Gynaecological abdominal-pelvic masses with malignant clinical features.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\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:"10307",leadTitle:null,fullTitle:"Urticaria - Diagnosis and Management",title:"Urticaria",subtitle:"Diagnosis and Management",reviewType:"peer-reviewed",abstract:"This book presents the most current knowledge in the diagnosis and management of urticaria. It also examines the scientific aspects of currently available treatments as well as potential new options for managing severe forms of the disease. Written by international experts in the field, the book addresses those aspects of diagnosing and treating urticaria important for physicians in various specialties, including dermatology, allergy, internal medicine, and more.",isbn:"978-1-83969-335-9",printIsbn:"978-1-83969-334-2",pdfIsbn:"978-1-83969-336-6",doi:"10.5772/intechopen.91493",price:119,priceEur:129,priceUsd:155,slug:"urticaria-diagnosis-and-management",numberOfPages:124,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"fb202eb1a1e092d3f660d4a1434a3692",bookSignature:"Eleni Papakonstantinou",publishedDate:"October 20th 2021",coverURL:"https://cdn.intechopen.com/books/images_new/10307.jpg",numberOfDownloads:1066,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:0,numberOfDimensionsCitationsByBook:0,hasAltmetrics:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 16th 2020",dateEndSecondStepPublish:"December 14th 2020",dateEndThirdStepPublish:"February 12th 2021",dateEndFourthStepPublish:"May 3rd 2021",dateEndFifthStepPublish:"July 2nd 2021",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"203520",title:"Dr.",name:"Eleni",middleName:null,surname:"Papakonstantinou",slug:"eleni-papakonstantinou",fullName:"Eleni Papakonstantinou",profilePictureURL:"https://mts.intechopen.com/storage/users/203520/images/system/203520.jpg",biography:"Dr. Eleni Papakonstantinou, MD, is a board-certified dermatologist-venereologist. She studied medicine at the Aristotle University of Thessaloniki, Greece, and continued with her dermatology specialty at the University of Magdeburg and Hannover Medical School, Germany (2012–2017), where she completed her dissertation in 2016 with research work on atopic dermatitis in children. During this time, Dr. Papakonstantinou gained wide experience in the dermatological field with a special focus on the diagnosis and treatment of chronic inflammatory skin diseases and the prevention and treatment of melanocytic and non-melanocytic skin tumors. Her research interests include atopic dermatitis, pruritus, and the pathophysiology of blistering dermatoses. In addition to lectures at national and international congresses, Dr. Papakonstantinou has published more than thirty scientific papers in international medical journals and her work has been recognized with various prizes (poster prize of the German Dermatological Society, Leipzig, 2016), the Michael Hornstein Memorial Scholarship (EADV Athens 2016), and a travel grant (EAACI Vienna, 2016). Since 2017, she has been a specialist dermatologist-venereologist in Germany and a fellow of the European Board of Dermatology-Venereology (FEBDV). She is currently working as a specialist dermatologist in a dermatological practice in Dortmund, Germany, and she co-administrates an international dermatologic network, Wikiderm International, which is an online learning platform presenting news from the world of dermatology.",institutionString:"Private Dermatological Practice Hautärzte am Markt Dortmund",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"175",title:"Dermatology",slug:"dermatology"}],chapters:[{id:"78367",title:"Introductory Chapter: Urticaria - Meeting the Diagnostic and Therapeutic Challenge",doi:"10.5772/intechopen.99868",slug:"introductory-chapter-urticaria-meeting-the-diagnostic-and-therapeutic-challenge",totalDownloads:126,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Eleni Papakonstantinou",downloadPdfUrl:"/chapter/pdf-download/78367",previewPdfUrl:"/chapter/pdf-preview/78367",authors:[{id:"203520",title:"Dr.",name:"Eleni",surname:"Papakonstantinou",slug:"eleni-papakonstantinou",fullName:"Eleni Papakonstantinou"}],corrections:null},{id:"76644",title:"Chronic Spontaneous Urticaria – Diagnosis and Management",doi:"10.5772/intechopen.97646",slug:"chronic-spontaneous-urticaria-diagnosis-and-management",totalDownloads:184,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Chronic urticaria can be subclassified into chronic spontaneous urticaria and chronic inducible urticaria. Up to 30% of cases are associated with functional immunoglobulin G antibodies to the high affinity immunoglobulin E receptor FcεRIα or to immunoglobulin A. Pathogenic activation of mast cells and basophils gives rise to release of pro-inflammatory mediators that lead to development of hives. CSU is a debilitating disease with a relapsing course. It affects 0.5–1% of the population at any given time. The duration of CSU is generally 1–5 years but can be longer in cases associated with angioedema and autoreactivity. CSU has detrimental effects on life quality with sleep-deprivation and psychiatric disorders being the most frequent. In a great number of patients an underlying cause or eliciting factor cannot be identified. Among the patients in which an aetiology is suspected, infections, medication, food and psychological factors are most commonly associated. A potential autoimmune cause has been reported in up to 50% of patients. Chronic inducible urticaria is characterised by its ability to be triggered consistently and reproducibly in response to a specific stimulus (pressure, temperature, vibration, water, heat, light). Antihistamines form the mainstay of therapy. In recalcitrant chronic urticaria, a variety of other drugs have been tried.",signatures:"Evmorfia Ladoyanni",downloadPdfUrl:"/chapter/pdf-download/76644",previewPdfUrl:"/chapter/pdf-preview/76644",authors:[{id:"68722",title:"Dr.",name:"Evmorfia",surname:"Ladoyanni",slug:"evmorfia-ladoyanni",fullName:"Evmorfia Ladoyanni"}],corrections:null},{id:"75738",title:"Clinical Phenotypes in NSAID-Induced Urticaria/Angioedema",doi:"10.5772/intechopen.96718",slug:"clinical-phenotypes-in-nsaid-induced-urticaria-angioedema",totalDownloads:178,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The skin clinical phenotypes of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity (NH) are very heterogeneous with several syndromes after NSAID intake, which include different symptoms, different organ involvement and different associated concomitant diseases and possibly different underlying pathophysiology and mechanisms. Making a correct diagnosis in NH is an exciting journey for any allergist. Thus, to classify these diseases properly will be pivotal for appropriate diagnostic and management strategy. Treatment modalities are depending on the clinical phenotypes of NH and they will embrace for each patient: the avoidance of culprit NSAID, the finding of well-tolerated NSAID and in certain cases, desensitization procedures when the NSAID treatment was absolutely needed as well as the control of associated diseases such as spontaneous chronic urticarial or allergic respiratory diseases. This review updates the recent evidence of classification, diagnostic strategies, and management of skin NSAID hypersensitivity reactions.",signatures:"Joaquin Quiralte, María del Robledo Ávila, Stefan Cimbollek and Joaquin Quiralte-Castillo",downloadPdfUrl:"/chapter/pdf-download/75738",previewPdfUrl:"/chapter/pdf-preview/75738",authors:[{id:"344032",title:"Dr.",name:"Joaquin",surname:"Quiralte",slug:"joaquin-quiralte",fullName:"Joaquin Quiralte"},{id:"346370",title:"Dr.",name:"María",surname:"del Robledo Ávila",slug:"maria-del-robledo-avila",fullName:"María del Robledo Ávila"},{id:"346371",title:"Dr.",name:"Stefan",surname:"Cimbollek",slug:"stefan-cimbollek",fullName:"Stefan Cimbollek"}],corrections:null},{id:"76128",title:"The Use of Omalizumab in Chronic Urticaria: Available Data and Future Aspects of Anti-IgE Treatment",doi:"10.5772/intechopen.97226",slug:"the-use-of-omalizumab-in-chronic-urticaria-available-data-and-future-aspects-of-anti-ige-treatment",totalDownloads:182,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Chronic urticaria (CU) defined as repeatedly occurred itchy wheals and/or angioedema for at least 6 weeks. Due to the unpredictability, recurrent and disabling symptoms, and a considerably impaired quality of life, effective and tolerable treatment for CU patients is crucial. Almost a half of patients with CU are refractory to H1-antihistamines, even though the dose of antihistamines is increased up to 4-fold. Recently treatment modulating IgE levels and activities provides an efficient therapeutic approach. Omalizumab, the only approved anti-IgE treatment for chronic spontaneous urticaria (CSU) patients until now, with a strong evidence of the efficacy and safety, opened a new horizon in the care of the patients whose urticaria is not controlled with antihistamines. Recent international guidelines recommend omalizumab as the first choice of treatment for antihistamine-refractory CSU. However, as it is not curative neither disease-modifying agent, there is a subpopulation of CSU patients responding partly or never to omalizumab. The other things to be solved in the treatment of CU is that clinical evidence is still limited on chronic inducible urticaria (CIndU) and special populations. Thus, a new anti-IgE treatment, ligelizumab is actively evaluated in the efficacy compared with both placebo and omalizumab. Further understandings on the pathogenesis of CU can lead to the development of new mechanism-based therapeutics for CU patients.",signatures:"Young-Min Ye",downloadPdfUrl:"/chapter/pdf-download/76128",previewPdfUrl:"/chapter/pdf-preview/76128",authors:[{id:"343886",title:"Prof.",name:"Young-Min",surname:"Ye",slug:"young-min-ye",fullName:"Young-Min Ye"}],corrections:null},{id:"77628",title:"The Role of Anti-IgE Antibodies in Urticaria",doi:"10.5772/intechopen.97025",slug:"the-role-of-anti-ige-antibodies-in-urticaria",totalDownloads:206,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Chronic urticaria, a common mast cell driven disease, has been considered so far an underestimated and difficult to treat disease, very often resulting in high physical, psychological and socio-economic burden. More than 60% of these patients are unresponsive to second generation H1 antihistamines, the first-line symptomatic treatment for urticaria. However, anti-IgE drugs (omalizumab and ligelizumab) showed improved activity in urticaria-treated patients with inadequate symptom control. Omalizumab has been widely proven to be very effective and well-tolerated in patients with antihistamine-refractory chronic spontaneous urticaria and inducible urticaria and is currently licensed for these indication as third-line treatment. Ligelizumab, a next-generation monoclonal anti-IgE antibody with higher affinity to IgE compared to omalizumab and a similar safety profile, has recently demonstrated to be even more effective than omalizumab. This review is focused on the role of anti-IgE antibodies in chronic urticaria.",signatures:"Patrizia Pepe and Victor Desmond Mandel",downloadPdfUrl:"/chapter/pdf-download/77628",previewPdfUrl:"/chapter/pdf-preview/77628",authors:[{id:"344432",title:"Dr.",name:"Patrizia",surname:"Pepe",slug:"patrizia-pepe",fullName:"Patrizia Pepe"},{id:"344498",title:"Dr.",name:"Victor Desmond",surname:"Mandel",slug:"victor-desmond-mandel",fullName:"Victor Desmond Mandel"}],corrections:null},{id:"76610",title:"New Biological Treatment Options in CSU",doi:"10.5772/intechopen.97647",slug:"new-biological-treatment-options-in-csu",totalDownloads:190,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Chronic spontaneous urticaria (CSU) is a devastating disease and is associated with many co-morbidities and long-lasting suffering. Therefore, patients always look for a most efficient therapeutic approach to achieve a full remission. In many patients, CSU remain refractory to off-label doses of antihistamines and short courses of steroids, and therefore are treated with omalizumab. However, 15–20% of severe CSU patients will stay unresponsive to omalizumab and are defined as being of un-met needs. 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The female pelvis is an anatomic region which is quite complex, because it contains some organs and systems accomplishing different and independent functions. The uro-genital system represents the main part of the female pelvis but there are also portions of other organs and systems such as some important blood vessels, gastrointestinal tracts, lymphatics, nerves and parts of the musculoskeletal system. All these structures might house or generate pelvic masses even in para-physiologic conditions, and not necessarily because of current diseases, or congenital alterations, inflammatory illness and tumours.
In order to understand the nature of a pelvic and/or abdominal mass it is necessary to collect as many as possible clinical data. A clinical classification constitutes the first step for finding out the aetiology. The age is indicative for diseases linked to different functional periods of the reproductive system; clinical history must investigate upon possible previous tumours, infectious or metabolic diseases and surgery. When collecting clinical history, pelvic pain which can be divided into acute, chronic and cyclic, must be directly addressed; alterations of body temperature, gastrointestinal symptoms (nausea, vomiting, diarrhoea, constipation, hematemesis, melena), urinary tract symptoms (oliguria, polyuria, stranguria, hematuria, urinary retention, incontinence), taste disturbance; pharmacological treatment in progress (anticoagulants), previous radiotherapy must be addressed.
