be needed in attempt to elongate the extensor mechanism and to re-establish the joint line. In patients with MCL insufficiency and bone loss in the metaphysis, a hinge TKA can be considered.
The closure of the quadriceps tendon should be performed between 30° and 60° of knee flexion, depending on the preoperative gravity of the SKN. The type of quadriceps release or TTO performed should be taken into account to consider the angulation of knee flexion during the closure. The intraoperative ROM after this surgical step should be documented with a photograph to demonstrate for the patient and the physiotherapist [26].
A light pressure dressing is applied, and cryotherapy can be used to reduce swelling and knee pain. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the ROM, accounting for the patient’s ability and level of pain. The use of the removable knee orthosis is debatable. It can be used in static or dynamic manner in attempt to avoid loss of motion after TKA [27]. The patient is immediately placed in a continuous passive motion (CPM) machine from 0° to 30° of flexion in the recovery room. The flexion is increased 10° a day or as tolerated. The physical therapy can be prescribed in the early stage of the postoperative rehabilitation protocol intercalated with the CPM to optimize the gain of knee motion [28]. The pain control is crucial to achieve the progressive ROM. The use of spinal or epidural catheters with analgesic infusion can be helpful after TKA in SKNs. The early quadriceps activation is recommended with physical methods (sensory transcutaneous electrical stimulation), active isometric contraction, and early deambulation with walker or crutches. After TTO and V-Y quadricepsplasty, the rehabilitation protocol is delayed to preserve bone and soft tissue healing, mainly between 4 to 6 weeks. A long orthosis is recommended in the lower limb to keep the gait secure. The recovery of quadriceps function is essential to achieve a satisfactory outcome during the day life activities, improve ROM, and obtain a stable gait [29].
The clinical results of TKA in SKNs are inferior in comparison with non-stiff knees with higher complication rates [21, 30]. The rate of complications ranges from 21–35% [31, 32]. The common complications are patellar tendon avulsion, partial or complete tear of MCL, bone fracture or avulsion (epicondyle (s), patella), stiffness after TKA, wound dehiscence, ligamentous imbalance between extension, and flexion gap. Gentle knee flexion and progressive subperiosteal soft tissue releases with the electrocautery can prevent intraoperative bone fracture. It is not uncommon a painful TKA in SKNs that can be a challenging situation to achieve a better functional outcome. Extension lag is associated with V-Y quadricepsplasty [32]. Aseptic loosening in the tibial component has been described in some SKNs [32, 33]. Osteoporotic bone can be considered as a risk factor for fractures around the knee.
The functional scores applied after TKA like Hospital for Special Surgery (HSS), Knee Society Score (KSS), Knee Society Functional Score (FS) have improved due to gain in postoperative ROM in comparison with preoperative status [11, 30, 31, 32, 33]. The range of improvement in ROM after TKA in SKNs is around 50°–70°. The range of improvement in KSS after TKA is between 30 and 45 points [30, 31, 32, 33]. In spite of the enhancement in motion, some residual flexion contracture is predictable in type 2 and 3 SKNs and can affect the pattern of the gait. A limp with overload in the lumbar spine can be expected in this scenario.
The TKA in SKNs is technically demanding with a time-consuming rehabilitation protocol. Patient expectation should be realistic according to the level of SKNs. The complication rate is greater than conventional TKA. A good preoperative evaluation is mandatory to avoid unexpected intra- and postoperative hassle.
