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\r\n\tHomeostasis is brought about by a natural resistance to change when already in the optimal conditions, and equilibrium is maintained by many regulatory mechanisms. All homeostatic control mechanisms have at least three interdependent components for the variable to be regulated: a receptor, a control center, and an effector. The receptor is the sensing component that monitors and responds to changes in the environment, either external or internal. Receptors include thermoreceptors and mechanoreceptors. Control centers include the respiratory center and the renin-angiotensin system. An effector is a target acted on to bring about the change back to the normal state. At the cellular level, receptors include nuclear receptors that bring about changes in gene expression through up-regulation or down-regulation and act in negative feedback mechanisms. An example of this is in the control of bile acids in the liver.
\r\n\tSome centers, such as the renin-angiotensin system, control more than one variable. When the receptor senses a stimulus, it reacts by sending action potentials to a control center. The control center sets the maintenance range—the acceptable upper and lower limits—for the particular variable, such as temperature. The control center responds to the signal by determining an appropriate response and sending signals to an effector, which can be one or more muscles, an organ, or a gland. When the signal is received and acted on, negative feedback is provided to the receptor that stops the need for further signaling.
\r\n\tThe cannabinoid receptor type 1 (CB1), located at the presynaptic neuron, is a receptor that can stop stressful neurotransmitter release to the postsynaptic neuron; it is activated by endocannabinoids (ECs) such as anandamide (N-arachidonoylethanolamide; AEA) and 2-arachidonoylglycerol (2-AG) via a retrograde signaling process in which these compounds are synthesized by and released from postsynaptic neurons, and travel back to the presynaptic terminal to bind to the CB1 receptor for modulation of neurotransmitter release to obtain homeostasis.
\r\n\tThe polyunsaturated fatty acids (PUFAs) are lipid derivatives of omega-3 (docosahexaenoic acid, DHA, and eicosapentaenoic acid, EPA) or of omega-6 (arachidonic acid, ARA) and are synthesized from membrane phospholipids and used as a precursor for endocannabinoids (ECs) mediate significant effects in the fine-tuning adjustment of body homeostasis.
\r\n\t
\r\n\tThe aim of this book is to discuss further various aspects of homeostasis, information that we hope to be useful to scientists, clinicians, and the wider public alike.
Complications of acute myocardial infarction are different and sometimes life threatening.
We can globally classify them in five categories: (1) ischaemic complications, which include infarct extension, recurrent infarction, and post infarction angina; (2) arrhythmic complications, in terms of atrial or ventricular arrhythmias, and sinus or atrioventricular node dysfunction; (3) embolic complications towards central nervous system or peripheral embolization; (4) inflammatory disturbances, such as pericarditis; (5) mechanical complications, as myocardial rupture, mitral valve dysfunction, ventricular aneurysms and cardiogenic shock up to heart failure.
Since the last years of the eighteenth century, many physicians discovered these clinical entities, firstly during autopsy, and progressively by doing pioneristic surgical efforts, starting by suturing heart wounds, and gradually trying to apply similar techniques on the infarcted heart.
Mechanical complications of myocardial infarction are direct consequences of anatomopathological changes occurring in ischaemic cardiac tissue. After a coronary occlusion, there is a lack in perfusion and in oxygen supply that cause functional, morphological, and biochemical alterations. In the first 30 minutes from the occlusion, reversible changes happen; macroscopically and microscopically there are no grossly damages yet, but myofibrils start to relax, and cells start to suffer. After half an hour, ischaemic necrosis begins, and the irreversible damage occurs. Complete necrosis of myocardial cells requires at least 2–4 hours, or longer, depending on the presence of collateral circulation, persistent or intermittent coronary arterial occlusion, pre-conditioning, and individual demand for oxygen and nutrients. The principal mechanism is coagulative necrosis, with neutrophil infiltration, oedema, and loss of myofibrils. After 6–12 hours, loss of vitality is complete. In one week, macrophagic phagocytosis and collagen disruption begin, and tissue becomes weaker; that is the most dangerous step in which heart ruptures are more frequent [1, 2, 3].
The irreversible damage starts at a subendocardic level, and when the ischemia is widespread, necrosis moves forward, involving the adjacent tissue both in width and in thickness. If coronary flow is promptly restored while the damage is still reversible yet, the cells\' vitality could be preserved. On the other hand, reperfusion damage could be present by generating free oxygen radicals and apoptosis activators.
After a couple of weeks, granulation tissue and neoangiogenesys begin, up to the formation of a scar in about two months from myocardial infarction. Remodelling of myocardial tissue is the final step; both infarcted and non-infarcted regions change in dimensions, thickness, and shape, with hypertrophy and dilatation of the myocardial wall, and with the possible formation of an aneurysm. Remodelling could be seen as a sort of haemodynamic compensation; nevertheless, degenerative changes in myocardial tissue may cause a depression in regional and global contractility, with a final lack in myocardial function [1, 2, 3].
As we will discuss, on a clinical level, signs and symptoms of mechanical complications of myocardial infarction may vary according to the seriousness of the damage, going from rare asymptomatic medical cases, through plainly symptomatic patients showing classical chest pain, up to more frequent catastrophic, and even sudden onset with cardiogenic shock. Because of these, a prompt diagnosis is important. While ECG may demonstrate the presence of an infarction and help locate the ischaemic lesion, transthoracic echocardiography with Doppler is the modality of choice for bedside diagnosis, capable of detecting heart ruptures, as well as valve defects or ventricular motion abnormalities. Its immediate availability and the detailed information it provides are fundamental in the management of these patients, helping in the decision-making process. The use of other diagnostic tools, such as angiography, is subdued to haemodynamic stability of the patient [3].
As far as therapy is concerned, most of all mechanical complications of myocardial infarction require an urgent surgical approach. Meanwhile, initial management with medical therapy should be administered immediately, in order to improve systemic and coronary perfusion, and stabilise the haemodynamic status. Supplement oxygen and mechanical ventilatory support while necessary should be provided, as well as analgesic therapy, in order to control pain and reduce sympathetic tone; crystalloid infusion should be administered when hypotension and relative hypovolemia is present, together with inotropic agents. Many more pharmacologic agents are useful, depending on every different clinical presentation, but the positioning of an intra-aortic-balloon pump (IABP) is always a support of choice in order to reduce cardiac workload and increase supply of oxygen by increasing coronary perfusion during diastole and reducing the after-load during systole [4].
Survival depends primarily upon the rapid recognition of each complication and upon an immediate therapy. Even if operative mortality remains high, surgery is the essential tool to avoid a fatal outcome.
In this chapter, we will analyse mechanical complications of myocardial infarction, such as ventricular free wall rupture, ventricular septal defect, papillary muscle rupture, ischaemic mitral regurgitation, left ventricle aneurysm, and cardiogenic shock. We will also deal with therapies for heart failure, and make a brief digression upon strategies against myocardial remodelling.
The first description of left ventricular free wall rupture appeared in 1647 by William Harvey, but until 1970, with operations managed by the teams of Hatcher and FitzGibbon, no successful surgery was done [5, 6].
Left ventricular free wall rupture (LVFWR) is the most frequent presentation of myocardial rupture: it occurs up to ten times more frequently than septal or papillary muscle rupture, and mostly hits the lateral midventricular wall along the apex to base axis (the incidence of right ventricular free wall rupture is very low, roughly 0.44%). Free wall rupture may occur at any time after myocardial infarction, most frequently after 3–7 days, when coagulative necrosis, neutrophil infiltration, and tissue lysis make myocardium weaker. Moreover, an increase in wall tension may overcome the tensile strength of the weakened wall. However, at least 1/4 of heart rupture occurs within the first 24 hours. Interstitial oedema, damage to collagen network and myocyte apoptosis are proposed mechanisms [7].