The are several gynaecological causes responsible for pelvic tumours. These are reported in table 1.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
\n\t\t\t\t | \n\t\t\tendometriosis | \n\t\t
organic and functional cysts | \n\t\t|
benign and malignant cancers | \n\t\t|
metastasis | \n\t\t|
\n\t\t\t\t | \n\t\t\ttubo-ovarian abscesses, pelvic inflammatory disease | \n\t\t
hydrosalpinx | \n\t\t|
para-ovarian cysts | \n\t\t|
ectopic pregnancy | \n\t\t|
neoplasm | \n\t\t|
\n\t\t\t\t | \n\t\t\tuterus body neoplasm | \n\t\t
fibroma | \n\t\t|
malformations | \n\t\t|
blood-pyometra | \n\t\t
Gynaecological abdominal-pelvic masses with malignant clinical features.
It has also to be taken into account the possibility that a non gynaecological lesion could be responsible for a mass. In table 2 the principal non-gynaecological causes for pelvic and abdominal swellings are reported.
The best examination in a clinical context is undoubtedly suprapubic and endovaginal ultrasonography. In young patients, especially in those who are in the reproductive age, ultrasonography shows the best accuracy in the differential diagnosis of ovarian and hydrosalpinx cysts, of the ectopic pregnancy, of uterine fibroids [1].
Ultrasonography permits to distinguish correctly between a benign and a malignant adnexal mass and, within these groups of diseases, to give an accurate diagnosis in most of the cases.
Nevertheless ultrasonography isn’t free from errors and limitations. Diagnostic errors are probable in the identification of masses which appear solid at US. In these cases is difficult to evaluate the uterine or ovarian or the extra-gynaecologic origin of the lesion. These cases require CT or MRI scan. In particular MRI has proven to be useful in detecting and staging of gynaecological malignancies and in detecting the origin of extra-gynecological pelvic masses [2].
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
\n\t\t\t\t | \n\t\t\tappendicular abscess | \n\t\t
neoplasms | \n\t\t|
diverticulitis, peridiverticular abscess | \n\t\t|
Crohn’s disease, segmental ileitis | \n\t\t|
impaction | \n\t\t|
mesenteric cysts | \n\t\t|
\n\t\t\t\t | \n\t\t\tpelvic kidney | \n\t\t
bladder globe | \n\t\t|
urachus cyst | \n\t\t|
bladder tumours | \n\t\t|
\n\t\t\t\t | \n\t\t\tlymphadenopathy | \n\t\t
peritoneal carcinomatosis | \n\t\t|
musculo-skeletal tumours | \n\t\t|
organ ectopia (migrant spleen) | \n\t\t|
pelvic vessel aneurysms | \n\t\t|
foreign bodies | \n\t\t|
pelvic dysmorphisms | \n\t\t|
complications of previous surgery | \n\t\t|
hematomas | \n\t\t|
musculo-skeletal inflammations | \n\t\t
Abdominal-pelvic extra gynaecological masses with malignant clinical features
They are intra peritoneal masses which originate from the gastrointestinal system, are localized in the pelvis and concern essentially tumours and inflammatory diseases. It is to be taken into account that, especially in adolescents and old patients who have a very long sigma, the loop can be palpated in the pouch of Douglas simulating, when full of faeces, an ovarian neoplasm.
In adolescents this condition can be caused by colon-sigma non-ganglionic diseases (mega-colon), where the altered peristalsis implies an abnormal accumulation of faecal material. This condition can also imply the invagination of intestinal traits which is not so infrequent especially in old patients. Among the digestive system diseases, which very frequently can simulate a gynaecological neoplasm, we count inflammatory diseases (acute and chronic) and tumours.
An acute, but mainly chronic, inflammation could cause the clinical evidence of an abdominal-pelvic mass and the reasons are the following:
formation of adhesions in intestinal loops, causing wall thickening and rigidity, sub mucosa and mesentery bleeding and oedema, inflammatory reaction of peritoneum and adjacent omentum.
bowel perforation and formation of peri-visceral phlegmon; in some cases the wall breaking causes the bleeding of an important vessel and shows the symptoms of haemorrhagic or peritonitic acute abdomen.
These anatomic-pathological aspects correspond to different CT scan findings, classified by Hinchey and his team in 4 stages, depending on the inflammation extension [3]:
Stage 0: inflammatory thickening of the intestinal wall, with oedema of the mucosa, luminal-stenosis, the inflammation being still circumscribed within the bowel wall.
Stage I-II-III: abscesses, unique or multiple, showing sometimes air-fluid level images connectible to liquid necrosis; generally these abscesses are adherent to the intestinal wall, or to the peritoneal folds. Such a picture corresponds to the condition of the diffusion of the inflammation beyond the visceral wall.
Stage IV involves intestinal perforation and faecal invasion of the peritoneum (Figure 1).
Contrast enhanced CT scan, during a portal phase showing an inflamed sigma, with perforated diverticulum in the medial side of the sigma.
The intestinal inflammation (whether circumscribed or widespread) might cause fistulas with adjacent anatomical regions and/or the most declivous portions of the pelvis such as the vagina and the rectum. The fistula is often the first symptom of the intestinal wall inflammation.
Besides, in patients with generalized sepsis, CT scan is useful for correctly positioning of drainage pipes into the abscesses in order to clean them up by saline and antibiotic washes [4].
Sigma-rectum tumours determine swellings of the left adnexal site, but they may also occupy the whole pelvis or the central portion of it. These tumours might appear as solid masses stenosing the intestinal trait where they originate from, or, rarely, masses with mainly extra luminal development.
Not infrequently, the tumoural mass associate with an intestinal inflammatory disease. Nonetheless, the mesenteric vessel congestion and the presence of small perivisceral liquid collections, appear to be the CT scan signs which are most related to diverticulitis and, to a lesser degree, tumours.
When the neoplasm does not involve the pelvic organs the CT scan diagnosis is simple and easy, showing the reproductive system integrity. Thought not infrequently, an intestinal primitive neoplasm may strictly stick to, and infiltrate the uterus; there might also be observed adnexal neoplastic masses which are not in direct continuity with original neoplasm (Figure 2).
Preoperative axial contrast enhanced CT scan during late phase showing a mass growing in the left ovary (white arrow). An adjacent mass is seen in in the sigmoid colon.
In these cases CT scan is unable to discriminate between a primitive ovarian neoplasm with peritoneal metastasis infiltrating the sigma-rectum, and a primitive intestinal tumour with adnexal metastasis (Krukenberg disease).
The presence of foreign bodies into the peritoneal cavity represents a not so infrequent finding; they are a consequence of surgical malpractice and that’s why they’re also known as “gossypiboma”. A “textiloma” is a complex made of a non- biodegradable foreign body plus the surrounding reactive tissue [5].
The pelvis can be site of textiloma either because of pelvic or abdominal surgery. In fact the position of the textiloma is affected by the omentum causing the foreign body phagocytosis with consequent fibrinoid-granulomatous reaction and strong adhesions. In this case the textiloma remains into the abdomen. If the surgery implies the removal of the omentum then the textiloma can move to the pelvis. In the case of pelvic surgery, the gossybipoma seems to have greater possibilities of changing its original position and moving either to the pelvic or the abdominal peritoneal cavity.
Recently, in operating rooms, sterile gauze with a radio-opaque marker is being used.
Ultrasonography might be useful in the differential diagnosis of garzomas; they appear as cystic masses, containing the foreign body in their core, with a rather irregular morphology and completely reflecting ultrasonic waves.
At CT scan the finding of a solid mass containing helical, or vortex-like opacities, or the presence of differently dense micro nodules, sometimes calcified, are very suggestive of textiloma. The solid part might be expression of the exudative reaction, while the fibrinoid reaction has a less specific meaning. After c.m. administration a slight peripheral enhancement of the pseudo-capsula. In this case the differential diagnosis with abscesses is very difficult.
At MRI they appear as a solid mass hypointense on T1 and hyperintense on T2, with no specific morphologic features [6].
Very rarely some intraperitoneal liquid collections might be considered as reproductive-system originating tumours. This may happen under particular conditions: patients who underwent previous surgery for abdominal masses; in the cases of intraperitoneal treatment with radioactive drugs where are present so strong adherences causing intraperitoneal fluid flow alterations. Bags of peritoneal effusion may also appear, and they are correctly identified by ultrasonography as liquid masses that can be exchanged as intraperitoneal masses. CT scan results better in defining the liquid bag topography which has low density values (0-10 HU), excluding, more safely, the possibility for the mass to be an intraperitoneal cyst.
It is the accumulation of mucinous material into the peritoneal cavity. It is due to peritoneal metastatic lesions secreting mucin; in most of the cases the principal cause is a mucinous ovarian neoplasia, but less frequently pseudomixomas can be due to malignant mucocele of the appendix and tumours of the stomach, of the colon, of the pancreas and of the breast. The pseudomixoma typical CT scan appearance is a hypodense, liquid mass localized among the intestinal loops; sometimes, inside the lesions, can be observed images of septa or solid buttons. The HU values range between 15 and 30.
It’s a primitive disease of the mesentery, with intraperitoneal and pelvic metastasis. It is defined as macrophage inflammatory infiltration of the mesenteric fat associated with scar-fibrous component. When this last element prevails, it is defined as liposclerosis. Panniculitis might be also consequent to previous abdominal surgery or radiotherapy.
CT scan is decisive for diagnosis: a fatty mass incorporating some mesenteric vessels without infiltrate them; the mass is homogeneous, circumscribed by a peripheral pseudocapsule well delimited. MRI fat suppression sequences further discriminates the fat components from the liquid ones. These aspects can be unique, affecting portions of the abdominal-pelvic peritoneum with multiple foci.
Tumours of omentum and intraperitoneal spaces originate from the tissues which constitute these structures: coelomic epithelium, mesothelium, fiber, fat and muscle connective tissue, lymphatic and blood vessels, nerves, embryonic residues. Usually, lesions in these sites are due to primitive abdominal tumours, especially intestinal and ovarian. Therefore, given an intraperitoneal neoplastic mass, it has first to be considered as a metastasis unless a primitive tumoural lesion is found elsewhere.
Peritoneal tumours can be cystic (dermoids, lymphangiomas, benign and borderline serous, micropapillary cystadenomas) and solid (serous, micropapillary cystoadenocarcinoma, malignant mesothelioma, small round cell desmoplastic tumour, fibroma, desmoids tumour, and others). Tumours morphology is often non-specific both at US and CT scans; It might appear either solid or cystic depending on the kind of tissue they are made of. In some casese they cannot be distinguished from mesenteric cysts. The more are the solid component and the complex aspect, the more must be the suspect of the mass being malignant.
In pre-ultrasound age was the most frequent pelvic mass the pelvic kidney originating from urinary system, an extremely easy ultrasound diagnosis even in the gynaecologic area. It is also possible that a pelvic supernumerary kidney leads to the same error.
Occasionally, great kidney-originating masses spreading to the pelvic retro peritoneum can simulate reproductive-system tumours; the same goes for huge cysts, or gigantic hydronephrosis. CT scan and MRI can, instead, easily establish the urinary-system origin of the retroperitoneal lesions.
Other causes for urinary-system originating extra-gynaecologic masses are malformations resulting from Müller ducts alterations associated to Wolff ducts malformations. The most frequent are represented by uterus didelfus with blind hemi-vagina. In the latter the mass is constituted of blood and mucus blocking the vagina. There might also originate some pockets of pelvic endometriosis, which are expression of abdominal reflux of vital endometrium. Finally, even an atresic hemi-horn, with or without communicating endometrium, can be a pelvic mass.
A bladder globe might resemble a pelvic mass in patients who underwent radical hysterectomy surgery or radiotherapy which damaged the bladder innervation and caused large stagnation. The bladder can also be site of extrinsic-diffusion tumours, or huge pseudo-diverticula resembling adnexal masses.
The urachus may be a site of inflammatory processes. Cysts are caused by persistence, of the intermediate tract of the urachus, after birth which doesn’t communicate with either the bladder or the navel and therefore may house a very slow-growing liquid collection. It appears macroscopically as a spherical, cystic formation with muscular-fibres and urothelium-constituted walls containing clear, citric liquid and urea. It might be an occasional finding during an ultrasonography or a CT exam. The middle position, the front site (between the Linea Alba and the parietal peritoneum) and the round appearance can easily suggest the origin. These cysts, if inflamed, might be confused with pelvic inflammations.