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He previously worked as a post-doctoral fellow at the Ben-Gurion University of Negev, Israel; University of the Free State, South Africa; and Central University of Technology Bloemfontein, South Africa. He obtained his Ph.D. in Organic Chemistry from Nagaoka University of Technology, Japan. He has published more than seventy-four journal articles and attended several national and international conferences as speaker and chair. Dr. Kendrekar has received many international awards. He has several funded projects, namely, anti-malaria drug development, MRSA, and SARS-CoV-2 activity of curcumin and its formulations. He has filed four patents in collaboration with the University of Central Lancashire and Mayo Clinic Infectious Diseases. His present research includes organic synthesis, drug discovery and development, biochemistry, nanoscience, and nanotechnology.",institutionString:"Visiting Scientist at Lipid Nanostructures Laboratory, Centre for Smart Materials, School of Natural Sciences, University of Central Lancashire",institution:null},{id:"428125",title:"Dr.",name:"Vinayak",middleName:null,surname:"Adimule",slug:"vinayak-adimule",fullName:"Vinayak Adimule",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/428125/images/system/428125.jpg",biography:"Dr. Vinayak Adimule, MSc, Ph.D., is a professor and dean of R&D, Angadi Institute of Technology and Management, India. He has 15 years of research experience as a senior research scientist and associate research scientist in R&D organizations. He has published more than fifty research articles as well as several book chapters. He has two Indian patents and two international patents to his credit. Dr. Adimule has attended, chaired, and presented papers at national and international conferences. He is a guest editor for Topics in Catalysis and other journals. He is also an editorial board member, life member, and associate member for many international societies and research institutions. His research interests include nanoelectronics, material chemistry, artificial intelligence, sensors and actuators, bio-nanomaterials, and medicinal chemistry.",institutionString:"Angadi Institute of Technology and Management",institution:null},{id:"284317",title:"Prof.",name:"Kantharaju",middleName:null,surname:"Kamanna",slug:"kantharaju-kamanna",fullName:"Kantharaju Kamanna",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284317/images/21050_n.jpg",biography:"Prof. K. Kantharaju has received Bachelor of science (PCM), master of science (Organic Chemistry) and Doctor of Philosophy in Chemistry from Bangalore University. He worked as a Executive Research & Development @ Cadila Pharmaceuticals Ltd, Ahmedabad. He received DBT-postdoc fellow @ Molecular Biophysics Unit, Indian Institute of Science, Bangalore under the supervision of Prof. P. Balaram, later he moved to NIH-postdoc researcher at Drexel University College of Medicine, Philadelphia, USA, after his return from postdoc joined NITK-Surthakal as a Adhoc faculty at department of chemistry. Since from August 2013 working as a Associate Professor, and in 2016 promoted to Profeesor in the School of Basic Sciences: Department of Chemistry and having 20 years of teaching and research experiences.",institutionString:null,institution:{name:"Rani Channamma University, Belagavi",country:{name:"India"}}},{id:"158492",title:"Prof.",name:"Yusuf",middleName:null,surname:"Tutar",slug:"yusuf-tutar",fullName:"Yusuf Tutar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/158492/images/system/158492.jpeg",biography:"Prof. Dr. Yusuf Tutar conducts his research at the Hamidiye Faculty of Pharmacy, Department of Basic Pharmaceutical Sciences, Division of Biochemistry, University of Health Sciences, Turkey. He is also a faculty member in the Molecular Oncology Program. He obtained his MSc and Ph.D. at Oregon State University and Texas Tech University, respectively. He pursued his postdoctoral studies at Rutgers University Medical School and the National Institutes of Health (NIH/NIDDK), USA. His research focuses on biochemistry, biophysics, genetics, molecular biology, and molecular medicine with specialization in the fields of drug design, protein structure-function, protein folding, prions, microRNA, pseudogenes, molecular cancer, epigenetics, metabolites, proteomics, genomics, protein expression, and characterization by spectroscopic and calorimetric methods.",institutionString:"University of Health Sciences",institution:null},{id:"180528",title:"Dr.",name:"Hiroyuki",middleName:null,surname:"Kagechika",slug:"hiroyuki-kagechika",fullName:"Hiroyuki Kagechika",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180528/images/system/180528.jpg",biography:"Hiroyuki Kagechika received his bachelor’s degree and Ph.D. in Pharmaceutical Sciences from the University of Tokyo, Japan, where he served as an associate professor until 2004. He is currently a professor at the Institute of Biomaterials and Bioengineering (IBB), Tokyo Medical and Dental University (TMDU). From 2010 to 2012, he was the dean of the Graduate School of Biomedical Science. Since 2012, he has served as the vice dean of the Graduate School of Medical and Dental Sciences. He has been