The real incidence of this complication is unknown, although the reported incidence is increasing (1–4%) among patients surviving hospital admissions due to an increment of the availability of non-invasive diagnostic tools. Free wall rupture accounts for 6–17% of in-hospital mortality [8]. The National Registry of Myocardial Infarction (NRMI) shows an elevated incidence of in-hospital mortality among patients treated with thrombolytic therapy (12.1%) than patients who were not treated (6.1%) [9]. In the Thrombolysis in Myocardial Infarction Phase II (TIMI II) trial, 16% of patients died within 18 hours of therapy. Moreover, patients who were treated with PTCA had an incidence of free wall rupture lower than that of patients receiving thrombolytic therapy [10].
Risk factors are age (usually over 60 years old), gender (female), a history of hypertension, and the absence of ventricular hypertrophy. Moreover, LVFWR occurs mostly after an ST elevation myocardial infarction (STEMI), and in areas lacking of fibrosis (that means in patients without history of previous angina or myocardial infarction). These last associations suggest that the size of necrosis and the absence of collateral blood flow (with lack of previous ischaemic symptoms) are important determinants in the aetiology of heart rupture [8].
To understand the clinical presentation of the LVFWR, it is worthy to speak about the morphological pattern of rupture. Pathologically, Perdigao and associates described four types of ruptures: the type I, or direct rupture, is a single dissection of the wall in only one direction and without dissection or blood infiltration (Fig. 1); type II is represented by a multiple dissection, with a multicanalicular trajectory and an extensive haemorrhagic infiltration of neighbouring tissue (Fig. 2); in type III, rupture is protected either by an intracardiac thrombus or by adhesions on the epicardial side (Fig. 3); type IV is characterised by an incomplete rupture, that doesn\'t cross the thickness of the ventricular wall, creating an intramural haematoma [12]. However, Becker and van Mantgem proposed a different classification that could be connected to the clinical presentation: acute, subacute, and chronic [13]. The acute rupture (also called "blow-out" rupture, corresponding to Perdigao type I-II) is characterized by a massive haemopericardium (Fig. 4); the presentation is dramatic, with sudden and recurrent or persistent chest pain and a rapid deterioration into electro-mechanical dissociation caused by pericardial tamponade. A severe jugular venous destention and cyanosis may be present. Death occurs within a few minutes. When the rupture area is smaller, and temporarily sealed by thrombus or pericardial adhesions, a subacute onset happens (also called “ooze” rupture or Perdigao type III, and occurs in 30–40% of cases). Clinical presentation may involve the gradual onset of signs and symptoms of cardiac tamponade. A variety of other signs may be present, such as arrhythmias, a severe hypotension, syncope, and, eventually, cardiogenic shock, but also malaise and nausea for few days.
A chronic rupture occurs when the leakage of blood is slow and when surrounding pressure on the epicardium temporarily controls the haemorrhage, with the formation of a false aneurysm (or pseudoaneurysm). This is a rare entity and usually occurs within three months after myocardial infarction. Clinical presentation, in this case, is represented by congestive heart failure, recurrent or persistent chest pain, ventricular arrhythmias, and even embolization [14].
Perdigao type IV (intramural haematoma) has no different presentation from the usual infarction.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t | \n\t\t |
Type I | \n\t\t\tAcute (“blow-out”) rupture | \n\t\t\tSingle dissection of the wall, in only one direction and without dissection or blood infiltration | \n\t\t\tFig. 1 | \n\t\t
Type II | \n\t\t\tMultiple dissection, with a multicanalicular trajectory and an extensive haemorrhagic infiltration of neighbouring tissue | \n\t\t\tFig 2 | \n\t\t|
Type III | \n\t\t\tSubacute (“ooze”) rupture | \n\t\t\tRupture is protected either by an intracardiac thrombus or by adhesions on the epicardial side | \n\t\t\tFig. 3 | \n\t\t
Chronic rupture (pseudoaneurysm) | \n\t\t\tPressure on the epicardium temporarily controls the haemorrhage | \n\t\t\t\n\t\t | |
Type IV | \n\t\t\t\n\t\t\t | Intramural haematoma | \n\t\t\t\n\t\t |
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Perdigao type I, a single dissection of ventricular free wall
Perdigao type II, multicanalicular trajectory of rupture
Perdigao type III, rupture is sealed by pericardial adhesions
Early diagnosis is improved by the use of transthoracic echocardiography, the fastest and most useful diagnostic test, with a high diagnostic sensitivity (≥ 70%) and specificity (> 90%). The most frequent finding is the presence of a pericardial effusion (> 5 mm), high-density intrapericardial echoes, right atrial or right ventricular wall compression with tamponade, and, in 50% of cases, visible wall defects [15]. The role of the invasive diagnostic tools is still unclear and depends on the haemodynamic stability of the patient. Most of the time, the definitive diagnosis is made at surgery. Generally, when Perdigao type I, II, III, and IV are non-haemodynamically stable they require a surgical approach. Type IV in haemodynamically stable patients can be treated conservatively [11, 17, 18, 19].
The first objective of treatment is to reach haemodynamic stability. Rapid infusions of crystalloid along with inotropic agents may help to achieve this; pericardiocentesis may be carried out prior to surgery and not only may confirm a haemorrhagic effusion, but also may decrease the threat of tamponade. Placement of IABP should be done [20].
Haemopericardium
Surgical repair of the rupture site is the definitive treatment, and it can be administered in different ways and with different techniques. Traditional and standard repair involves performing infartectomy (including the area hit by the rupture) and reconstructing the ventricle or close the damage with simple pledgeted suture (Fig. 5), with or without cardiopulmonary bypass. Both techniques have a shortcoming: in the first case, a ventricular cavity distortion may damage the ventricular function; on the other hand, stitches are placed in a necrotic—and so weaker—tissue. Different authors heave recently reported newer surgical strategies, usually performed in the presence of oozing or sealed rupture (type III), by using different biological materials such as pericardium (Fig. 6) and newer acellular xenogeneic extracellular matrix patches, and non-biological patches made of polyethylene terephthalate polyester fibre (Dacron) or polytetrafluoroethylene fluoropolymer resin (Teflon). Suturless techniques with fibrin tissue-adhesive collagen fleece, and Gelatin-Resorcin Formaldehyde glue are described [12, 16, 21, 22, 23].
In the matter of chronic rupture, the treatment of choice is still surgery, but obviously the timing depends on the balance between risks and benefits. Pseudoaneurysm can be repaired by the closure of the neck or by using a patch (similar to true aneurysm). Percutaneous approaches (by using the AmplatzerTM occluder) are described as well [24].
The mortality rate is significantly high. It is strictly linked to the preoperative haemodynamic condition of patient and to a prompt diagnosis.
The damage has been closed with simple pledgeted suture
The damage has been sealed by using a pericardial patch
Ventricular septal defect (VSD), firstly described by Latham in 1845 [25], is a serious complication of myocardial infarction that is little less frequent than free wall rupture. Its incidence has been estimated between 1% and 2% of all myocardial infarctions even if the advent of reperfusion therapy has decreased this value below 0.5%. However, the mortality is still high, with 60–70% of patients dying within the first 2 weeks, and less than 10% survives after 3 months [26].
As for free wall rupture, risk factors for septal rupture include advanced age, hypertension, and no previous myocardial infarction or angina.
The acute rupture occurs 3–7 days after a huge transmural infarction, with the weakening of the septal wall, but the median decrease below 24 h with the use of thrombolysis. Late rupture is possible (as long as 2 weeks). Pathophysiologically, this results in a left-to-right shunt with diversion of blood flow towards pulmonary circulation. Systemic vasoconstriction in response to peripheral hypotension and hypoperfusion worsens the shunt. As a consequence, low cardiac output and cardiogenic shock occur [2].