By these terms are meant malformations of the sacral canal which is the inferior portion of the vertebral canal. In the sacral canal are contained the spinal meninges, the final portion of the cauda equina and the epidural space between the meninges and the bone walls; often such malformations associate with alterations of kidney, bladder and urinary system-growth. The malformation that is most simulating an adnexal pelvic mass is the anterior, sacral meningocele. This is constituted of meningeal herniation through anterior defects of the sacrum-coccyx. They can be either unique or associated with more complex malformations of the terminal thread, as in the caudal regression syndrome, in the generalized mesenchymal dysplasia (neurofibromatosis type 1 or Marfan syndrome).
The mass appears as a simple cyst, homogeneous and anechoic at US.
CT scan, but mainly MRI can precisely detect the origin of the lesion. It is possible to study the alterations of the sacrum, anterior defects, and the whole morphology of the sacrum-coccyx using sagittal reconstruction with CT. The mass is like a simple cyst, with no enhancement and without capsule.
The main signal characteristic is T2 hyperintensity at MRI. Finally, both CT and MRI is able to perfectly detect the neck of the meningocele (Figure 3).
MPR sagittal reconstruction of a CT scan showing an anterior sacral meningocele direcly connected to the medullar canal.
From pelvic retroperitoneum can originate benign or malignant tumours, whose histology might cover all the tissues normally present in the retroperitoneum; mesenchyme: sarcomas, leiomyosarcomas, fibrosarcomas; adipose tissue: lipomas, liposarcomas; nervous system: benign and malignant schwannomas, paragangliomas, neurogenic tumors; hemangiomas: mature and immature teratomas.
The evaluation of these masses is difficult by US. The most preferred techniques are still CT and MRI.
CT imaging appearance is that of a solid mass, only rarely homogeneous in density; it is so mainly as far as neurologic benign tumours (benign schwannomas) or masses rich in well-differentiated striated muscle component (neurofibromas) are concerned. Malignant masses are inhomogeneous, infiltrating the retroperitoneal structures.. Edged and regular contours, the footprint of the surrounding structures without infiltration suggest the benignity.
The masses rich in fatty component, given their retroperitoneal origin, are usually histologically malignant and aggressive; these masses must be distinguished from all pelvic intraperitoneal lipomas. Factors of malignity are represented by the inhomogeneity, the infiltrative character of the edges and the presence of a rich, solid tissue component.
Neurofibromas are solid, neurogenic benign tumours which show enhancement in CT. Both CT and MRI are the first-choice techniques of investigation in the suspect of a pelvic, retroperitoneal mass; this is due to their ability in the topographic localization of the mass and the good ability in the tissue characterization. Probably MRI reaches higher results in the diagnostic accuracy (easy characterization of lipomas, liposarcomas and mature teratomas). If a definitive diagnosis can\'t be reached by CT or MRI, then guided needle biopsy can be useful. In figure 4 a MRI scan of a schwannoma is presented.
MRI T2-weighted sagittal scan showing a retroperitoneal oval-shaped solid lesion (white arrow) in straight contact with the anterior part of the sacrum, which turned out to be a schwannoma.
They must be considered, finally, other rare, non-gynecological causes for pelvic masses, represented by neoplasias originating from different tissues of the pelvis. We can therefore report some cases of anterior abdominal wall muscles fibromas, pelvic sarcomas, aneurysmal dilatation of the iliac vessels.
It has been proved that serum Ca125 are helpful in the diagnostic evaluation of pelvic masses, particularly in adnexal masses.
An increase (ranging from 80 to 90%) of Ca125 serum levels are associated with ovarian, epithelial, malignant, non-mucinous tumours. Besides, Ca125 is related to the volume of the tumour mass. Ca125 represents the gold standard tumoural markers for ovarian cancer in two different clinical conditions: as a diagnostic tool for evaluating the risk of malignancy of an adnexal mass and as a monitoring tool in the evaluation of the disease state, in patients already treated for adnexal cancer [7,8].
Ca125 serum levels equal or below 35 U/ml are normal. Ca125 serum levels greater then 50-65 U/ml (in the 80-90% of postmenopausal patients) is associated with a malignancy. Classifying patients with increased Ca125 and a pelvic mass by age, permits a rise in positive predictive value of the association of 80% in patients older then 50 and only 50% in younger ones.
On the other hand this marker increases (in 60-70% of the cases) also in advanced endometrial adenocarcinoma and/or in recurrence.
Other gynaecological malignant solid tumours can increase Ca125 serum levels (60% in pancreatic cancer, 20-25% in breast, lung and colon tumours). Other non tumoral conditions can be associated with increased levels of Ca125 such as endometriosis, peritonitis, tubo-ovarian abscess, diverticulitis, adenomyosis, uterine fibroids, ascites.
Best specificity and sensitivity results have been reached by integrating different diagnostic techniques like markers and ultrasonography and clinical history to create risk index [9].
Female pelvic masses are mainly caused by gynaecological diseases. For classificatory purposes it’s important to know whether the disease originates from the uterus or from the ovaries. This is often difficult to establish, that’s why we tend to use another classification based on malignity/benignity criteria. In this case, the main goal of the radiologist is to characterize the mass from a histological point of view, using different imaging techniques.
The imaging main parameters are:
size and shape;
vascularisation;
associated signs.
As far as size is concerned we can say that the bigger the ovarian mass, the higher is the probability that that mass is malignant.
As far as shape is concerned it must be considered the presence of septa, solid components (papillary excrescences) and mass echogenicity.
The presence of septa highly increases the probability of malignity. This finding becomes more relevant when associated with the thickness of the septa.
The presence of papillary excrescences or solid lesions inside or outside a cystic mass is highly suggesting of malignity.
Ultrasonography permits distinguishing between cystic or solid masses. A certain mass is defined as cystic when the content echogenicity is liquid, with back wall shadowing. On the contrary, a completely solid mass is characterized by more or less homogeneous, multiple internal echoes, giving it a parenchimal-like appearance. Generally speaking it can be said that the higher the echogenicity of a mass the higher the risk of malignity.
In table 3 the most important echographic morphological criteria for the definition of malignancy scores are reported.
\n\t\t\t\t | \n\t\t\tdiameter of less than 5 cm | \n\t\t
thin, smooth walls | \n\t\t|
anechoic content | \n\t\t|
lack of septa or less than 3, thin septa | \n\t\t|
no liquid into the Douglas space | \n\t\t|
no solid intracystic vegetations | \n\t\t|
\n\t\t\t\t | \n\t\t\tdiameter greater than 5 cm | \n\t\t
smooth, thick walls | \n\t\t|
hypoechoic or solid, homogeneous content | \n\t\t|
more than 3 thin septa | \n\t\t|
a bit of liquid in the Douglas space | \n\t\t|
no solid, intracystic vegetations | \n\t\t|
\n\t\t\t\t | \n\t\t\tdiameter greater than 5 cm | \n\t\t
thick, irregular, nodular walls | \n\t\t|
many thick septa | \n\t\t|
intracystic, solid component | \n\t\t|
intraperitoneal carcinomatosis | \n\t\t
Echographic morphological criteria for the definition of malignancy scores.
Morphological scores for the prediction of malignancy of the masses have been made up by ultrasonography.
Historically the parameters evaluated were size (currently it is considered an adnexal mass a lesion with a diameter greater than 4 cm), echogenicity (considering the masses as solid, simple cystic, complex cystic ), presence and shape of septa (single or multiple, whether or not associated with vegetating solid components adhering to them), and persistence over time of the tumour.
Since 1974, Kobayashi reported a 70% diagnostic accuracy of ultrasound in the differentiation of ovarian cancer from other pelvic tumours. The presence of papillae, nodules and thickened septa within cysts were elements suggestive of malignant adnexal disease [10]. In 1979 De Land showed how the risk of malignancy increased linearly with the increase of the solid component within the mass [11]. More recently, Hermann, in 1987, classified the pelvic masses into three categories in relation to the morphological complexity: simple cystic forms, complex forms and solid forms [12].
In 1989 Grandberg went another step further, precisely defining others parameters. He defined: the number of the intracystic papillae, the solid, intracystic component percentage and the presence of septa, reporting the malignancy risk percentage for each of those parameters [13].
In 1990 Jacobs tried to introduce a multifactorial score for the diagnosis of malignancy. He did it considering: the gynecological examination, the trans-abdominal ultrasound and the determination of serum Ca125. It was devised an echographic-morphological score assigning the value 1 to each parameter: multiloculated cyst, presence of solid spots, evidence of metastasis, presence of ascites, bilateral adnexal lesions. All these parameters were included in an analysis that showed how statistically significant were the age, the postmenopausal status, the ultrasound score, the Ca125 value and the clinical impression. This score has been defined as RMI (risk of malignancy index) [14]. In 1992 Kuriak linked flow metric data obtained by Colour Doppler to the morphologic score proposing a multiparametric score [15].
Recently, in 2011 a new scoring sistem was proposed called Pelvic Masses Score (PMS). It takes into account the Sassone score, the base 10 logarithm of the Ca125 level, the central/septal vascular distribution, the menopausal state and the resistance index [15, 16,17].
Currently, morphological scores have been extensively used in clinical practice mainly because they allowed a better morphologic characterization of pelvic masses.
The vascularisation of a pelvic mass is the second element for a diagnosis of malignancy. Once again, ultrasonography represents the first step in the evaluation of this data. The echo color Doppler examination of a pelvic mass has to be performed when there are masses which are strongly suspected to be malignant. Clearly benign masses don’t need such examination. Nevertheless the echo color Doppler examination may be very useful in the interpretation of a mass which isn’t clearly benign [15].
The pathogenic factor that justifies the use of colour Doppler in the differential diagnosis of a pelvic mass nature, is represented by the fact that the tumour’s new vessels lack a muscular coat, and that causes low resistance to blood flow, generating low Pulsatility Index and Resistive Index values and absence of diastolic notch.
Besides it has to be considered that the flowmeter samples must be multiples and collected from different parts of the mass, that is, not only from the periphery but, more importantly, from the core of the mass. In fact, we believe that many malignant tumours tend to start the new vessel production from the centre of the mass, while peripheral lesion vessels may result from preexisting vessels. A peripheral vascularization of the mass is basically benign, often deriving from ipsilateral uterine artery. Intralesional vascularisation and the presence of vessel in the solid component of the mass or in the septa or papillae, are elements that strongly suggest malignancy. The vascular confluence represents another indication of malignancy [18].
Malignant ovarian tumours represent the fifth death cause among US female population; the sixth neoplasia for frequency, the second, most frequent female tumour after endometrial ones and the first death cause as far as gynaecologic tumours are concerned [19].
This illness is more frequent in peri-or post-menopausal women, but there are characteristic histological types for each age group. In adolescents and in women who are younger than 20, half of the tumours comes from germ cells; in post menopausal age they have a most frequent epithelial origin.
The causes for the occurrence of ovarian cancer are not defined; epidemiological studies show that the most affected people by ovarian cancer are represented by peri or post-menopausal, middle or upper class, with no children or just one and with problems in getting pregnant women.
The majority of ovarian tumors begins without well-defined symptoms; as a matter of fact early stages are mostly incidental findings representing just a 20%. In most of the cases they are diagnosed when they are at an advanced stage, that is when the cancer has spread outside the pelvis. The most common symptoms are given by the effect on neighbouring organs: polyuria, dysuria, constipation, sudden increase in abdominal circumference, amenorrhoea, polymenorrhea.
In table 4 WHO histological classification of the tumours of the ovary is presented.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
\n\t\t\t\t | \n\t\t\tSerous tumors | \n\t\t
Mucinous tumors | \n\t\t|
Endometrioid tumors (including variants with squamous differentiation) | \n\t\t|
Clear cell tumours | \n\t\t|
Transitional cell tumours | \n\t\t|
Squamous cell tumours | \n\t\t|
Mixed epithelial tumours (specify components) | \n\t\t|
Undifferentiated and unclassified tumours | \n\t\t|
\n\t\t\t\t | \n\t\t\tGranulosa-stromal cell tumours | \n\t\t
Sertoli-stromal cell tumours | \n\t\t|
Sex cord-stromal tumours of mixed or unclassified cell types | \n\t\t|
Steroid cell tumours | \n\t\t|
\n\t\t\t\t | \n\t\t\tPrimitive germ cell tumours | \n\t\t
Biphasic or triphasic teratoma | \n\t\t|
Monodermal teratoma and somatic-type tumours associated with dermoid cysts | \n\t\t|
Germ cell sex cord-stromal tumours | \n\t\t|
\n\t\t\t\t | \n\t\t\tAdenocarcinoma, adenoma, others | \n\t\t
\n\t\t\t\t | \n\t\t\tSmall cell carcinoma, Hepatoid carcinoma, Wilms tumours, others | \n\t\t
\n\t\t\t\t | \n\t\t\tLuteoma of pregnancy, Stromal hyperthecosis, Stromal hyperplasia, Fibromatosis, others | \n\t\t
\n\t\t\t\t | \n\t\t\tMalignant lymphoma, Leukemia, Plasmacytoma | \n\t\t
\n\t\t\t\t | \n\t\t\tGastro-intestinal tract (stomach, colon, pancreas), Breast, Renal cell carcinoma, Melanoma, Others | \n\t\t
WHO histological classification of tumours of the ovary.