the director of the IBB since 2020. Dr. Kagechika’s major research interests are the medicinal chemistry of retinoids, vitamins D/K, and nuclear receptors. He has developed various compounds including a drug for acute promyelocytic leukemia.",institutionString:"Tokyo Medical and Dental University",institution:{name:"Tokyo Medical and Dental University",country:{name:"Japan"}}},{id:"94311",title:"Prof.",name:"Martins",middleName:"Ochubiojo",surname:"Ochubiojo Emeje",slug:"martins-ochubiojo-emeje",fullName:"Martins Ochubiojo Emeje",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94311/images/system/94311.jpeg",biography:"Martins Emeje obtained a BPharm with distinction from Ahmadu Bello University, Nigeria, and an MPharm and Ph.D. from the University of Nigeria (UNN), where he received the best Ph.D. award and was enlisted as UNN’s “Face of Research.” He established the first nanomedicine center in Nigeria and was the pioneer head of the intellectual property and technology transfer as well as the technology innovation and support center. Prof. Emeje’s several international fellowships include the prestigious Raman fellowship. He has published more than 150 articles and patents. He is also the head of R&D at NIPRD and holds a visiting professor position at Nnamdi Azikiwe University, Nigeria. He has a postgraduate certificate in Project Management from Walden University, Minnesota, as well as a professional teaching certificate and a World Bank certification in Public Procurement. Prof. Emeje was a national chairman of academic pharmacists in Nigeria and the 2021 winner of the May & Baker Nigeria Plc–sponsored prize for professional service in research and innovation.",institutionString:"National Institute for Pharmaceutical Research and Development",institution:{name:"National Institute for Pharmaceutical Research and Development",country:{name:"Nigeria"}}},{id:"436430",title:"Associate Prof.",name:"Mesut",middleName:null,surname:"Işık",slug:"mesut-isik",fullName:"Mesut Işık",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/436430/images/19686_n.jpg",biography:null,institutionString:null,institution:{name:"Bilecik University",country:{name:"Turkey"}}},{id:"268659",title:"Ms.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/268659/images/8143_n.jpg",biography:"Dr. Zhan received his undergraduate and graduate training in the fields of preventive medicine and epidemiology and statistics at the West China University of Medical Sciences in China during 1989 to 1999. He received his post-doctoral training in oncology and cancer proteomics for two years at the Cancer Research Institute of Human Medical University in China. In 2001, he went to the University of Tennessee Health Science Center (UTHSC) in USA, where he was a post-doctoral researcher and focused on mass spectrometry and cancer proteomics. Then, he was appointed as an Assistant Professor of Neurology, UTHSC in 2005. He moved to the Cleveland Clinic in USA as a Project Scientist/Staff in 2006 where he focused on the studies of eye disease proteomics and biomarkers. He returned to UTHSC as an Assistant Professor of Neurology in the end of 2007, engaging in proteomics and biomarker studies of lung diseases and brain tumors, and initiating the studies of predictive, preventive, and personalized medicine (PPPM) in cancer. In 2010, he was promoted to Associate Professor of Neurology, UTHSC. Currently, he is a Professor at Xiangya Hospital of Central South University in China, Fellow of Royal Society of Medicine (FRSM), the European EPMA National Representative in China, Regular Member of American Association for the Advancement of Science (AAAS), European Cooperation of Science and Technology (e-COST) grant evaluator, Associate Editors of BMC Genomics, BMC Medical Genomics, EPMA Journal, and Frontiers in Endocrinology, Executive Editor-in-Chief of Med One. He has\npublished 116 peer-reviewed research articles, 16 book chapters, 2 books, and 2 US patents. His current main research interest focuses on the studies of cancer proteomics and biomarkers, and the use of modern omics techniques and systems biology for PPPM in cancer, and on the development and use of 2DE-LC/MS for the large-scale study of human proteoforms.",institutionString:null,institution:{name:"Xiangya Hospital Central South University",country:{name:"China"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"418340",title:"Dr.",name:"Jyotirmoi",middleName:null,surname:"Aich",slug:"jyotirmoi-aich",fullName:"Jyotirmoi Aich",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038Ugi5QAC/Profile_Picture_2022-04-15T07:48:28.png",biography:"Biotechnologist with 15 years of research including 6 years of teaching experience. Demonstrated record of scientific achievements through consistent publication record (H index = 13, with 874 citations) in high impact journals such as Nature Communications, Oncotarget, Annals of Oncology, PNAS, and AJRCCM, etc. Strong research professional with a post-doctorate from ACTREC where I gained experimental oncology experience in clinical settings and a doctorate from IGIB where I gained expertise in asthma pathophysiology. A well-trained biotechnologist with diverse experience on the bench across different research themes