Classification of the defect are of three types: type I ruptures show an abrupt tear in the wall of normal thickness; in type II, the infarcted myocardium erodes before the rupture, and is covered by thrombus; type III shows perforation of an aneurysm grown after infarct healing. Moreover, defects can be classified in two other categories: simple and complex. Multiple defects may be present in 5–11% of cases, and are probably caused by infarct extension. Simple rupture is a discrete lesion, with holes located at a similar level in both ventricles and in a linear path. This is the typical pattern of an anterior infarction and usually hits the part in which the septum meets the free wall. On the other hand, inferior infarction usually leads to a complex type, which presents a meandering dissection path between ventricles and extensive haemorrhage in the nearby tissue that occurs near the base of the heart. Midseptal defects are rare and are usually elicited from the occlusion of a perforating artery [4].
In both cases, rupture may vary in size from mm to cm. This determines the magnitude of left-to-right shunting, influencing the clinical presentation (from asymptomatic to cardiogenic shock), and the likelihood of survival. Signs and symptoms may include recurrent chest pain and dyspnoea, but even a precipitous onset of haemodynamic compromise characterised by hypotension and biventricular failure (often predominantly right-sided failure), up to cardiogenic shock is possible. At physical examination, a harsh and loud pansystolic murmur at the left lower sternal border is present in over 90% of cases. A palpable thrill can be detected in up to 50% of patients [27].
ECG shows changes associated to myocardial infarction and may help to correlate the localization of infarction with the type of septal rupture.
Historically, the gold standard diagnostic tool was right cardiac catheterization using a Swan-Ganz catheter, useful also to differentiate among other clinical entities (mitral ischaemic regurgitation and papillary muscle rupture). In septal rupture, it is easy to find oxygen saturation step-up between the right atrium and pulmonary artery greater than 9% (in papillary rupture, giant V-waves in pulmonary artery wedge pressure are shown). Nowadays, the use of echocardiography (both transthoracic and transesophageal) has almost replaced this diagnostic tool. Doppler may easily and accurately identify the location, the size, and the presence of the shunt, indeed, with 100% specificity and 100% sensitivity. It may also assess the ventricles function and estimate the right ventricle systolic pressure. The use of angiography is debatable; it can provide important information about coronary lesions, but, on the other hand, may delay the surgical treatment [28].
Kirklin and colleagues reveal that nearly 25% of patients with post infarction septal rupture and no surgical intervention died within the first 24 hours, 50% died within 1 week, 65% within 2 weeks, 80% within 4 weeks [28]; only 7% lived longer than one year. In the GUSTO-I trial, the 30-day mortality rate was lower in patients treated with surgical repair than in patients treated only medically (47% vs. 94%). The same results for the 1-year mortality rate (53% vs. 97%) [29]. In the SHOCK trial, the in-hospital mortality rate was higher in patients with cardiogenic shock due to septal rupture (87.3%) than in patients with cardiogenic shock from all other causes (59.2% with pure left ventricle failure and 55.1% with acute mitral regurgitation) [30].
The optimal approach varies with the clinical presentation. Medical therapy is considered to be a support tool in the offing of surgery, and is usually managed with the use of pharmacologic support with vasodilators (which reduce afterload, thereby decreasing left ventricular pressure and the left to right shunt), inotropic agents (which may increase the cardiac output), diuretics, and IABP. In patients with cardiogenic shock, death is inevitable in the absence of urgent surgical intervention. Delayed elective surgical repair is feasible in patients with heart failure without shock, but an unpredictable and rapid deterioration is always lurking in general; adverse outcomes are correlated with advanced age and a lengthy delay between septal rupture and operation [28].
The surgical approach has been performed since 1959 when Cooley and associates performed the first successful surgical repair through a right ventriculotomy with incision of right ventricular outflow tract [31]. Disadvantages of this approach were suboptimal exposure and failure to eliminate the bulging segment of infarcted left ventricular wall. Later, Heimbecker [32] and colleagues developed a different technique, performing a left ventriculotomy. Nowadays, multiple techniques are described. Apical amputation is simpler, but apical defects are rare. This technique was proposed in the 1970s by Daggett [33]. After the resection, the ventricular free walls are linked using Teflon strips. Other techniques involve infarct exclusion and defect closure with a patch (biological or synthetic) using both stitches and glues [34].
Preservation of the geometric configuration of the ventricles is an important target, together with the closure of the defect.
Even a percutaneous approach has been considered, mostly in order to close contingent residual defects (residual defects are present in about 28% of survived patients) or sometimes used for the acute stabilization of critically ill patients. However, no long-term outcome data about this mini-invasive technique are available [35].
Despite continuous advances in surgical approaches, operative mortality remains high (20–50%), with no clear differences between different techniques (Fig. 7–13) [34].
Anterior repair of VSD [Adapted from Chikwe J, Beddow E, Glenville B. Cardiothoracic Surgery. Oxford University Press 2006]
VSD, anterior surgical approach
VSD closure with synthetic patch
VSD closure with synthetic patch
Ventricular free walls are linked using Teflon strips
Apical resection [Adapted from Chikwe J, Beddow E, Glenville B. Cardiothoracic Surgery. Oxford University Press 2006]
Posterior repair of VSD [Adapted from Chikwe J, Beddow E, Glenville B. Cardiothoracic Surgery. Oxford University Press 2006]
Papillary muscle rupture (PMR) is a rare entity and occurs in about 1% of patients with acute myocardial infarction. It accounts for 5% of infarct-related deaths. Mortality may be as high as 50% in the first 24 h, and up to 80% in the first week, when only medical treatment is applied. Timing of rupture stays in a range between 1 and 14 days, but 80% occurs in 7 days [36].
Rupture of papillary muscles results from infarction of the muscle itself and leads to an ischaemic mitral regurgitation by lack of leaflet tethering (Carpentier type II, see next chapter for further information).
PMR is most common with an inferior myocardial infarction, and the posteromedial papillary muscle is most often involved (6 to 12 times more frequently than anterolateral papillary muscle); that\'s because of its single blood supply through the posterior descending coronary artery (anterolateral papillary has a dual blood supply, instead, from the left anterior descending and left circumflex arteries) [36, 37, 39].
Among risk factors, there is, once again, the absence of a previous infarction in medical history.
PMR may be complete, with a massive mitral regurgitation and rapid onset of symptoms up to hemodynamic collapse and death, or partial, with a moderate to severe mitral regurgitation. Clinical presentation may vary according to the completeness of rupture, but usually presents dyspnoea, hypotension, acute pulmonary oedema, and cardiogenic shock. At the physical examination, a soft murmur without thrill may be present, even if the absence of new heart murmur does not exclude the diagnosis.
The gold standard in diagnosis is Doppler transthoracic and transesophageal echocardiography, with the evidence of a tear in papillary tissue and the flail of mitral leaflet leading to severe mitral regurgitation (Fig. 14, 15). Left ventricular function is usually hyperdynamic as a result of ventricular contraction against the low impedance left atrium. Haemodynamic monitoring with a Swan-Ganz catheter can reveal large (> 50 mmHg), early V waves in the pulmonary capillary wedge pressure, and no increase in oxygen saturation from right atrium to right ventriculum (useful to conduct differential diagnosis with septal rupture) [36, 37, 38].
Echo findings in complete papillary muscle rupture
Echo findings in complete papillary muscle rupture
The only real treatment for papillary muscle rupture is surgery, although it is high risk (operative mortality up to 20–25%) [37]. Medical therapy could be performed in order to reach a hemodynamic stability prior to emergency surgery, and includes aggressive afterload reduction in order to decrease the regurgitant fraction by using nitrates, sodium nitroprusside, diuretics, and IABP.