Ovarian tumours spread by contiguity, through the intra peritoneal route, by blood and lymphatic. 9% of cases in advanced stage show intra peritoneal carcinomatosis, and 70% ascites.
In table 5 the ovarian tumour FIGO staging is reported [19].
The adnexal masses invasion by contiguity is the direct infiltration of the adjacent anatomical structures. Hence the bladder can be involved through neoplastic deposits in the vesico-uterine fold. The sigma-rectum can also be involved through the rectovesical pouch. In both cases the tumour infiltration very rarely reaches the mucosa.
The intraperitoneal tumour spreading follows the physiologic routes. The most affected sites are: the rectovesical pouch, the para-colic gutters (especially the right one), and the right sub-diaphragmatic peritoneum.
The omentum, through its phagocytic function, collects cancer cells and constitutes an ovarian cancer typical site for cell proliferation. Lymphatic drainage of the ovary in the pelvis and, in the para aortic zone through the infundibulum pelvic ligament, permits the pelvic and lombo-aortic lymphatic metastatic spreading. Neoplastic emboli, reach the left subclavian vein through the thoracic duct, penetrate into the bloodstream and stop in the lung. Pulmonary involvement happens directly through both ovarian veins and the pelvic venous plexus. Upper abdominal metastases (most of the cases liver and spleen) seem to be related to blood-borne neoplastic emboli originating from the sigmoid and superior haemorrhoidal plexus.
STAGE | \n\t\t\tDESCRIPTION | \n\t\t
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
IA | \n\t\t\tone ovary affected, no ascites, absence of capsular infiltration, absence of neoplastic proliferations on the outer surface of the mass;no malignant cells in ascites or peritoneal washings. | \n\t\t
IB | \n\t\t\tTumour limited to both ovaries; capsule intact, no tumour on ovarian surface; no malignant cells in ascites or peritoneal washings. | \n\t\t
IC | \n\t\t\tTumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings | \n\t\t
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
IA | \n\t\t\tExtension and/or implants on uterus and/or tube|s|;no malignant cells in ascites or peritoneal washings | \n\t\t
IB | \n\t\t\tExtension to other pelvic tissues; no malignant cells in ascites or peritoneal washings | \n\t\t
IC | \n\t\t\tPelvic extension (2a or 2b) with malignant cells in ascites or peritoneal washings | \n\t\t
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
IIIA | \n\t\t\tMicroscopic peritoneal metastasis beyond pelvis | \n\t\t
IIIB | \n\t\t\tMacroscopic peritoneal metastasis beyond pelvis 2 cm or less in greatest dimension | \n\t\t
IIIC | \n\t\t\tPeritoneal metastasis beyond pelvis more than 2 cm in greatest dimension and/or regional lymph node* metastasis | \n\t\t
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t Note: Liver capsule metastasis is T3/stage III, liver parenchymal metastasis M1/stage IV. Pleural effusion must have positive cytology for M1/stage IV. | \n\t\t
\n\t\t\t\t | \n\t\t\tThe classification applies to malignant surface epithelial-stromal tumours including those of borderline malignancy. (Non-epithelial ovarian cancers may also be classified using this scheme). *. Regional lymph nodes are the hypogastric (obturator), common iliac, external iliac, lateral sacral, para-aortic, and inguinal nodes. | \n\t\t
Ovarian tumours FIGO staging
The use of CT and of MRI in the preoperative phase of malignant ovarian tumours it’s a debated argument even today. A correct diagnosis can be done using only ultrasound, as reported in this chapter. However, it is essential to know the CT and MRI appearance of these tumours mainly because they are easy to compare in investigations performed for other purposes.
In literature there are numerous publications which compare ultrasound, CT and MRI for their ability to distinguish between malignant and benign pelvic masses. The CT reaches a specificity and sensibility of about 92,8 and 88% respectively based on the morphology of the lesions and their vascularization after the injection of Contrast Material [20,21].
In our Institution all MDCT studies were performed using a 64-multislices MDCT system (Somatom Sensation 64, Siemens medical solutions, Forchheim, Germany). MDCT images were obtained from the abdomen and pelvic, covering the area from the diaphragm to the symphysis pubis (craniocaudal). The contrast medium (IOVERSOL 350 mg /ml – Optiray, Covidien Imaging Solutions, Hazelwood, MO) was administered at a dose of 1.5 mL per kg, with a variable flow rate of 3-4 mL per second through the antecubital vein of the right arm.
MRI with paramagnetic contrast Material, on the other hand, not only distinguishes better gynaecological lesions from non-gynaecological ones, but also allows a better tissue characterization of the mass. The CT aspect of an ovarian malignant mass is characteristic though, as ultrasound, it is not able to define the anatomical-pathological variant. The mass can be localized exclusively in the adnexal site or, if size is conspicuous, involve the entire pelvic region. Sometimes, when the whole pelvis is filled with the tumour, it is impossible to make out the adnexal origin. The masses are usually complex with thickened and often nodular walls. Not infrequently there are numerous intralesional septa delimiting different chambers which vary in density and are not communicating with each other. Solid components, usually growing in the liquid section of the mass, are often present at the confluence of the thickened septa. An ovarian cancer very rarely infiltrates the retroperitoneal pelvic structures reaching the bone wall.
Even though it’s large and closely adjacent to bladder and bowel, this cancer very rarely fully infiltrates these structures’ walls, and if there were infiltrations they’d just involve some peritoneal folds and the rectovesical pouch. The nodular peritoneal dissemination can be correctly evaluated by CT scan in the presence of ascites which facilitates the detection of nodules adhering to the intestinal tract and between the mesenteric sheets. The parenchymal nodules adhering to hepatic peritoneum, gastro-colic, gastro-duodenal and spleno-gastric ligament, are more easily distinguishable. An indirect sign of peritoneal microscopic infiltration is the rigidity of the peritoneal layers taking a radial, rail and fanned aspect. When the omentum is highly involved than it’s called “omental cake”finding. The great omentum, which has the function of filtering the free, peritoneal liquid, becomes the site of neoplastic solid metastases, sometimes very large, which often join, forming a neoplastic plaster adherent to the anterior parietal peritoneum [22].
At MRI, the malignant ovarian cancer appears as a big, heterogeneous solid and cystic mass. The solid component shows, in T1, low or intermediate signal intensity, while the intensity is quite high in T2. This aspect, however, can be conditioned by the presence of intra lesional haemorrhagic foci, or areas of necrosis. Also the cystic component of the complex mass can have a different signal behaviour. The malignant cystic, ovarian tumours contain abundant proteinaceous or haemorrhagic material causing a high signal intensity both in T1 and in T2. After intravenous paramagnetic contrast material injection, some thickening of the capsule can also be detected, with the presence of septa or intra-cystic vegetations which can be either associated to the mass solid component or not. By gadolinium administration it is obtained an optimal characterization of the solid components of the complex adnexal mass [23]
Lately, Diffusion weighted Imaging (DWI) as a useful tool to improve the radiological diagnosis of malignant tumors, especially for endometrial and cervical tumours. Concerning ovarian cancer, while initially promising DWI in cystic ovarian tumors proved to be limited, particularly for differentiating benign from malignant lesions [24–25]. In a large retrospective analysis the majority of malignant ovarian tumors, mature cystic teratomas, and endometriomas exhibited abnormal signal intensity on DWI, whereas benign lesions did not. A Few studies addressed the use of DWI for peritoneal dissemination of gynaecological cancer assessment: a high sensitivity (90%) and specificity (95.5%) in evaluation of peritoneal dissemination was proven. Nevertheless, the study population was small [24,25].
Preoperative evaluation of upper abdominal organs by ultrasonography or CT scan is important. At the disease onset, in fact, spleen or liver metastases are frequently found according to the tumour stage [26]. For this reason, staging must always include the study of upper abdominal organs. The intraperitoneal, often multifocal, spread of the ovarian cancer is very frequent and well assessable by both CT and MRI (Figure 5).
A Contrast Enhanced CT scan showing typical intraperitoneal calcified implants in a serous papillar ovarian cancer (III stage FIGO classification).
The results of preoperative CT and MRI in advanced stages of ovarian cancer can predict the success of the radical surgery. The residual post-surgery tumor must be absent or of a diameter less than 2 cm. This is a very important goal: in these conditions the patients respond better to chemotherapy and have a more favorable prognosis. Through a quantitative score that examines five common anatomic, frequently affected by the disease sites by CT scan, one can select the patients who are eligible to the initial radical treatment. The criteria for the tumor unresectability include the presence of metastases with a diameter greater than 2 cm localized in the following sites: mesenteric root; gastro-splenic ligament; epiploic pouch; hepatic hilum; hepatic, intrasegmental peritoneal reflection; diaphragm and liver dome. Besides other unresectability criteria are: lymphadenopathy greater than 1 cm above the celiac zone; presence of extraperitoneal, presacral disease [26].
By the term PID it’s meant female genitalia inflammations not only affecting reproductive organs but also the whole pelvic zone, including the pelvic peritoneum. From a pathogenetic point of view PID includes primary and secondary forms, representing In the primary forms, which represent more than 90% of the cases, the inflammation affects initially the lower genital tract (cervico-vaginal tract), spreading subsequently to the uterus, the adnexal glands up to the pelvic peritoneum. In the pathogenesis exogenous factors are involved of such as sexually transmitted germs and instrumental factors; or endogenous factors as in the case of the pathological transformation of cervico-vaginal saprophyte flora. The secondary forms,which are quite rare, are determined from the diffusion to the internal genitalia, through blood, lymphatic or by contiguity, of pathogenic microorganisms from extragenital outbreaks: pyelitis, cysto-pyelitis, cystitis, colitis but especially appendicitis, peri-appendiceal abscess, diverticulitis.
For each pathogenic PID form there have been recognized risk factors. In the case of the primitive exogenous venereal PID they are represented by the young age, frequency and precocity of sexual relationships, number of partners and sex during the menstrual phase.
In the case of primitives exogenous iatrogenic PIDs the most important risk factors are: the use of intrauterine devices (IUD), voluntary termination of pregnancy, endometrial biopsies, hysteroscopy, hysterosalpingography and tubal insufflation. The PID aetiology needs to be continuously updated. It is currently considered to be poly-microbial. We assisted to a reduction of the pathogenic role of Neisseria gonorreae down to 15-20% compared to association of both aerobic and anaerobic germs: streptococci, staphylococci, E.Coli (10-40%); Mycoplasma (10-30%), Chlamydia trachomatis (40-60%). PID includes several pelvic diseases clinically distinguishable into acute and chronic forms. Acute infections are caused by uterine cervical flora that spreads from the mucosal surface to the uterus and fallopian tubes, finally affecting the pelvic and/or abdominal peritoneum. The subacute and chronic form widely varies in extension and severity, including tubal lesions with the formation of pelvic liquid collections and connectival reaction widespread, or by formation of extensive and tenacious adhesions. In order to have an accurate and early PID diagnosis it is essential to the use of imaging techniques. Laparoscopy is essential not only for recognizing the disease but also in order to isolate the pathogenic germs, favouring a targeted therapy.
Based on the laparoscopic findings there are three distinct forms of acute salpingitis, each with different prognostic significance:
light form: the tubes are hyperemic, edematous, covered with exudate or by deposits of fibrin, but are mobile and with patent ostia;
moderate form: the signs are more evident and there are doubts about the ostia patency;
serious form: there is pelvic and peritoneal inflamnation with closed ostia and/or abscess formation.
Ultrasonography was used to confirm the pelvic abscess clinical diagnosis, thanks to its accuracy, sensitivity and specificity. Compared to laparoscophy, endovaginal ultrasonography can recognize almost all of the cases of severe tubal damage, but just 65% of slight tubal damage. Ultrasonography is also very helpful in the follow-up of pelvic inflammation patients, for evaluating the effectiveness of therapy.
On the other hand ultrasonography may be negative both in the acute and in chronic salpingitis. In PID detection of some liquid into the recto-vescical pouch, it may result easy with US, and it may have a higher diagnostic value whenever the liquid presented diffuse or inhomogeneous echogenicity, indicating a blood or purulent collection.
CT scan is not so useful as far as mild and moderate forms are concerned; it’s crucial in the recognition and evaluation of the chronic PID.
MRI seems to be very useful in the diagnosis of this disease; it is in fact possible to characterize the inflammation activity, better distinguishing the acute state from the subacute and chronic ones.