ranging from asthma to cancer and other infectious diseases. An individual with a strong commitment and innovative mindset. Have the ability to work on diverse projects such as regenerative and molecular medicine with an overall mindset of improving healthcare.",institutionString:"DY Patil Deemed to Be University",institution:null},{id:"349288",title:"Prof.",name:"Soumya",middleName:null,surname:"Basu",slug:"soumya-basu",fullName:"Soumya Basu",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035QxIDQA0/Profile_Picture_2022-04-15T07:47:01.jpg",biography:"Soumya Basu, Ph.D., is currently working as an Associate Professor at Dr. D. Y. Patil Biotechnology and Bioinformatics Institute, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India. With 16+ years of trans-disciplinary research experience in Drug Design, development, and pre-clinical validation; 20+ research article publications in journals of repute, 9+ years of teaching experience, trained with cross-disciplinary education, Dr. Basu is a life-long learner and always thrives for new challenges.\r\nHer research area is the design and synthesis of small molecule partial agonists of PPAR-γ in lung cancer. She is also using artificial intelligence and deep learning methods to understand the exosomal miRNA’s role in cancer metastasis. Dr. Basu is the recipient of many awards including the Early Career Research Award from the Department of Science and Technology, Govt. of India. She is a reviewer of many journals like Molecular Biology Reports, Frontiers in Oncology, RSC Advances, PLOS ONE, Journal of Biomolecular Structure & Dynamics, Journal of Molecular Graphics and Modelling, etc. She has edited and authored/co-authored 21 journal papers, 3 book chapters, and 15 abstracts. She is a Board of Studies member at her university. She is a life member of 'The Cytometry Society”-in India and 'All India Cell Biology Society”- in India.",institutionString:"Dr. D.Y. Patil Vidyapeeth, Pune",institution:{name:"Dr. D.Y. Patil Vidyapeeth, Pune",country:{name:"India"}}},{id:"354817",title:"Dr.",name:"Anubhab",middleName:null,surname:"Mukherjee",slug:"anubhab-mukherjee",fullName:"Anubhab Mukherjee",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y0000365PbRQAU/ProfilePicture%202022-04-15%2005%3A11%3A18.480",biography:"A former member of Laboratory of Nanomedicine, Brigham and Women’s Hospital, Harvard University, Boston, USA, Dr. Anubhab Mukherjee is an ardent votary of science who strives to make an impact in the lives of those afflicted with cancer and other chronic/acute ailments. He completed his Ph.D. from CSIR-Indian Institute of Chemical Technology, Hyderabad, India, having been skilled with RNAi, liposomal drug delivery, preclinical cell and animal studies. He pursued post-doctoral research at College of Pharmacy, Health Science Center, Texas A & M University and was involved in another postdoctoral research at Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Santa Monica, California. In 2015, he worked in Harvard-MIT Health Sciences & Technology as a visiting scientist. He has substantial experience in nanotechnology-based formulation development and successfully served various Indian organizations to develop pharmaceuticals and nutraceutical products. He is an inventor in many US patents and an author in many peer-reviewed articles, book chapters and books published in various media of international repute. Dr. Mukherjee is currently serving as Principal Scientist, R&D at Esperer Onco Nutrition (EON) Pvt. Ltd. and heads the Hyderabad R&D center of the organization.",institutionString:"Esperer Onco Nutrition Pvt Ltd.",institution:null},{id:"319365",title:"Assistant Prof.",name:"Manash K.",middleName:null,surname:"Paul",slug:"manash-k.-paul",fullName:"Manash K. Paul",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/319365/images/system/319365.png",biography:"Manash K. Paul is a scientist and Principal Investigator at the University of California Los Angeles. He has contributed significantly to the fields of stem cell biology, regenerative medicine, and lung cancer. His research focuses on various signaling processes involved in maintaining stem cell homeostasis during the injury-repair process, deciphering the lung stem cell niche, pulmonary disease modeling, immuno-oncology, and drug discovery. He is currently investigating the role of extracellular vesicles in premalignant lung cell migration and detecting the metastatic phenotype of lung cancer via artificial intelligence-based analyses of exosomal Raman signatures. Dr. Paul also works on spatial multiplex immunofluorescence-based tissue mapping to understand the immune repertoire in lung cancer. Dr. Paul has published in more than sixty-five peer-reviewed international journals and is highly cited. He is the recipient of many awards, including the UCLA Vice Chancellor’s award and the 2022 AAISCR-R Vijayalaxmi Award for Innovative Cancer Research. He is a senior member of the Institute of Electrical and Electronics Engineers (IEEE) and an editorial board member for several international journals.",institutionString:"University of California Los Angeles",institution:{name:"University of California Los Angeles",country:{name:"United States of America"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/219081/images/system/219081.