The surgical technique depends upon the location and the completeness of the rupture. With partial PMR, some surgeons prefer to stabilise the patient and delay surgery for 6–8 weeks after myocardial infarction to avoid operating on the necrotic myocardial tissue. However, an acute intervention in patients that cannot be stabilized must be considered. A surgical repair of the papillary muscle head is really rare, but possible, with pledgeted sutures and the addition of glue to strengthen the repair. Mitral valve repair rather than replacement should be attempted when there is no papillary muscle necrosis [36, 37].
The excised mitral valve showing complete rupture of the papillary muscle
Ischaemic mitral regurgitation (IMR) is a functional entity that occurs in 8% to 50% of patients after myocardial infarction. Unlike the structural mitral regurgitation, here the valve leaflets and valvular apparatus are normal, even if the coexistence of coronary artery disease and non-ischaemic mitral disease has led to a poor understanding of this clinical entity [40].
Carpentier described three general types of mitral regurgitation according to different pathophysiologic mechanisms: type I, in which there is a normal leaflet motion, and regurgitation is caused by annular dilatation from ischemia of adjacent ventricular wall or by leaflet perforation; type II, in which we can find an increased leaflet motion, with a prolapse of valve leaflet (in this case, regurgitation is caused either by papillary muscle rupture or in papillary muscle elongation due to chronic ischemia, and usually lead to an asymmetric leak); type IIIa, with leaflet restriction during systole and diastole (not seen in ischaemic mitral regurgitation); type IIIb, leaflet restriction only during systole caused by a dysfunction of ventricular wall, dilated after ischaemic injury, with systolic tethering of papillary muscle (as a consequence, there\'s a failure in mitral coaptation).
IMR could be acute or chronic, but both result from ischemia of ventricular wall and missed coaptation. The remodelling secondary to acute and chronic ischemia remains the principal mechanism for IMR and depends on apical tethering and an excessive tenting volume, which cause coaptation failure of the mitral leaflets. Mild-to-moderate mitral regurgitation is often clinically silent and detected on Doppler echocardiography performed during the early phase of myocardial infarction.
Risk factors are advanced age, female sex, large infarct, multivessel coronary artery disease, and, unlike other mechanical complications, history of a previous myocardial infarction or recurrent ischemia.
The acute onset of severe IMR is a life-threatening complication and arises from a few hours to weeks after myocardial infarction; in this case, a sudden volume overload is imposed on the left ventricle, increasing preload and a small increase in total stroke volume. Acute mitral regurgitation usually results from the rupture of papillary muscles or chordae tendineae: haemodynamic deterioration is sudden, because no compensatory structural changes in atrium and ventricle are possible. Pulmonary congestion, as well as cardiogenic shock, may occur. Clinical features include pulmonary oedema, chest pain, and dyspnoea. A new pansystolic murmur can be detected, best heard at the apex [40, 44].
Chronic IMR occurs as a consequence of ventricular dilatation secondary to ischaemic ventricular remodelling (both regional or global), with papillary muscle displacement and failure of leaflet coaptation. During chronic onset of the disease, the left atrium and ventricle may develop an offsetting hypertrophy and dilatation. Enlargement of the left atrium allows volume overload, but may cause arrhythmias, such as atrial fibrillation, and the formation of thrombi. Until systolic dysfunction prevents effective ventricular contraction, patients are asymptomatic. After that, exertional dyspnoea and fluid retention may be present [40].
The gold standard diagnostic tool is echocardiography, both transthoracic and transeosophageal, which assess mitral valve apparatus, the mechanism of regurgitation, and the ventricular function [3, 15]
Medical therapy may have a supportive role in case of acute onset of mitral regurgitation, while in chronic cases it is useful in decreasing the regurgitant volume and improve ventricular function by using ACE-inhibitors, and to reduce remodelling by using beta-blockers. Most patients with acute mitral regurgitation are managed with percutaneous coronary intervention (PCI) or thrombolysis. Surgery is usually reserved for acute and severe cases, which do not ameliorate after these approaches, and for chronic patients symptomatic for coronary disease.
Repair versus replacement of the mitral valve is still debatable. Mitral valve repair is generally preferred whenever possible based on valve pathology and patient stability: it avoids long-term anticoagulation, decreases infective endocarditis risk, and provides greater leaflet durability. Among repairs, different techniques are available, but annuloplasty with prosthetic ring is the gold standard [41, 42]. On the other hand, valve replacement is usually reserved for situations where the valve cannot be reasonably repaired, or when repair is unlikely to be tolerated clinically. Moreover, it being a faster procedure is better in high-risk surgical candidates. Mitral valve replacement could be managed by using the chordal-sparing techniques, a range of procedures that permit the resuspension of chordae and the preservation of subvalvular anatomy [43].
Percutaneous approaches are available, but often limited to patients with lots of comorbidity and a poor surgical outcome [40].
The earliest reports of a ventricular aneurysm appeared in 1757, during an autopsy managed by Galeati and Hunter; but the first surgical approach to this pathology was performed in 1942 by Beck.
A true aneurysm is the result of the gradual thinning and the expansion of the scarred left ventricular wall after transmural infarction. This is a different entity from a pseudoaneurysm, which does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus [45, 47, 49].
The 85% of true aneurysm is located anterolaterally, near the apex of the heart. Two types of true aneurysm are present: a traditional aneurysm, namely a region of myocardium with an abnormal diastolic contour and a systolic dyskinesia, with a paradoxic bulging; and a functional aneurysm, in which bulging is not present, but is characterised by large areas of akinesia, that affects ventricular function. They originate from two distinct phases of myocardial infarction. First, an early expansion phase defined as the deformation or stretch of infarcted myocardium during the first week after the ischaemic injury: wall thinning due to the degradation of collagen matrix and dilatation lead to an augmentation in both systolic and diastolic wall stress, following LaPlace law, and to a greater request of oxygen supply. Fibre stretching is progressive until fibrosis and scarring. Increased diastolic stretch, elevated catecholamines and stimulation of natriuretic peptides may demonstrate increased fibre shortening and myocardial hypertrophy as adaptive changes. The second phase is constituted by late remodelling. Here, the aneurysm is composed of scar tissue; systolic and diastolic ventricular dysfunctions are present, in fact aneurysm does not contract nor distend (this impairs diastolic filling and increases left ventricular end-diastolic pressure). Mechanism of compensation such as chamber dilatation, hypertrophy, and changes in ventricular geometry lead to a poor contractile function, and eventually heart failure [46, 48]
The incidence of true aneurysm is 10–35% after transmural myocardial infarction, even if it may result from trauma, Chagas\' disease, sarcoidosis, or may be congenital as well. Risk factors seem to be the presence of a previous infarction in medical history and a decreased ejection fraction (less than 50%).
Clinical presentation often involves angina (in more than 60% of patients, three-vessels coronary disease is present), dyspnoea, and symptoms of congestive heart failure. Atrial and ventricular arrhythmias may occur in the scar tissue, producing palpitations, syncope, and even sudden death. A mural thrombus is often found (50%) [43, 44, 45, 50, 51, 52, 53].
Even if echocardiography is a useful diagnostic tool capable of identifying false aneurysm and assessing ventricular function, angiography and left ventriculography is the gold standard, estimating the size of aneurysm and evaluating cardiac function and kinesis, as well as coronary status. Tomographic three-dimensional echocardiography and magnetic resonance imaging are the most reliable means of evaluating left ventricular volume. Positron emission tomography (PET) can be helpful in an early phase to differentiate true aneurysm from hibernating myocardium with reversible dysfunction. Even magnetic resonance imaging can be useful, but cannot assess coronary anatomy.