The salpingitis initial phase, which is characterized by hyperemia and edema, can be laparoscopically evaluated but not by ultrasound, CT scan and MRI. However, it is a very short lasting phase and is rarely demonstrated even by a early laparoscopy. Salpingitis often follows and is associated with endometritis which can be sonographically demonstrated: the uterus is large, with loss of normal endometrial echogenicity and with irregular, undefined borders; sometimes the cavity may contain hypoechoic material. Even CT scan and MRI don’t show, at this stage, any ovarian alterations, while in the presence of endometritis nonspecific uterine abnormalities can be detected: hyper- hypodense endocavitary formations (due to liquid collections) with no enhancement after CM injection.
In the exudative phase, exudate collects in the tubes, covers the fimbrial peritoneum and can spill out of the still open tubal ostium, or, when it’s closed, the tubes stretch and become filled with exudate (laparoscopically moderate or severe PID).
By ultrasound, adnexal region appears magnified, with well-defined contours and with a cystic appearance; begins to form a multilobed, often multisepted, sausage-like mass. The content can be more or less echogenic depending on the blood or exudative component. In some cases of this last condition some pseudo-niches determined by thickening of the tubal mucosa are observable inside the dilated tube.
By CT scan the adnexal region may appear swollen and inhomogeneous; after the CM administration it can be highlighted a marginal rim of intense enhancement delimiting the various ectatic portions of the tube. The pious-sactosalpinge has a more or less folded intestinal-like appearance and by this feature it can be distinguished from other ovarian liquid formations; the density is varying from serous to corpuscular (Figure 6).
MPR coronal reconstruction of a Contrast Enhanced CT scan during portal phase showing bilateral swelling of the tubes which have an intestinal like appearance in a sactosalpingitis (white arrows).
If an early therapy it hasn’t been established, the next step of the inflammation involves the involvement of the ovary. The bag filled with pus extend the the fallopian tubes and ovarian parenchyma making them lose their cleavage planes, wrapped by tenacious adhesions. The tubo-ovarian abscess rupture (3.5%) is a surgical emergency. The tubo-ovarian abscess appears as an adexal or retro-uterine mass, often with internal baffles and sometimes images of gaseous levels. During the appropriate antibiotic treatment the mass becomes better defined and cystic. It can often be found some liquid into the recto-vescical pouch and endo uterine abnormalities can coexist. The echo color Doppler may be helpful in the mass characterization. The hyperaemia and angiogenesis caused by acute inflammation result in an increase of both systolic and diastolic flow velocity, with decreased PI and RI. These altered flow conditions may be reversible during the gradual disappearing of the inflammation. The differential diagnosis must consider the acute salpingitis with sactosalpinx, the tubarian piocele, other conditions of chronic pelvic inflammation without masses.
CT scan, at this stage, detects the adnexal or retro-uterine mass. After CM administration, in the most acute forms, may be evident an intensely enhanced, marginal rim, which is a typical sign of ongoing inflammation. In the acute and sometimes even in chronicle forms the central part of the swelling presents various densities but not contrast enhancement; sometimes there are baffles which delimit internal chambers. In chronic forms the mass may present irregular contours, inhomogeneous density and contrast enhancement.
In neglected cases and in those which do not respond to treatment, the inflammation extends to the entire pelvic peritoneum, the bowel, the contralateral ovary, the bladder and the ureters. The anatomical-pathological framework includes peritoneal inflamnation, distant abscesses and, in the chronicle evolution, adhesions between peritoneal organs, inflammatory infiltration of the peritoneum and retroperitoneal tracts.
By ultrasonography, the pelvis appears very irregular showing ill-defined, irregular contoured masses with both solid and liquid component; under these conditions, the uterus and the ovaries can be indistinguishable. It can be associated, in this framework, hydroureteronephrosis.
CT scan easily recognizes the pelvis structural-anatomical upheaval. By CT scan/MRI certain signs are very obvious which, if present, provide an accurate picture of the disease severity. These signs are: fascial and peritoneal thickening; peri-rectal, peri-vescical, intestinal, pre-sacral, pre-vescical and latero-pelvic fat’s increase in density and inhomogeneities; involvement of extra-genital structures; masses that can be dumped to the uterus, may spread to the recto-vescical pouch and to the parametrium. The contours are irregular and hazy [27].
MRI seems to play an important role in the diagnosis of pelvic inflammation as can be used in the initial phase of the disease (the exudative one), or in the tubo-ovarian abscess and pelvic peritonitis. By MRI, the tubo-ovarian abscess appears as a simple or complex cystic mass, with irregular but neat and well defined walls. The cystic component has signal intensity similar or modestly higher than fluid one (low T1 signal and high T2 one); only rarely it may present a high protein content and therefore a blood-like signal (Figure 7).
Axial MR scan of a bilateral acute salpingitis. Huge dilatation and bilateral swelling of the tubes can be seen.
Ovarian metastatic tumours are quite frequent: they are about 5-10% in the US, and 15-18% in Japan. On Imaging it has to be always considered the possibility of a metastatic tumour whenever a pelvic mass is found. Nevertheless is has been observed that even using all the different imaging methods and machines they can’t differentiate with certainty a primary pelvic mass from a secondary one. Both by ultrasonography and CT scan have been described the Krukenberg tumours whose pattern may greatly vary. The common gastric Krukenberg presents a solid, homogeneous, bilateral mass pattern (Figure 8), while the metastasis from colon-rectum have a more often cystic, complex, necrotic pattern.
Contrast enhanced CT during portal phase showing two heterogeneously enhanced round masses in a patient suffering from gastric cancer. Histology of the resected masses showed signet-ring cells consistent with Krukenberg metastases.
At US gastric Krukenberg tumours can be bilateral, consisting of complex masses with different percentages of solid and cystic components, frequently associated with ascites. At CT scan Krukenberg tumours are described as mainly solid, with rich peripheral C. E., with cystic component in the cortical or intralesional site masses. The cystic components’ walls present a high C.E.
At MRI It is represented by a solid, T2 hypointense, consisting of dense stromal tissue component. It has been than observed that when an apparentely malignant adnexal mass is bilateral, shows well defined but irregular contours, is associated with peritoneal carcinomatosis without ascites, it is 7 times more likely to be a Krunenberg than a primary ovarian tumor.
Mature cystic ovarian teratomas are benign tumours recognisable, using various imaging techniques, by certain characteristics. Already from direct examination of the pelvis, it is possible to obtain very clear images showing teeth-like characteristics, either singular or grouped from a common germinal follicle.
The appearance of dermoid cysts at US is highly variable and depends on the homogeneity and composition of the newly formed tissue. The calcifications inside the mass, characterised by acoustic barriers, are not, however, pathognomonic, as they are also seen in other benign tumours (Brenner) or in malignant adnexal masses. Similar images can be also frequently observed in teratomas and it is possible to recognise not only the Rokitansky protuberance, but also the presence of skin appendages, locks of hair, sebum and glands. The fatty component can also present crude images indicating acoustic barriers, located within a fluid; this is due to varying acoustic impedance of different fat components.
The ultrasound morphology of the mass can be that of a homogenous formation, with elevated echogenicity and a solid appearance; on the other hand it can appear as a cystic formation, either simple or complex depending on the acoustic impedance of the intralesional structures. In some cases, the ultrasound cannot provide a definite diagnosis of teratoma and in others it cannot exclude malignant characteristics.
In CT scans however, the appearance of dermoid cysts is often pathognomonic. CT is the ideal method to evaluate tissue fatty components, leading to a correct diagnosis in case of adnexal fatty mass. Even when other hypodense tissue, like sebum and hair, are present, the fat is recognisable and the, usually, polymorphic appearance in the ultrasound is defined more clearly. CT scans can also correctly identify calcification, better define their morphology and therefore reach a diagnosis. In CT scans it is also very easy to identify fat buoyancy, a pathognomonic sign of dermoid cysts (Figure 9).
A Contrast Enhanced CT scan showing a huge lesion in the left hemipelvis (white arrow). A fluid –fat level can be seen within the lesion; there is a heterogeneous floating part with soft tissue density. This lesion turned out to be a dermoid cyst.
Even in magnetic resonance imaging (MRI) the diagnosis of dermoid cysts is based on the evidence of fat within the lesion. T1 and T2 weighted images are not enough for this purpose and so fat suppression techniques need to be implemented (Figure 10).
T2-weighted images non-fat saturated (left picture) with fat saturation (right picture) in a MRI scan of a patient with a pelvic mass (white arrow), showing a heterogeneous mass in the left ovary in which there is a signal drop in fat saturated image. The mass proved to be a dermoid cyst.
A differential diagnosis is necessary for endometriotic and mucinous cysts. Diagnostic difficulties may arise when there is a small fat component, or a high levels of hematic content that masks the fatty signals. MRI can correctly evaluate fatty levels and fat buoyancy components, like the Rokitansky nodule; these semiological aspects help differentiate diagnosis. Chemical shift artifacts caused by the presence of fat are also useful in the diagnosis of dermoid cysts. Intravenous administration of gadolinium causes contrast enhancement of the cyst walls and of the Rokitansky nodule [28,29].
Mature teratomas are, in most cases, benign tumours; on occasion, there may be an immature component, with malignant characteristics; this occurs in about 1% of all benign teratomas. The tumour most commonly associated with the teratoma is the squamous-cell carcinoma.
Malignancy signs in a dermoid are indicated by tissue showing clear enhancement. In addition, as the malignant component often infiltrates different dermoid tissues, the capsule, or the extracapsular anatomic structures, it is possible to assess the nature of the cyst by its aggressive morphological appearance. Complications of cystic dermoids are represented by ovarian torsion, or by acute rupture of the mass in the peritoneum.
It is also important to remember that a dysontogenetic pelvic mass may not necessarily originate from the ovary. Sacrococcygeal teratoma and primary retroperitoneal teratomas are more frequent. Sacrococcygeal teratomas are most common dysontogenetic masses in infants; the diagnosis can also be done in uterus, with direct ultrasound visualisation of a pre-sacral mass often associated with polyhydramnios. In many cases the masses are visible externally, developing in the subcutaneous tissue of the intergluteal area;
The masses can have macroscopic appearances, ranging from predominantly cystic, to mixed, to predominantly solid; the last one is most likely to be malignant.
Imaging plays an important role in the diagnosis of these tumours: firstly, through CT ad MRI scans it is possible to differentiate between other abnormalities of the terminal filum such as meningocele and myelomeningocele. It is possible to identify other abnormalities also associated with teratomas in the sacrococcygeal area. Rarely it’s possible to observe the growth into the vertebral canal or bone destruction due to teratoma. The association with anal stenosis, vesicoureteral reflux, presacral abscess and skin changes may be indicative of Currarino syndrome.
This work has been funded by Covidien AG.
Hemorrhage is the cause of 12.0–18.0% of deaths during pregnancy [1, 2, 3]. Severe postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity [4, 5] and is increasing in incidence worldwide [6, 7], especially in low resource countries [8]. Emergency hysterectomy is increasingly performed to treat uncontrollable PPH [1, 2, 3]. It was performed at the time of, or within 24 h of, a vaginal or abdominal delivery for the treatment of hemorrhage that was unresponsive to unservative approaches [9]. Variability in the incidence of PPH-related hysterectomy is different in various countries and even among institutions [9, 10, 11, 12, 13].
According to recent reports, 0.20–5.09 of every 1000 postnatal women across the globe have undergone an emergency hysterectomy [14]. Hysterectomy is considered to be a safe, low-risk surgery. It is, by nature, unplanned and performed expeditiously in the case of severe PPH. It may not be the best option for all women, especially those who still want to have children. Some people may have an adverse reaction to the anesthetic, heavy bleeding, and infection around the incision site [15].
The guidelines of the World Health Organization (WHO) aim to prevent and manage PPH by active management of the third stage of labor (AMTSL) [16]. Thai government policy to prevent PPH in 2013 was involved in the project—Every Woman Every Child (EWEC) to decrease maternal mortality and child mortality by 16 million cases in 2015 [17, 18]. However, the incidence of PPH was increased from 2.30 to 2.65% from 2009 to 2015 [19]. In low-resource city with various ethnic groups, surrounded by mountains and forests as in Chiang Rai province and Sakon Nakhon province [20, 21]. The incidence of PPH is increasing in Chiang Rai from 1.12 to 2.07%, but maternal death from PPH decreased from 3.05 to 1.23% during 2012-2015 [20]. In the fiscal year 2014–2015, PPH-related hysterectomy decreased in number from 2 cases to 1 case [20]. In Sakon Nakhon, during 2015–2018 the incidence of PPH is about 1.13–1.39%. The maternal deaths were decreased from 33.83 to 27.84 per 100,000 infant live births. However, it was higher than the standard criterion of 17.0 per 100,000 infant live births [21].