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals. He is currently working on the protective activity of phenolic compounds in disorders associated with oxidative stress and inflammation.",institutionString:null,institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Dr.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. She has been a Professor since 1996. Currently, she is the Head of the Laboratory of Metabolism, a division of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation. N.V. Beloborodova has many years of clinical experience in the field of intensive care and surgery. She studies infectious complications and sepsis. She initiated a series of interdisciplinary clinical and experimental studies based on the concept of integrating human metabolism and its microbiota. Her scientific achievements are widely known: she is the recipient of the Marie E. Coates Award \\"Best lecturer-scientist\\" Gustafsson Fund, Karolinska Institutes, Stockholm, Sweden, and the International Sepsis Forum Award, Pasteur Institute, Paris, France (2014), etc. Professor N.V. Beloborodova wrote 210 papers, five books, 10 chapters and has edited four books.',institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"354260",title:"Ph.D.",name:"Tércio Elyan",middleName:"Azevedo",surname:"Azevedo Martins",slug:"tercio-elyan-azevedo-martins",fullName:"Tércio Elyan Azevedo Martins",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/354260/images/16241_n.jpg",biography:"Graduated in Pharmacy from the Federal University of Ceará with the modality in Industrial Pharmacy, Specialist in Production and Control of Medicines from the University of São Paulo (USP), Master in Pharmaceuticals and Medicines from the University of São Paulo (USP) and Doctor of Science in the program of Pharmaceuticals and Medicines by the University of São Paulo. Professor at Universidade Paulista (UNIP) in the areas of chemistry, cosmetology and trichology. Assistant Coordinator of the Higher Course in Aesthetic and Cosmetic Technology at Universidade Paulista Campus Chácara Santo Antônio. Experience in the Pharmacy area, with emphasis on Pharmacotechnics, Pharmaceutical Technology, Research and Development of Cosmetics, acting mainly on topics such as cosmetology, antioxidant activity, aesthetics, photoprotection, cyclodextrin and thermal analysis.",institutionString:null,institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"334285",title:"Ph.D. Student",name:"Sameer",middleName:"Kumar",surname:"Jagirdar",slug:"sameer-jagirdar",fullName:"Sameer Jagirdar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334285/images/14691_n.jpg",biography:"I\\'m a graduate student at the center for biosystems science and engineering at the Indian Institute of Science, Bangalore, India. I am interested in studying host-pathogen interactions at the biomaterial interface.",institutionString:null,institution:{name:"Indian Institute of Science Bangalore",country:{name:"India"}}},{id:"329248",title:"Dr.",name:"Md. Faheem",middleName:null,surname:"Haider",slug:"md.-faheem-haider",fullName:"Md. Faheem Haider",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329248/images/system/329248.jpg",biography:"Dr. Md. Faheem Haider completed his BPharm in 2012 at Integral University, Lucknow, India. In 2014, he completed his MPharm with specialization in Pharmaceutics at Babasaheb Bhimrao Ambedkar University, Lucknow, India. He received his Ph.D. degree from Jamia Hamdard University, New Delhi, India, in 2018. He was selected for the GPAT six times and his best All India Rank was 34. Currently, he is an assistant professor at Integral University. Previously he was an assistant professor at IIMT University, Meerut, India. He has experience teaching DPharm, Pharm.D, BPharm, and MPharm students. He has more than five publications in reputed journals to his credit. Dr. Faheem’s research area is the development and characterization of nanoformulation for the delivery of drugs to various organs.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"329795",title:"Dr.",name:"Mohd Aftab",middleName:"Aftab",surname:"Siddiqui",slug:"mohd-aftab-siddiqui",fullName:"Mohd Aftab Siddiqui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329795/images/system/329795.png",biography:"Dr. Mohd Aftab Siddiqui is an assistant professor in the Faculty of Pharmacy, Integral University, Lucknow, India, where he obtained a Ph.D. in Pharmacology in 2020. He also obtained a BPharm and MPharm from the same university in 2013 and 2015, respectively. His area of research is the pharmacological screening of herbal drugs/natural products in liver cancer and cardiac diseases. He is a member of many professional bodies and has guided many MPharm and PharmD research projects. Dr. Siddiqui has many national and international publications and one German patent to his credit.",institutionString:"Integral University",institution:null}]}},subseries:{item:{id:"2",type:"subseries",title:"Prosthodontics and Implant Dentistry",keywords:"Osseointegration, Hard Tissue, Peri-implant Soft Tissue, Restorative Materials, Prosthesis Design, Prosthesis, Patient Satisfaction, Rehabilitation",scope:"