Medical therapy aims to minimise the remodelling of the left ventricle: both in acute and chronic heart failure; ACE inhibitors may reduce ventricular wall stress, as well as ventricular dilatation. Beta-blockers do the same. Nitrates may reduce hypertrophy, but it seems they don\'t affect mortality.
Anticoagulation with warfarin is indicated for patients with a mural thrombus. Patients should be treated initially with intravenous heparin, with a target aPTT of 50–70 seconds. Warfarin is started simultaneously, and the INR target is 2–3 for a period of 3 to 6 months. The use of anticoagulation without the presence of a thrombus is controversed. Anticoagulation should be reinitiated if a new thrombus develops, and an echocardiographic follow up must be done [54].
Asymptomatic patients with a small aneurysm may be treated medically. However, an aneurysm that occupies more than 25% of the ventricular surface may significantly affect the global function. When refractory heart failure or ventricular arrhythmias are present, as well in the presence of a huge aneurysm, surgery is indicated.
Resection of the aneurysm may be followed by conventional closure or newer techniques to maintain LV geometry. In the plication technique, a direct closure of the aneurysm without excision is performed; this is usually done for very small aneurysms without internal thrombus [55]. Another conventional strategy, the linear repair, was first introduced by Cooley in 1958. In this technique, the incision is extended round the aneurysm leaving a rim of scar tissue and buttressed mattress sutures are placed successively. With this technique, changing ventricular geometry is possible [55].
Other newer techniques aim to maintain ventricular geometry by using the external patch (procedure performed by Daggett) or inverted T closure of ventriculotomy (as done by Komeda) [56], or circular patch technique for posterior aneurysms [57]. Finally, endoaneurysmorraphy, a procedure proposed by Jatene, Dor, and Cooley, positions an endocardial patch in order to preserve both normal ventriculum and septal geometry [58, 59, 60].
Traditional aneurismectomy: Linear closure [Adapted from Chikwe J, Beddow E, Glenville B. Cardiothoracic Surgery. Oxford University Press 2006]
Traditional aneurismectomy: Patch closure [Adapted from Chikwe J, Beddow E, Glenville B. Cardiothoracic Surgery. Oxford University Press 2006]
Cardiogenic shock is a clinical syndrome characterised by end-organ hypoperfusion, due to a rapid worsening of ventricular function.
It occurs in 5–8% of hospitalised patients with STEMI, and 12% of these cases are caused by a mechanical complication of myocardial infarction. Cardiogenic shock may also occur in 2.5% of non-coronary cases: any cause of acute, severe left or right ventricular dysfunction such as acute myopericarditis, tako-tsubo cardiomyopathy, hypertrophic cardiomyopathy, acute valvular regurgitation caused by endocarditis or chordal rupture due to trauma or degenerative disease, as well as aortic dissection, severe aortic or mitral insufficiency. Moreover, cardiac tamponade or massive pulmonary embolism may lead to this kind of shock [60, 61, 62, 63, 64].
Risk factors are directly related to the principal trigger. In the context of myocardial infarction, risk factors may include older age, hypertension, diabetes mellitus, multivessel coronary artery disease, prior myocardial infarction or angina, anterior location of infarction, prior diagnosis of heart failure, STEMI, and left bundle-branch block.
Considering the ischaemic aetiology of cardiogenic shock, pathological mechanism starts with the ischaemic injury of myocite, with loss of effective contractility, and a systolic and diastolic dysfunction. A decrease in cardiac output leads to a decrease in systemic and coronary perfusion. A vicious cycle originates, with the worsening of hypoperfusion and the increasing of infarcted regions of myocardium. To compensate the decrease in stroke volume and cardiac output, sympathetic tone is increased, eliciting tachycardia, systemic vasoconstriction, and increased contractility of the healthy non-ischaemic myocardium. This results in an increase in the cardiac workload and oxygen consumption. When these compensatory mechanisms cannot meet the increased demand, there\'s once again a progression in myocardial injury. Even systemic inflammation may contribute to myocardial dysfunction, decreasing systemic perfusion. The spiral worsening of ventricular function and a subsequent shock was thought to occur after the loss of at least 40% of the left ventricular mass [60].
The definition of cardiogenic shock includes haemodynamic parameters, such as persistent hypotension (systolic blood pressure < 90 mmHg, with severe reduction in cardiac index < 1.8 L/min/m2), elevated filling pressure, and pulmonary capillary wedge pressure < 15 mmHg. Signs and symptoms include cool and sweaty extremities, cyanosis, decreased urine output, and/or alteration in mental status. Haemodynamic abnormalities go from mild hypoperfusion to profound shock, and the short-term outcome is directly related to the severity of the haemodynamic derangement [60, 61, 62, 63, 64].
The diagnosis is usually made with invasive haemodynamic monitoring using pulmonary artery catheterisation (Swan-Ganz catheter); however, Doppler echocardiography may help to confirm the elevation of the left ventricle filling pressures, and may assess mechanical causes of shock above all. ECG confirms ischaemic aetiology.
Therapies should not be delayed. On the pharmacological side, no drugs have been shown to improve survival, but they are fundamental in supporting and stabilising the patients prior to the definitive therapy. Support includes inotropic and vasopressor agents, which should be used in the lowest possible doses (higher vasopressor doses are associated with poorer survival due to a combination between hemodynamic derangement and direct toxic effects).
IABP has long been a mainstay of mechanical therapy for cardiogenic shock [66, 67, 68, 69]. It improves coronary and peripheral perfusion via diastolic balloon inflation and augments left ventricular performance via systolic balloon deflation with an acute decrease in afterload. Nowadays, the reported efficacy of this mechanical support in studies has been variable; some studies, such as the IABP-SHOCK II trial have downgraded IABP, showing no significant differences in treatment groups [71]. Despite this fact, IABP remains in wide use, driven by substantial anecdotal evidence as well as meta-analytic results [70].
In the vicious cycle that characterises cardiogenic shock, revascularisation fulfills an important role, increasing the likelihood of survival with good quality of life (in the randomized SHOCK trial, a 13% increase in 1-year survival in patients assigned to early revascularisation was found) [30]. Mechanical reperfusion may be obtained with a percutaneous approach (angioplasty with or without stenting) or with surgical approach (coronary artery bypass grafting). The optimal revascularisation strategy for patients with multivessel coronary artery disease and cardiogenic shock is not clear. At large, immediate coronary artery bypass surgery is the preferred method of revascularisation when severe triple-vessel or left main disease is present, and should be performed when mechanical complications coexist. Percutaneous coronary intervention of the infarct-related artery is recommended in the case of single or double-vessel disease, or when surgery is not possible [60, 65]. In the STICH (Surgical Treatment for Ischaemic Heart Failure) trial, the addition of coronary artery bypass surgery to medical therapy reduced the most common modes of death (sudden death and fatal pump failure events), with beneficial effects principally seen after two years [72].
Temporary mechanical circulatory support may theoretically interrupt the vicious spiral of ischaemic damage, and allow for recovery of stunned and hibernating myocardium. This kind of support involves circulation of blood through a device that drains venous blood and returns it to the systemic arteries with pulsatile or continuous flow after passing a membrane oxygenator. The major limitations of temporary mechanical circulatory support are device-related complications and irreversible organ failure.
It is possible to distinguish between two main classes of devices with short-term and long-term support. Short-term devices are usually placed in patients with acute heart failure, with a refractory cardiogenic shock and/or mechanical complications of myocardial infarction.
Veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) assists both ventricles and provides a continuous flow with maintenance of a pulsatile arterial pressure unless the circulation is completely supported by the cardio pulmonary bypass device. This pump may be beneficial in cases of severe cardiogenic shock refractory to other pharmacological and mechanical support measures, although its use has not been tested in randomised clinical trials. In a recent meta-analysis, it is shown that VA-ECMO provides acceptable short-term survival for adult patients with cardiogenic shock and stable long-term survival outcomes at up to 3 years. These benefits, however, must be considered alongside the significant associated risks in the decision to institute this type of haemodynamic support [73, 74].