A tool developed from significantly high-risk factors [22, 23, 24] associated with PPH was performed in western societies and Thailand [25, 26, 27, 28, 29]. These tools can detect PPH earlier and can reduce the number of maternal deaths and PPH-related hysterectomies in Thailand [20, 21].
This study aimed to synthesize knowledge about the early management of PPH, summarize the appropriate risk score tool for the prediction of PPH, and reduce the number of maternal deaths and PPH-related hysterectomy cases in two lower resource cities in the north and northeast of Thailand.
The objective of this study was to synthesize knowledge about the early management of PPH and an appropriate risk score tool to reduce PPH-related hysterectomy cases in two lower resource cities in the north and northeast of Thailand.
The study reviewed the results of the author’s research in four steps as follows:
The research review was approved by the Ethics Committee for Human Research at Khon Kaen University, Thailand [HE 601234, HE 611093], the Chiang Rai Regional Hospital Ethics Committee on July 21st, 2017, and the Ethics committee of Sakon Nakhon Hospital (SKHREC 422562). Most of the research was based on secondary data. Those who volunteered had signed a consent form.
There are four steps to this research result as follows:
Risk factors | Subgroup | Statistical procedures | ||
---|---|---|---|---|
Heterogeneity Test I2 | Estimate size (fixed effect) | |||
OR (95% CI) | ||||
I. Eight of high-risk factors (odds ratio > 2.0) | ||||
1. Antepartum hemoglobin level | >10 g/dL | 95.71 | 4.80 (4.00–5.76) | <0.001 |
2. Coagulopathy | 35.18 | 11.96 (2.64–54.10) | 0.004 | |
3. History of prior pregnancy and delivery | Prior PPH | 40.89 | 4.01 (2.32–6.93) | <0.001 |
4. Complication of current pregnancy, 1st stage of labor, received procedure of 1st stage of labor | Fibroid | 89.97 | 0.73 (0.70–0.75) | <0.001 |
5. Complication of current pregnancy, 1st stage of labor, received procedure of 1st stage of labor | Multiple pregnancy | 51.23 | 2.69 (2.32–3.11) | <0.001 |
6. Complication of current pregnancy, 1st stage of labor, received procedure of 1st stage of labor | Gestational hypertensive disorder | 69.13 | 2.07 (1.72–2.50) | <0.001 |
7. Placenta factors | Placenta previa | 28.44 | 5.01 (3.61–6.97) | <0.001 |
8. Placenta Factors | Placenta accrete | 0.00 | 3.55 (1.84–6.86) | <0.001 |
II. Six moderate risk factors (odds ratio > 1.5–2.0) | ||||
1. Obstetric factors parity | Nulliparous | 72.62 | 1.93 (1.53–2.43) | <0.001 |
2. Gestational age (large gestational age) | >40 weeks | 47.19 | 1.35 (1.28–1.42) | <0.001 |
3. Placenta factors | Placenta abruption | 39.13 | 1.70 (1.06–2.73) | 0.029 |
4. Complication of current pregnancy, 1st stage of labor, received procedure of 1st stage of labor | Chorioamnionitis | 0.00 | 1.85 (1.45–2.98) | 0.012 |
5. Complication of current pregnancy, 1st stage of labor, received procedure of 1st stage of labor | Induction of labor | 69.33 | 1.77 (1.57–2.00) | <0.001 |
6. Complication of current pregnancy, 1st stage of labor, received procedure of 1st stage of labor | Augmentation of Labor | 69.66 | 1.57 (1.35–5.87) | <0.001 |
III. Seven of low-risk factors (odds ratio > 1.0–1.5) | ||||
1. Individual factors maternal age | <20 years old | 31.40 | 1.36 (1.26–1.46) | <0.001 |
2. Individual factors maternal age | >35 years old | 17.37 | 1.32 (1.29–1.35) | <0.001 |
3. 1 Body mass index (BMI) level | <30 kg/m2 | 0.00 | 1.17 (1.05–1.31) | 0.050 |
3. 2 Body mass index (BMI) level | >30 kg/m2 | 0.00 | 1.18 (1.01–1.38) | 0.027 |
4. Obstetric Factors parity | Primiparous | 97.64 | 1.29 (1.18–1.41) | <0.001 |
5. Gestational age | >42 weeks | 47.19 | 1.35 (1.28–1.42) | <0.001 |
6. Complication of current pregnancy, 1st stage of labor, received procedure of 1st stage of labor | Gestational diabetes mellitus | 0.00 | 1.35 (1.22–1.45) | <0.001 |
7. Complication of current pregnancy and 1st stage of labor receive procedure | Received analgesic drugs | 10.03 | 1.38 (1.27–1.49) | <0.001 |
Med calc version 18.6 was used to analyze risk factors for PPH during vaginal deliveries.
Source: approved by I-Tuporn, et al. [29].
This study was analyzed and identified risk factors for PPH via vaginal deliveries from 20 articles from 2005 to 2017 in Thailand and globally, using MedCalc version 18.2.1 and version 18.6 [30].
The results showed that 21 factors, including eight high-risk factors for PPH (odds ratio > 2.0) include antepartum hemoglobin ≤10 g/dL, coagulopathy, prior PPH, fibroid, placenta previa, placenta accrete, multiple pregnancy, and gestational hypertensive disorder. Six moderate risk factors for PPH (odds ratio > 1.5–2.0) include nulliparous status, large gestational age, placenta abruption, chorioamnionitis, induction, and augmentation of labor. Seven low-risk factors for PPH (odds ratio > 1.0–1.5) include maternal age < 20 years old and ≥ 35 years old, BMI level, primiparous, gestational age ≥ 42 weeks, gestational diabetes mellitus, and having received analgesic drugs.
Form for recording risk scores to predict postpartum hemorrhage (PPH) of blood loss over 300 ml after vaginal delivery. Source: approved by I-Tuporn, et al. [
The results showed that the eight predictors of I-Tuporn et al. [31] (Figure 1) from the cause of PPH (4 T’s and 7 steps of the clinical prediction model of Steyerberg) [32, 33] and by comparison with the standard monogram of Biguzzi [34], Sittipan [28], and Suta [27] could predict postpartum blood loss over 300 ml at Chiang Rai Regional Hospital with a sensitivity of 80.7%, a specificity of 60.8%, and the ROC curve equal to 0.71 at the optional cut-off score of four marks or above (see Figure 1) [31].
Level of blood loss | ROC curve | Sensitivity (%) | Specificity (%) | Accuracy (%) | Positive predictive value (%) | Negative predictive value (%) | 95% CI | P-Value |
---|---|---|---|---|---|---|---|---|
>250 ml | 0.627 | 57.33 | 61.95 | 59.84 | 58.01 | 61.48 | 0.592–0.662 | <0.001 |
>275 ml | 0.608 | 15.69 | 92.92 | 56.04 | 66.96 | 54.66 | 0.554–0.662 | <0.001 |
>300 ml | 0.606 | 15.48 | 92.92 | 55.94 | 66.66 | 54.60 | 0.552–0.661 | <0.001 |
>500 ml | 0.653 | 5.02 | 98.66 | 53.94 | 77.41 | 53.19 | 0.563–0.744 | 0.004 |
Review of risk score at the different levels of blood loss from 250 ml. to 500 ml. in 1001 cases who underwent vaginal delivery at Sakhon Nakhon hospital, Thailand, during June 2018 to December 2019.
Source: Approved by Nutravong et al. [35], on An Appropriate Assessment of PPH by using a Risk Score Tool for prediction at Sakon Nakhon, Hospital, Thailand oral presentation in the International Webinar on Primary Healthcare and Medicare held during November 08–09, 2021/Vienna Austria.
It found that the eight predictors of I-Tuporn et al. [31] (Figure 1) can be used to predict early PPH in Sakon Nakhon Hospital since blood loss is 250 ml and over with a sensitivity of 57.33%, a specificity of 61.95%, and a ROC curve equal to 0.62 (Table 2 and Figure 2).
The ROC curve’s performance at different levels of blood loss at over (a) 250 mL, (b) 275 mL, (c) 300 mL, and (d) 500 mL of a risk score for PPH prediction from 1001 cases after delivery at Sakon Nakhon hospital, Thailand from July 2018 to December 2019.
The results of one-year follow-up showed the incidence of Chiang Rai Regional Hospital.
The number of cases of PPH-related hysterectomy decreased from 4.61% to 3.81% from 2019 to 2020 report of. It had no cases of PPH-related hysterectomy but had reported no maternal death per 100,000 infant live births, 36.60 and 37.36 respectively.
In Sakon Nakhon province, the incidence of PPH decreased from 1.39 to 1.10%, but there was no report of PPH-related hysterectomy. The maternal death rate decreased from 27.84 to 15.12 per 100,000 live births, from 2018 to 2019 (Table 3).
Setting | Pregnancy Problems | Fiscal years | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | 2020 | |||
Thailand* | Incidence of PPH | 2.30% | 2.37% | 2.44% | 2.40% | 2.39% | 2.54% | 2.65% | NA | NA | NA | NA | NA | |
Chiang Rai** Province | Incidence of PPH | NA | NA | NA | 1.12% | 1.15% | 1.34% | 2.07% | NA | NA | NA | NA | NA | |
PPH related Hysterectomy | NA | NA | NA | NA | NA | 2 | 1 case | NA | NA | NA | NA | NA | ||
Maternal death/100,000 infant live birth | NA | NA | NA | 3.05 | 4.58 | 1.82 | 1.23 | NA | NA | NA | NA | NA | ||
Chiang Rai** Regional Hospital | Incidence of PPH | NA | NA | NA | NA | 9.0% | 1.98% | 2.64% | 2.58% | 2.61% | 3.85% | 4.61% | 3.81% | |
PPH related Hysterectomy | NA | NA | NA | NA | 1 case | NA | NA | NA | NA | NA | NA | NA | ||
Maternal death/ 100,000 infant live birth | NA | NA | NA | NA | NA | 36.14 | 18.09 | NA | NA | 17.45 | 36.60 | 37.36 | ||
Sakon Nakhon*** Province | Incidence of PPH | NA | NA | NA | NA | NA | NA | 1.13% | 0.93% | 1.00% | 1.39% | 1.10% | NA | |
PPH related Hysterectomy | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||
Maternal death/100,000 infant live birth | NA | NA | NA | NA | NA | NA | 33.83 | 17.68 | 26.88 | 27.84 | 15.12 | NA |
Statistics on PPH, PPH-related hysterectomy, and maternal deaths were collected in Thailand’s Chiang Rai Province. Chiang Rai regional hospital, Sakon Nakhon Province.
Medical Department, Ministry of Public Health document 2013 [17].
Ajalapung, 2015 [20].
Statistic Report for NE Thailand, 2019 [21].
Remarks: The standard Criterion of maternal deaths was 17 per 100,000 infant live birth.
The postpartum hemorrhage (PPH) in I-Tuporn et al. [31] study, which was conducted in the Chiang Rai Regional Hospital in 2017, was 2.61%. It was lower than the study in Chonburi Hospital (4.95%) [28] and Maharat Nakorn Ratchasima Hospital (6.67%) [26], but it was related to the report of Bhumibol Adulyadej Hospital (1.98%) [25] and the report of Calvert et al. [36] that presented Asia’s regional PPH rate of 1.90% [36].
Emergency hysterectomy for the treatment of severe hemorrhage from vaginal delivery was not reported widely in Chiang Rai Regional Hospital or Sakon Nakhon province. It was presented only some years ago and reported only a few cases. However, the maternal death rate in Sakon Nakhon province from 2015 to 2018 was higher than the standard criterion of 17 per 100,000 infant live births. It was decreased in the year 2019 to 15.12 per 100,000 infant live births after this hospital used a risk score tool with 8 predictors by I-Tuporn et al. [31] to detect earlier PPH and early treatment as blood loss over 250 mL from the collector bag.
The risk score tool for the prediction of PPH in Thailand had five studies [25, 26, 27, 28, 29]. They were developed in different settings. They had some similar risk factors for the detection of PPH. The study of I-Tuporn et al. [31] developed the risk score tool with 8 predictors, covering the cause of PPH (4 T’s and 7 steps of the clinical prediction model of Steyerberg [32, 33] and by comparison with the standard monogram of Biguzzi [34], Sittipan [28], and Suta et al. [27]) I-Tuporn et al. [31] risk score tool could be used in low-resource cities with various ethnic groups, as in Chiang Rai and Sakon Nakhon province, which are in the north and northeast of Thailand, respectively.