Other short term supports are axial flow pumps, with pumps positioned across the aortic valve to provide active support by transvalvular left ventricle assistance, placed with percutaneous or peripheral surgical approach (e. g., The Impella Recover® - Impella CardioSystems GmbH, Aachen, Germany), and the left atrial-to-femoral arterial left ventricular assist devices, with percutaneously inserted transseptal and arterial cannulae connected to a centrifugal pump (e. g., The Tandem HeartTM pVAD - Cardiac Assist Technologies, Inc., Pittsburgh, PA, USA) [75].
Studies have shown that these mechanical supports may reverse haemodynamic and metabolic parameters in cardiogenic shock more effectively than with standard IABP treatment alone.
However, when end-stage heart failure occurs, cardiac transplantation remains the gold standard, even if the lack of suitable donor organs significantly limits this therapeutic option.
Implantation of a long-term ventricular assist device as a bridge to transplantation or as a destination therapy is an established life-sustaining treatment option for select patients [76, 77, 78, 79].
As seen in the beginning of this chapter, at the bottom of any mechanical complication after a myocardial infarction is the process that starts with an ischaemic injury and finishes with the remodelling of the myocardial tissue. As a result of myocite apoptosis, fibrous tissue deposition and the formation of a myocardial scar, heart failure occurs [2].
Although modest cardiomyocyte turnover occurs in the adult heart, it is insufficient for the restoration of a normal contractile function after substantial cardiomyocyte loss, and even if this cardiac remodelling can be slowed or sometimes reversed by intense pharmacological therapy (thrombolysis, ACEi, beta-blockers, and statins), this process is often progressive.
Several studies aim to find new therapeutic strategies for daily practise against myocardial remodelling. Many of them focused on biochemical patterns occurring during the remodelling process, principally on the ischaemic-reperfusion injury, by searching strategies against the generation of reactive oxygen species (ROS) in the ischaemic myocardium, or by interacting with complex cytokines pathways [80].
On the other hand, stem cells therapy seems to be another new approach to the problem of remodelling. Replacement and regeneration of functional cardiac muscle after an ischaemic insult co
uld be achieved by either stimulating proliferation of endogenous mature cardiomyocytes (reinitiating mitosis) or resident cardiac stem cells or by implanting exogenous donor-derived or allogeneic cardiomyocytes. New strategies may consist of transplanted bone marrow-derived cardiomyocyte or endothelial precursors, foetal cardiomyocytes, and skeletal myoblasts [81, 82, 83, 84].
It is a characteristic of our common human identity that young children are endowed with a high level of curiosity and are eager to learn. Making sense of their world is critical not just for their well-being but for their very survival. How the adult world responds to this is overwhelmingly crucial that has been recognized for generations and enshrined in the famous Jesuit saying:
History also tells us that the adult world’s responsibility to children has often been wanton. In the nineteenth century when the industrial revolution in the western world was at its height children as young as five years of age were sent to work for long hours in factories. They were treated as slaves. In the twentieth century children were often regarded as a necessary nuisance. C
It was the work of Berger and Luckman [4] that first alerted scholars to the fact that the adult world through culture and ideology imposes conceptual constructions on different groups in society. Childhood and senior citizenship are two examples. Different cultures attribute different characteristics to the different stages in the human life span (for example, innocence in the case of children, relative helplessness in the case of senior citizens) such that their individual members are treated in the context of these constructions often in conflict with their actual reality. In terms of childhood, social constructionism seeks to understand how children and knowledge about childhood is constructed by whom, why and most substantially what purpose it serves [5]. The social construction of childhood plays a powerful role not only in shaping the experiences afforded to children by the adult world but also in the emergence of their individual identities (
Any specific social construction of childhood is not universal. It differs remarkably in different parts of the world. Childhood is neither universally similar nor natural rather it is tied close to social circumstances and cultural process [5]. Such cultural process forms part of what Bronfenbrenner described as the macro-level of social influence in his work on the ecology of childhood [6]. In the contemporary world, it is possible to identify three macro constructions of childhood: the
The
The
The
Each of the above constructions of childhood is both culturally and ideologically located. How any given society at any given time endorses a specific political ideology determines which construction of childhood plays out in the ecology of children’s lives though in many societies there is an on-going conflict between different constructions particularly in the US. In most countries throughout the word the State now plays an active role in determining what counts as Education. It is part of the ideological State apparatus first articulated by Althusser [14] to maintain social order and stability.
A major challenge for ECEC is the ideology in which both the policy and practice are rooted. The term ‘ideology’ emerged from the political and revolutionary turmoil in France at the end of the eighteenth century [15, 16] though as a concept it was first used by Francis Bacon in the sixteenth century. It was originally associated with a profound shift in a ‘world view’ from an essentially disposition based on superstition and religious dogma to a disposition based on scientific and logical thought rooted in the Scottish Enlightenment associated with two Scottish philosophers Adam Smith and David Hulme [17]. It is a disposition that initiated the period of intellectual thought now known as ‘Modernity’ in Western and other English-speaking countries and resulted in significant financial prosperity for some and devastating poverty for others. However, during the subsequent 100 or so years its meaning evolved into its present conception based on fundamentally different sets of axiomatic principles concerning a society’s social and economic arrangements in particular the relationship between the State, its institutions, the family and the individual.
In present-day democratic and capitalist countries policy and practice in Education, particularly in ECEC, has been influenced by three dominant political ideologies which are competing for our future. They are: Conservatism, Liberalism and Social Democracy. Each of these ideologies has a set of powerful social and economic principles, often adopted by people with fervent belief though there are significant contested variants and overlaps both within and between them [18].
Of the three democratic ideologies conservatism has perhaps the longest lineage in history. Its variant or extreme form, referred to as neo-liberalism, has been and continues to be highly influential, particularly in present-day USA [19, 20]. In basic and perhaps over simplified terms, one of conservatism’s dominant principles is often referred to as the
In contrast, at the heart of Liberalism is the freedom, well-being and welfare of the ‘individual’ though there is some divergence between the original principles of Liberalism and individuals being liberal-minded [15]. It is taken for granted that if individuals seek to improve themselves morally, socially and educationally society will also improve. Liberalism maintains that the State should allow individuals to be free to choose their own life - style, to be free to express their views/opinions without fear of punishment or recriminations as these matters, according to Liberal ideology, make a profound contribution to the ‘sum of human happiness’. In addition, citizens in a democratic society should be allowed to choose how they are governed by the State as this principle is the bedrock of democracy. Coupled with this, people are expected to be self-reliant, tolerant and to show respect for others. Cooperation at all levels of society, respect for human rights and social justice and the provision of welfare for the vulnerable are also basic principles of Liberal ideology. Critically important for Education is that the State should pursue policies aimed at providing opportunity for all irrespective of ‘race’, gender, socio-economic status, sexual preference and disability.
Social Democracy, described in the UK as the Third Way [21], is a relatively new ideology and has some overlap with Liberalism. The hallmark of Social Democracy is the concept of the
In countries where conservative ideology is highly influential, the
In the US the origins of this development can be found the federal report
In contrast to the above, Liberal ideology with its emphasis on the individual and alignment with the
Aims of pre-school education in Scotland [
These aims were subsequently incorporated into the national curriculum guidelines for children aged 3 to 5 and adopted by ECEC establishments in both the public and private sectors [27]. To the present day, the aims outlined in Figure 1 act as a yardstick for a ‘quality’ ECEC experience. They are fundamental to the recent re-structuring and integration of the school curriculum in Scotland referred to as the
The
The overwhelming challenge for ECEC in the modern world that is now required is to address the deep divisions, both social and economic, that have emerged in many countries throughout the word during the Age of Modernity and at the same time both to respect and celebrate diversity in a way that children come to understand how they can make a positive contribution to this process. The challenge is both exciting and daunting as it requires enlightened professionals, politicians and parents to engage in a new dialog informed by a fundamental awareness of the deep-seated problems facing humanity. But where to start? There is a very powerful case for ECEC being in the vanguard of educational reform.
First, over the past 30 years there has been several large-scale longitudinal studies which have reported on the long-term effects of ‘quality’ ECEC [29, 30, 31, 32]. The findings of these studies consistently show that young children’s experience of high quality ECEC has a long-lasting positive effect on their later opportunities and success both in schooling and in adulthood. Secondly, and more specifically, there are studies that demonstrate the economic benefits of ECEC particularly in terms of productivity and economic efficiency in the workplace [31]. Thirdly, recent developments in neuroscience, particularly in the field of social cognitive neuroscience, provide evidence that socio-emotional competence develops as a function of changes in the dynamic interaction between regulatory processes that lesson such reactions as stress and anxiety [33]. Fourthly, and very important, is the research in the field of health, both mental and physical well-being which shows that ECEC can help to prevent disease and mental instability [34].
It is now abundantly clear that, taken as a whole, this body of research and scholarship makes an immensely strong case for investment and reform in ECEC.
Drawing on the Swedish system of ECEC where there is a common educational experience for children in their pre-school years financed from public funds, the challenge for governments in the developed world is to reform the relationship between the public and private sectors in ECEC provision in countries where such a division exists. One example of a national government currently taking a policy initiative is in Scotland. The Scottish Government and local authorities have committed to making an unprecedented investment in ECEC through near doubling of the funded entitlement from August 2020 for all three- and four-year old children and eligible two-year olds in all ECEC sectors- public, private and voluntary [35].
Scotland has had a devolved administration since 1997 and currently has a minority Nationalist government which ideologically is liberal and centre-left politically. It is very committed to expanding and improving early learning and childcare (referred to as ELC in Scotland) by allocating considerable new resources to the sector.
Since the introduction of free part-time places 20 years ago for all three- and four-year old children subject to parental wishes, virtually all can now access two years of free ELC before the start of primary school at age 5 (see Table 1 below). The new policy also includes the provision of ELC for ‘eligible’ two-year old children. The criteria for such eligibility are aimed at those children who experience the greatest disadvantage from their circumstances and includes children from low socio-economic status families receiving State benefits who are often single-parent families with vulnerable children.
Type of setting | % |
---|---|
Local Authority nursery school/class | 62 |
Other local authority setting | 15 |
Private and voluntary providers | 23 |
Percentage of children in Scotland aged 5 by 2015 attending an ELC setting by type [32].
From Table 1 it can be seen that access to ELC in Scotland is very high. The problem, however, is not that places aren’t available but that places in the public sector are largely part-time (3 hours per day). Private sector provision tends to be open most of the day and throughout the year and is more compatible with the routine of working parents. The problem largely impacts on women either by limiting their scope for a successful career or by downloading stress in the management of their domestic arrangements.
With regard to the specific aspects of the policy [35] the principles and practice focus on the expansion and improvement of ELC services in public, private and voluntary provision. It intends to do this by requiring all providers of ELC services which enter into a contract with the local authority to meet new ELC National Standards (see Figure 2) in order for the private and voluntary sectors to access direct government funding for providing an ELC service for 1140 hours per year for each child who is admitted. Included in the 10 National Standards is the requirement for the private and voluntary sectors to provide a common educational experience consistent with the National Curriculum.
The list of National Standards for ELC provision in Scotland [
To ensure compliance with the above Standards the National Care Inspectorate (NCI) will make unannounced visits to ELC settings and publish reports which will be available in the public domain making them universally accessible. With regard to National Standard 3 in Figure 2, new arrangements are currently being developed to instigate joint inspections of all ELC settings between the NCI and Her Majesty’s Inspectorate for Education (HMIE). If a specific setting is considered unacceptable on any of the Standards, the NCI can require that the setting address its shortcomings within a given time period and has powers to close the setting altogether in acute circumstances.
The policy of the Scottish Government is a bold attempt to bring the private and public sectors of ECEC provision into close alignment whilst still recognizing the parents should be able to make choices for their children which are not based on their ability to pay expensive fees for high-status institutions in the child-care market. The new policy adopts a ‘funding follows the child approach’ whereby parents (and carers) can access their child’s funding entitlement from any ELC setting in the public, private or voluntary sectors. The criteria for choosing an ECEC setting for one’s child will now become wider and based more on the geographic location, the opening hours of the setting and the NCI inspection reports as opposed to family income.
The second major challenge for national and local governments is to instigate a root and branch review of national curriculum guidelines for ECEC with a view that the guidelines be re-structured. To do so, requires governments to outline what they regard as the primary purpose of ECEC. The detailed re-structuring should then be undertaken by representatives of the various stakeholder groups in ECEC.
In the modern world, the thinking associated with post-modernism is gathering momentum [36]. It is crucially relevant for ECEC [13]. At the onset of the Age of Modernity some 250 years ago the dominant intellectual challenge and inspiration at that time was to differentiate between rational/scientific thinking and thinking based on superstition rooted in religious dogma. It is a mode of thinking that has dominated the English- speaking world for over two centuries and still acts as a dominant driver for many people. The world now faces a new challenge, the challenge of post-modernism which requires us to differentiate between the ‘self’ and the ‘social’ in our understanding, awareness and behavior. ECEC is heavily implicated in the transition from modernity to postmodernism and carries an immense responsibility.
Central to this responsibility is the requirement to focus children’s learning to encompass the two concepts of social justice and social responsibility. Social justice encompasses three main themes: fairness, opportunity and respect and are axiomatic to how the adult world intersects with childhood. The challenge for ECEC settings is to make a public declaration that the principles of social justice are pursued in the setting in which children are encouraged to become aware about fairness, to take up new and challenging opportunities and to respect the views of others [25]. Such a declaration needs to be negotiated with the children’s parents as it contains sensitive and potentially threatening challenges to many parents whose mind-sets may be deeply rooted in a particular ideology outlined above. Keeping parents informed about all aspects of the setting is a vital part of effective communication [12], not least to offer advice about ensuring that their child is enthusiastically engaged in the learning process and is aware of the importance of social responsibility.
Throughout 2020 and well into 2021 the lack of social responsibility particularly in many western countries has become a matter of deep concern and deeply shameful. The rapid spread of the deadly virus covid 19 has taken place as a consequence of enormous number of people rejecting the scientific advice aimed at limiting the spread of the virus. Is this a failure of education on a massive scale such that acceptance of constraints on individual freedom in times of crisis has been abandoned? ECEC settings and professionals need to recognize that fundamental rethinking is required. The curriculum needs to be restructured to embrace social justice at the core. In addition, teachers need to become more aware about how the ‘hidden curriculum’ impacts on children’s subjectivity. The discourse that teachers use, often subconsciously, with children both individually and collectively, plays a significant role in shaping children’s social attitudes [37].
A critical issue in this transformation is the professional education of teachers. Initially, the selection of students for access to courses of initial teacher education (ITE) should be revisited such that those admitted be required to display a commitment to social justice. Specific courses in social justice should be included in the curriculum. Furthermore, the organization of ITE courses needs to be re-thought. Without too much upheaval, it should be possible to introduce new arrangements such that all ITE students attend the same classes and courses for at least the first year in order to acquire a common understanding of what it means to be a ‘teacher’ such as currently happens in Sweden [13].