The results of the Chiang Rai and Sakon Nakhon provinces study after 1 year of follow-up showed that the maternal death rate in Sakon Nakhon province had decreased to normal criterion, and there were no reports of PPH-related hysterectomy cases in these two provinces.
In conclusion, the problems of PPH concerned the Thai government. Many projects were carried out in accordance with World Health Organization’s (WHO) [16] guidelines to reduce PPH, PPH-related hysterectomy, and maternal death.
Due to some settings in Thailand, the government’s policy is not suitable for some women because of their low resources and distance from the cities. Some of the settings are surrounded by mountains and forests, and it is very hard to refer a pregnant woman with PPH to the provincial hospital. Most of them belong to different ethnic groups and cannot communicate with other people. Therefore, some of them die before seeing a doctor.
There should be a policy of early detection of PPH in those lower resource settings by using an appropriate risk score tool to predict the PPH risk for a pregnant woman’s life.
The authors would like to thank all of the respondents for their valuable contributions to this study and extend their special gratitude to the Department of Obstetrics and Gynecology in Chiang Rai Regional Hospital and Sakon Nakhon Hospital for the data support, and the Thai Society of Maternal and Fetal Medicine for funding support.
All authors declare that they have no conflicts of interest.
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in Dermatology",fullTitle:"Current Genetics in Dermatology"},signatures:"Tomoki Kosho",authors:[{id:"153541",title:"Dr.",name:"Tomoki",middleName:null,surname:"Kosho",slug:"tomoki-kosho",fullName:"Tomoki Kosho"}]},{id:"53880",doi:"10.5772/67269",title:"Anatomy and Physiology of Hair",slug:"anatomy-and-physiology-of-hair",totalDownloads:7829,totalCrossrefCites:5,totalDimensionsCites:8,abstract:"Hair is one of the characteristic features of mammals and has various functions such as protection against external factors; producing sebum, apocrine sweat and pheromones; impact on social and sexual interactions; thermoregulation and being a resource for stem cells. Hair is a derivative of the epidermis and consists of two distinct parts: the follicle and the hair shaft. The follicle is the essential unit for the generation of hair. The hair shaft consists of a cortex and cuticle cells, and a medulla for some types of hairs. Hair follicle has a continuous growth and rest sequence named hair cycle. The duration of growth and rest cycles is coordinated by many endocrine, vascular and neural stimuli and depends not only on localization of the hair but also on various factors, like age and nutritional habits. Distinctive anatomy and physiology of hair follicle are presented in this chapter. Extensive knowledge on anatomical and physiological aspects of hair can contribute to understand and heal different hair disorders.",book:{id:"5461",slug:"hair-and-scalp-disorders",title:"Hair and Scalp Disorders",fullTitle:"Hair and Scalp Disorders"},signatures:"Bilgen Erdoğan",authors:[{id:"193661",title:"Dr.",name:"Bilgen",middleName:null,surname:"Erdoğan",slug:"bilgen-erdogan",fullName:"Bilgen Erdoğan"}]},{id:"52801",doi:"10.5772/66156",title:"Psychosocial Aspects of Hair Loss",slug:"psychosocial-aspects-of-hair-loss",totalDownloads:2553,totalCrossrefCites:6,totalDimensionsCites:7,abstract:"Hair loss (alopecia) is a common dermatological condition that affects men and women of all ages. It can be due to a wide variety of causes including scarring and non-scarring diseases. Although alopecia is not a life-threatening condition, it has significant psychological impact on the quality of life. Mental disorders such as anxiety, depression, social phobia, posttraumatic stress disorder, and suicidal thoughts are increased among alopecia patients. On the other hand, alopecia frequency increases during the course of psychological disorders. In this chapter, psychosocial aspects of hair loss and the relationship between alopecia and psychological disorders are reviewed.",book:{id:"5461",slug:"hair-and-scalp-disorders",title:"Hair and Scalp Disorders",fullTitle:"Hair and Scalp Disorders"},signatures:"Hilal Gokalp",authors:[{id:"193580",title:"M.D.",name:"Hilal",middleName:null,surname:"Gokalp",slug:"hilal-gokalp",fullName:"Hilal Gokalp"}]},{id:"62733",doi:"10.5772/intechopen.79807",title:"Ethosomes: An Exciting and Promising Alcoholic Carrier System for Treating Androgenic Alopecia",slug:"ethosomes-an-exciting-and-promising-alcoholic-carrier-system-for-treating-androgenic-alopecia",totalDownloads:1089,totalCrossrefCites:1,totalDimensionsCites:5,abstract:"Androgenetic alopecia (male-pattern hair loss) is characterized by the deposition of dihydrotestosterone at the pilosebaceous unit of the scalp. Oral administration of drugs (like finasteride) which can reverse androgenic alopecia causes undesired effects to the body. Targeting these drugs directly to the pilosebaceous unit of the scalp will enhance the pharmacological response at the desired site by reducing undesired systemic side effects. This chapter discusses about ethosomes, a specially tailored ethanolic vesicular carriers which can efficiently deliver various drugs with different physicochemical properties to and through the skin. The unique characteristics of the ethosomal carriers, their composition, preparation methods, and the mechanism of permeation, safety, and practical experience (finasteride and herbal extracts) have been discussed in detail.",book:{id:"6961",slug:"alopecia",title:"Alopecia",fullTitle:"Alopecia"},signatures:"Veintramuthu Sankar, Santhanam Ramesh and Karthik Siram",authors:[{id:"254541",title:"Prof.",name:"Sankar",middleName:null,surname:"Veintramuthu",slug:"sankar-veintramuthu",fullName:"Sankar Veintramuthu"},{id:"260986",title:"Mr.",name:"Karthik",middleName:null,surname:"Siram",slug:"karthik-siram",fullName:"Karthik Siram"},{id:"260991",title:"Dr.",name:"Santhanam",middleName:null,surname:"Ramesh",slug:"santhanam-ramesh",fullName:"Santhanam Ramesh"}]},{id:"42516",doi:"10.5772/54609",title:"Epidermolysis Bullosa Simplex",slug:"epidermolysis-bullosa-simplex",totalDownloads:4272,totalCrossrefCites:2,totalDimensionsCites:3,abstract:null,book:{id:"3038",slug:"current-genetics-in-dermatology",title:"Current Genetics in Dermatology",fullTitle:"Current Genetics in Dermatology"},signatures:"Ken Natsuga",authors:[{id:"152977",title:"Dr.",name:"Ken",middleName:null,surname:"Natsuga",slug:"ken-natsuga",fullName:"Ken Natsuga"}]}],mostDownloadedChaptersLast30Days:[{id:"53880",title:"Anatomy and Physiology of Hair",slug:"anatomy-and-physiology-of-hair",totalDownloads:7836,totalCrossrefCites:5,totalDimensionsCites:8,abstract:"Hair is one of the characteristic features of mammals and has various functions such as protection against external factors; producing sebum, apocrine sweat and pheromones; impact on social and sexual interactions; thermoregulation and being a resource for stem cells. Hair is a derivative of the epidermis and consists of two distinct parts: the follicle and the hair shaft. The follicle is the essential unit for the generation of hair. The hair shaft consists of a cortex and cuticle cells, and a medulla for some types of hairs. Hair follicle has a continuous growth and rest sequence named hair cycle. The duration of growth and rest cycles is coordinated by many endocrine, vascular and neural stimuli and depends not only on localization of the hair but also on various factors, like age and nutritional habits. Distinctive anatomy and physiology of hair follicle are presented in this chapter. Extensive knowledge on anatomical and physiological aspects of hair can contribute to understand and heal different hair disorders.",book:{id:"5461",slug:"hair-and-scalp-disorders",title:"Hair and Scalp Disorders",fullTitle:"Hair and Scalp Disorders"},signatures:"Bilgen Erdoğan",authors:[{id:"193661",title:"Dr.",name:"Bilgen",middleName:null,surname:"Erdoğan",slug:"bilgen-erdogan",fullName:"Bilgen Erdoğan"}]},{id:"53947",title:"Infections, Infestations and Neoplasms of the Scalp",slug:"infections-infestations-and-neoplasms-of-the-scalp",totalDownloads:3547,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"This chapter reviews common cutaneous infections, infestations, and neoplasms of the scalp. Infections of the scalp are subdivided into three major groups. The most seen are: (1) Bacterial: Folliculitis, folliculitis decalvans, tufted hair folliculitis and acne keloidalis nuchae. (2) Fungal: Tinea capitis, favus and kerion celsi. (3) Protozoal: Syphilitic alopecia. Pediculosis capitis is the most common worldwide infestation of the scalp. The neoplasms of the scalp are large group of different diseases due to arising different origin. In the following section, trichilemmal cyst, proliferating trichilemmal cyst, nevus sebaceous and cylindroma are discussed in detail.",book:{id:"5461",slug:"hair-and-scalp-disorders",title:"Hair and Scalp Disorders",fullTitle:"Hair and Scalp Disorders"},signatures:"Filiz Canpolat",authors:[{id:"191617",title:"Associate Prof.",name:"Filiz",middleName:null,surname:"Canpolat",slug:"filiz-canpolat",fullName:"Filiz Canpolat"}]},{id:"53525",title:"Trichoscopy and Trichogram",slug:"trichoscopy-and-trichogram",totalDownloads:2633,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Hair and scalp examination techniques can be classified into three categories: noninvasive methods (clinical history, general examination, photography, hair count, weighing shed hair, pull test, global hair counts, dermoscopy, electron microscopy, laser scanning microscopy, etc.); semi‐invasive methods (the trichogram, unit areatrichogram); and invasive methods (biopsies in cicatritial alopecia). Scalp dermoscopy or trichoscopy is one of thenoninvasive techniques for the evaluation of patients with hair loss that allows for magnified visualization of the hair and scalp skin. It may be performed with a manual dermoscope (10× magnification) or a videodermoscope (up to 1000× magnification). This method is simple, quick, and easy to perform, is well‐accepted by patients, and is useful for monitoring treatment, determining severity of the disease and follow‐up. It is a simple, minimally invasive and rapid technique for measuring hair follicle activity. Trichogram represents a semi‐invasive technique for the evaluation of patients with hair loss that allows the microscopic examination of hairs plucked from the scalp and provides information about the state of the proximal end of the hair shaft and the distal end. The trichogram is a useful complementary tool for clinical evaluation, diagnosis, and the monitoring of treatment response.",book:{id:"5461",slug:"hair-and-scalp-disorders",title:"Hair and Scalp Disorders",fullTitle:"Hair and Scalp Disorders"},signatures:"Melike Kibar",authors:[{id:"189899",title:"Dr.",name:"Melike",middleName:null,surname:"Kibar Ozturk",slug:"melike-kibar-ozturk",fullName:"Melike Kibar Ozturk"}]},{id:"42524",title:"Hereditary Palmoplantar Keratosis",slug:"hereditary-palmoplantar-keratosis",totalDownloads:4592,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"3038",slug:"current-genetics-in-dermatology",title:"Current Genetics in Dermatology",fullTitle:"Current Genetics in Dermatology"},signatures:"Tamihiro Kawakami",authors:[{id:"155091",title:"Associate Prof.",name:"Tamihiro",middleName:null,surname:"Kawakami",slug:"tamihiro-kawakami",fullName:"Tamihiro Kawakami"}]},{id:"63066",title:"Pharmacological Treatment of Alopecia",slug:"pharmacological-treatment-of-alopecia",totalDownloads:1460,totalCrossrefCites:1,totalDimensionsCites:3,abstract:"In this chapter, we will explore non-surgical treatments of alopecia. Unlike many other areas of medicine, pharmacological treatments for alopecia are relatively new. There are only two treatments which are approved by the Food and Drug Administration (FDA); the rest are drugs developed for other indications which have gained popular off-label use to promote hair growth. The reasons for this are many, including the designation of alopecia by the FDA as a cosmetic disease. This designation has restricted alopecia development programs to compounds with virtually no side effects. Unfortunately, it has also led to off-label use of far more dangerous compounds as alopecia treatments, without the benefit of controlled trials. There is a growing recognition that alopecia, particularly alopecia areata and chemotherapy-induced alopecia, are disorders which significantly alter the quality of life, similar to acne vulgaris and psoriasis, and merit treatment accordingly. There have also been several recent advances in our understanding of the hair cycle, revealing new targets for developing alopecia therapies. As a result, there is a more robust slate of programs for developing new pharmacological treatments for alopecia. In this chapter, we will review current pharmacological treatments for alopecia and selected treatments under development (i.e., those with significant preclinical or clinical data which have appeared in the published literature).",book:{id:"6961",slug:"alopecia",title:"Alopecia",fullTitle:"Alopecia"},signatures:"Robert Gensure",authors:[{id:"16515",title:"Dr.",name:"Robert",middleName:null,surname:"Gensure",slug:"robert-gensure",fullName:"Robert Gensure"}]}],onlineFirstChaptersFilter:{topicId:"1003",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:9,numberOfPublishedChapters:139,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:122,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:21,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983",scope:"Biochemistry, the study of chemical transformations occurring within living organisms, impacts all areas of life sciences, from molecular crystallography and genetics to ecology, medicine, and population biology. Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"August 2nd, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:33,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"14",title:"Cell and Molecular Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",isOpenForSubmission:!0,editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",slug:"rosa-maria-martinez-espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",biography:"Dr. Rosa María Martínez-Espinosa has been a Spanish Full Professor since 2020 (Biochemistry and Molecular Biology) and is currently Vice-President of International Relations and Cooperation development and leader of the research group 'Applied Biochemistry” (University of Alicante, Spain). Other positions she has held at the university include Vice-Dean of Master Programs, Vice-Dean of the Degree in Biology and Vice-Dean for Mobility and Enterprise and Engagement at the Faculty of Science (University of Alicante). She received her Bachelor in Biology in 1998 (University of Alicante) and her PhD in 2003 (Biochemistry, University of Alicante). She undertook post-doctoral research at the University of East Anglia (Norwich, U.K. 2004-2005; 2007-2008).\nHer multidisciplinary research focuses on investigating archaea and their potential applications in biotechnology. She has an H-index of 21. She has authored one patent and has published more than 70 indexed papers and around 60 book chapters.\nShe has contributed to more than 150 national and international meetings during the last 15 years. Her research interests include archaea metabolism, enzymes purification and characterization, gene regulation, carotenoids and bioplastics production, antioxidant\ncompounds, waste water treatments, and brines bioremediation.\nRosa María’s other roles include editorial board member for several journals related\nto biochemistry, reviewer for more than 60 journals (biochemistry, molecular biology, biotechnology, chemistry and microbiology) and president of several organizing committees in international meetings related to the N-cycle or respiratory processes.",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"15",title:"Chemical Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",isOpenForSubmission:!0,editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",slug:"sukru-beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",biography:"Dr. Şükrü Beydemir obtained a BSc in Chemistry in 1995 from Yüzüncü Yıl University, MSc in Biochemistry in 1998, and PhD in Biochemistry in 2002 from Atatürk University, Turkey. He performed post-doctoral studies at Max-Planck Institute, Germany, and University of Florence, Italy in addition to making several scientific visits abroad. He currently works as a Full Professor of Biochemistry in the Faculty of Pharmacy, Anadolu University, Turkey. Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. Dr. Beydemir is also Rector of Bilecik Şeyh Edebali University, Turkey.",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",slug:"deniz-ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",biography:"Dr. Deniz Ekinci obtained a BSc in Chemistry in 2004, MSc in Biochemistry in 2006, and PhD in Biochemistry in 2009 from Atatürk University, Turkey. He studied at Stetson University, USA, in 2007-2008 and at the Max Planck Institute of Molecular Cell Biology and Genetics, Germany, in 2009-2010. Dr. Ekinci currently works as a Full Professor of Biochemistry in the Faculty of Agriculture and is the Head of the Enzyme and Microbial Biotechnology Division, Ondokuz Mayıs University, Turkey. He is a member of the Turkish Biochemical Society, American Chemical Society, and German Genetics society. Dr. Ekinci published around ninety scientific papers, reviews and book chapters, and presented several conferences to scientists. He has received numerous publication awards from several scientific councils. Dr. Ekinci serves as the Editor in Chief of four international books and is involved in the Editorial Board of several international journals.",institutionString:null,institution:{name:"Ondokuz Mayıs University",institutionURL:null,country:{name:"Turkey"}}},editorThree:null},{id:"17",title:"Metabolism",coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",isOpenForSubmission:!0,editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",slug:"yannis-karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",biography:"Yannis Karamanos, born in Greece in 1953, completed his pre-graduate studies at the Université Pierre et Marie Curie, Paris, then his Masters and Doctoral degree at the Université de Lille (1983). He was associate professor at the University of Limoges (1987) before becoming full professor of biochemistry at the Université d’Artois (1996). He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. His teaching areas are energy metabolism and regulation, integration and organ specialization and metabolic adaptation.",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null},{id:"18",title:"Proteomics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",isOpenForSubmission:!0,editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",slug:"paolo-iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",biography:"Paolo Iadarola graduated with a degree in Chemistry from the University of Pavia (Italy) in July 1972. He then worked as an Assistant Professor at the Faculty of Science of the same University until 1984. In 1985, Prof. Iadarola became Associate Professor at the Department of Biology and Biotechnologies of the University of Pavia and retired in October 2017. Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. He is a Consultant Reviewer for several journals, including the Journal of Chromatography A, Journal of Chromatography B, Plos ONE, Proteomes, International Journal of Molecular Science, Biotech, Electrophoresis, and others. He is also Associate Editor of Biotech.",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",slug:"simona-viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",biography:"Simona Viglio is an Associate Professor of Biochemistry at the Department of Molecular Medicine at the University of Pavia. She has been working since 1995 on the determination of proteolytic enzymes involved in the degradation process of connective tissue matrix and on the identification of biological markers of lung diseases. She gained considerable experience in developing and validating new methodologies whose applications allowed her to determine both the amount of biomarkers (Desmosine and Isodesmosine) in the urine of patients affected by COPD, and the activity of proteolytic enzymes (HNE, Cathepsin G, Pseudomonas aeruginosa elastase) in the sputa of these patients. Simona Viglio was also involved in research dealing with the supplementation of amino acids in patients with brain injury and chronic heart failure. She is presently engaged in the development of 2-DE and LC-MS techniques for the study of proteomics in biological fluids. The aim of this research is the identification of potential biomarkers of lung diseases. She is an author of about 90 publications (According to Scopus: H-Index: 23; According to WOS: H-Index: 20) on peer-reviewed journals, a member of the “Società Italiana di Biochimica e Biologia Molecolare,“ and a Consultant Reviewer for International Journal of Molecular Science, Journal of Chromatography A, COPD, Plos ONE and Nutritional Neuroscience.",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null}]},overviewPageOFChapters:{paginationCount:42,paginationItems:[{id:"82914",title:"Glance on the Critical Role of IL-23 Receptor Gene Variations in Inflammation-Induced Carcinogenesis",doi:"10.5772/intechopen.105049",signatures:"Mohammed El-Gedamy",slug:"glance-on-the-critical-role-of-il-23-receptor-gene-variations-in-inflammation-induced-carcinogenesis",totalDownloads:8,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Chemokines Updates",coverURL:"https://cdn.intechopen.com/books/images_new/11672.jpg",subseries:{id:"18",title:"Proteomics"}}},{id:"82875",title:"Lipidomics as a Tool in the Diagnosis and Clinical Therapy",doi:"10.5772/intechopen.105857",signatures:"María Elizbeth Alvarez Sánchez, Erick Nolasco Ontiveros, Rodrigo Arreola, Adriana Montserrat Espinosa González, Ana María García Bores, Roberto Eduardo López Urrutia, Ignacio Peñalosa Castro, María del Socorro Sánchez Correa and Edgar Antonio Estrella Parra",slug:"lipidomics-as-a-tool-in-the-diagnosis-and-clinical-therapy",totalDownloads:7,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Fatty Acids - Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/11669.jpg",subseries:{id:"17",title:"Metabolism"}}},{id:"82440",title:"Lipid Metabolism and Associated Molecular Signaling Events in Autoimmune Disease",doi:"10.5772/intechopen.105746",signatures:"Mohan Vanditha, Sonu Das and Mathew John",slug:"lipid-metabolism-and-associated-molecular-signaling-events-in-autoimmune-disease",totalDownloads:17,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Fatty Acids - Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/11669.jpg",subseries:{id:"17",title:"Metabolism"}}},{id:"82483",title:"Oxidative Stress in Cardiovascular Diseases",doi:"10.5772/intechopen.105891",signatures:"Laura Mourino-Alvarez, Tamara Sastre-Oliva, Nerea Corbacho-Alonso and Maria G. Barderas",slug:"oxidative-stress-in-cardiovascular-diseases",totalDownloads:10,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Importance of Oxidative Stress and Antioxidant System in Health and Disease",coverURL:"https://cdn.intechopen.com/books/images_new/11671.jpg",subseries:{id:"15",title:"Chemical Biology"}}}]},overviewPagePublishedBooks:{paginationCount:33,paginationItems:[{type:"book",id:"7006",title:"Biochemistry and Health Benefits of Fatty Acids",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7006.jpg",slug:"biochemistry-and-health-benefits-of-fatty-acids",publishedDate:"December 19th 2018",editedByType:"Edited by",bookSignature:"Viduranga Waisundara",hash:"c93a00abd68b5eba67e5e719f67fd20b",volumeInSeries:1,fullTitle:"Biochemistry and Health Benefits of Fatty Acids",editors:[{id:"194281",title:"Dr.",name:"Viduranga Y.",middleName:null,surname:"Waisundara",slug:"viduranga-y.-waisundara",fullName:"Viduranga Y. Waisundara",profilePictureURL:"https://mts.intechopen.com/storage/users/194281/images/system/194281.jpg",biography:"Dr. Viduranga Waisundara obtained her Ph.D. in Food Science\nand Technology from the Department of Chemistry, National\nUniversity of Singapore, in 2010. She was a lecturer at Temasek Polytechnic, Singapore from July 2009 to March 2013.\nShe relocated to her motherland of Sri Lanka and spearheaded the Functional Food Product Development Project at the\nNational Institute of Fundamental Studies from April 2013 to\nOctober 2016. She was a senior lecturer on a temporary basis at the Department of\nFood Technology, Faculty of Technology, Rajarata University of Sri Lanka. She is\ncurrently Deputy Principal of the Australian College of Business and Technology –\nKandy Campus, Sri Lanka. She is also the Global Harmonization Initiative (GHI)",institutionString:"Australian College of Business & Technology",institution:{name:"Kobe College",institutionURL:null,country:{name:"Japan"}}}]},{type:"book",id:"6820",title:"Keratin",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6820.jpg",slug:"keratin",publishedDate:"December 19th 2018",editedByType:"Edited by",bookSignature:"Miroslav Blumenberg",hash:"6def75cd4b6b5324a02b6dc0359896d0",volumeInSeries:2,fullTitle:"Keratin",editors:[{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}}]},{type:"book",id:"7978",title:"Vitamin A",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7978.jpg",slug:"vitamin-a",publishedDate:"May 15th 2019",editedByType:"Edited by",bookSignature:"Leila Queiroz Zepka, Veridiana Vera de Rosso and Eduardo Jacob-Lopes",hash:"dad04a658ab9e3d851d23705980a688b",volumeInSeries:3,fullTitle:"Vitamin A",editors:[{id:"261969",title:"Dr.",name:"Leila",middleName:null,surname:"Queiroz Zepka",slug:"leila-queiroz-zepka",fullName:"Leila Queiroz Zepka",profilePictureURL:"https://mts.intechopen.com/storage/users/261969/images/system/261969.png",biography:"Prof. Dr. Leila Queiroz Zepka is currently an associate professor in the Department of Food Technology and Science, Federal University of Santa Maria, Brazil. She has more than fifteen years of teaching and research experience. She has published more than 550 scientific publications/communications, including 15 books, 50 book chapters, 100 original research papers, 380 research communications in national and international conferences, and 12 patents. She is a member of the editorial board of five journals and acts as a reviewer for several national and international journals. 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The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. 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She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"322007",title:"Dr.",name:"Maria Elizbeth",middleName:null,surname:"Alvarez-Sánchez",slug:"maria-elizbeth-alvarez-sanchez",fullName:"Maria Elizbeth Alvarez-Sánchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",country:{name:"Mexico"}}},{id:"337443",title:"Dr.",name:"Juan",middleName:null,surname:"A. Gonzalez-Sanchez",slug:"juan-a.-gonzalez-sanchez",fullName:"Juan A. Gonzalez-Sanchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico System",country:{name:"United States of America"}}},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}},{id:"338856",title:"Mrs.",name:"Nur Alvira",middleName:null,surname:"Pascawati",slug:"nur-alvira-pascawati",fullName:"Nur Alvira Pascawati",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universitas Respati Yogyakarta",country:{name:"Indonesia"}}}]}},subseries:{item:{id:"3",type:"subseries",title:"Bacterial Infectious Diseases",keywords:"Antibiotics, Biofilm, Antibiotic Resistance, Host-microbiota Relationship, Treatment, Diagnostic Tools",scope:"