Another challenge to ECEC professionals is the need for each ECEC centre to develop policies and practices that are inclusive of all children’s contemporary diverse characteristics.
It has become evident in many countries throughout the world that parents now understand the value of ECEC and want access to ECEC services for their young children before they start elementary school. This is a major change in social attitude from that 50 years ago when the education of young children was regarded as the sole responsibility of the family, principally mothers. Yet, under the influence of ne0liberalism, many parents are ignoring the long- term benefits of ECEC for their child’s psychological and social well-being for the possible short- term advantages which they think will lead to greater economic benefits for their child in the future [23].
However, even though their child may attend an ECEC setting, this does not mean that parents should take ‘a back seat’. Parents still have a responsibility to engage with their children in helping them to understand, be knowledgeable, be socially competent and gradually become aware of the wider world. The challenge to parents in supporting their children to be successful is to ‘raise your game’ through more meaningful engagement both with the child and the ECEC setting. Children learn a great deal about their identity and subjectivity from their parents in the first few years of life. The foundations of their social attitudes are subconsciously transmitted from parent to child through discourse that often contains deeply held values about the world at large [36]. This means that parents need to become more aware of how they interact with their children even at a casual level. All too often many parents with busy lives are content to have their children self-engaged with, for example, an electronic device to play games or watch a video over lengthy periods of time. Such action on the part of parents is a form of abuse of the parent–child relationship and can lead to an addiction which is socially disengaged.
Reading stories with children is another activity that is popular with many parents. However, the choice of stories is critical. Parents should not shy away from choosing stories that contain sensitive issues regarding race, gender, socio-economic status and even same-sex relationships as well as stories that feed children’s imagination. Such situations are ideal for helping children to learn how to regulate their socio-emotional learning and for parents to encourage children to reflect on the behavior of others as actors in the stories keeping in mind the principles of social justice and social responsibility.
Social responsibility can also be practiced in the family even when children are young.
Children should be encouraged to participate in domestic routines. Helping to plan and prepare meals and tidy up afterwards as collaborative activities are valuable situations for the effective socialization of children.
Parents can also help their child to establish social networks with other children and show an active interest in their child’s social relationships. A key aspect of children’s learning about relationships is their awareness of ‘others’. Parents have considerable influence in helping children to raise their consciousness concerning how their actions impact on others such that they are able to regulate their actions with friends, family members and strangers especially at the level of micro-social engagement.
It is becoming evident to many that the education of children, particularly young children, now faces a daunting challenge. The increasing social and economic divergence in the modern world is staggering and potentially a major threat to our stability and security. But can the key stakeholders in education recognize the challenge and embrace a commitment to adapt policies and practices to address a fundamental re-alignment in the mind-set of children in terms of their social attitudes and social justice? First, it requires an awareness that education is deeply implicated in efforts to bring about greater fairness, more opportunities for young people and respect for others. Teachers have a very considerable responsibility in their day-to-day engagements with children so they need to be persuaded not only that reform in a post-modernist context can be achieved but also that many current social attitudes and injustices must be challenged. Reform is possible, but it needs the understanding, the commitment and the vision in those empowered to instigate it. Second, it needs parents to become more aware about the power they exert over their children and to use that power in a more democratic way to promote social justice. Such is the challenge for the education of children in modern times.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr.",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Rheinmetall (Germany)",country:{name:"Germany"}}},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. 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The application of this test has significantly changed the practice of medical laboratories in which it is used for detection and quantification of molecules such as hormones, peptides, antibodies, and proteins. Various technical variants of this test can detect antigen (native or foreign) or antibody, determine the intensity of the immune response whether pathological or not; the type of induced immune response as well as the innate immunity potential; and much more. These capabilities, as well as the high sensitivity and robustness of the test and a small price, make it possible to quickly and reliably diagnose diseases in most laboratories. Besides, ELISA is a test that is also used in veterinary medicine, toxicology, allergology, food industry, etc. Despite the fact that it has existed for almost 50 years, different ELISA tests with different technical solutions are still being developed, which improves and expands the application of the this exceptional test. The aim of this chapter is to empower the rider to optimize, standardize and validate an enzyme linked immunosorbent assay.",book:{id:"9850",slug:"norovirus",title:"Norovirus",fullTitle:"Norovirus"},signatures:"Rajna Minic and Irena Zivkovic",authors:[{id:"325806",title:"Ph.D.",name:"Irena",middleName:null,surname:"Zivkovic",slug:"irena-zivkovic",fullName:"Irena Zivkovic"},{id:"325839",title:"Dr.",name:"Rajna",middleName:null,surname:"Minic",slug:"rajna-minic",fullName:"Rajna Minic"}]},{id:"56750",title:"Laboratory Approach to Anemia",slug:"laboratory-approach-to-anemia",totalDownloads:6255,totalCrossrefCites:2,totalDimensionsCites:4,abstract:"Anemia is a major cause of morbidity and mortality worldwide and can be defined as a decreased quantity of circulating red blood cells (RBCs). The epidemiological studies suggested that one-third of the world’s population is affected with anemia. Anemia is not a disease, but it is instead the sign of an underlying basic pathological process. However, the sign may function as a compass in the search for the cause. Therefore, the prediagnosis revealed by thorough investigation of this sign should be supported by laboratory parameters according to the underlying pathological process. We expect that this review will provide guidance to clinicians with findings and laboratory tests that can be followed from the initial stage in the anemia search.",book:{id:"5942",slug:"current-topics-in-anemia",title:"Current Topics in Anemia",fullTitle:"Current Topics in Anemia"},signatures:"Ebru Dündar Yenilmez and Abdullah Tuli",authors:[{id:"183998",title:"Ph.D.",name:"Ebru",middleName:null,surname:"Dündar Yenilmez",slug:"ebru-dundar-yenilmez",fullName:"Ebru Dündar Yenilmez"},{id:"209103",title:"Prof.",name:"Abdullah",middleName:null,surname:"Tuli",slug:"abdullah-tuli",fullName:"Abdullah Tuli"}]},{id:"33133",title:"Waist Circumference in Children and Adolescents from Different Ethnicities",slug:"waist-circumference-in-children-and-adolescents-from-different-ethnicities",totalDownloads:8023,totalCrossrefCites:4,totalDimensionsCites:7,abstract:null,book:{id:"642",slug:"childhood-obesity",title:"Childhood Obesity",fullTitle:"Childhood Obesity"},signatures:"Peter Schwandt and Gerda-Maria Haas",authors:[{id:"29867",title:"Prof.",name:"Peter",middleName:null,surname:"Schwandt",slug:"peter-schwandt",fullName:"Peter Schwandt"}]}],onlineFirstChaptersFilter:{topicId:"185",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82740",title:"Secondary Pneumothorax from a Surgical Perspective",slug:"secondary-pneumothorax-from-a-surgical-perspective",totalDownloads:4,totalDimensionsCites:0,doi:"10.5772/intechopen.105414",abstract:"Although less frequent than the primary spontaneous pneumothorax (PSP), secondary pneumothoraces (SP) are a common clinical problem with a wide range of severity, depending on the triggering cause(s) and patient clinical condition. By definition, an SP occurs in those patients with an underlying condition that alters the normal lung parenchyma and/or the visceral pleura and determines air entry in the pleural space (e.g., COPD) or, eventually, following trauma or invasive procedures (i.e., iatrogenic pneumothorax). Less frequent, yet described, is SP occurring in neoplastic patients or infectious ones. The gravity of an SP is directly correlated to the underlying cause and patients’ clinical conditions. For example, it may be a life-threatening condition in an end-stage COPD but less severe in a catamenial related syndrome. In this chapter, we are providing a surgical overview of the most relevant and updated information on etiology, incidence, pathophysiology, and management of secondary pneumothoraces.",book:{id:"11045",title:"Pleura - A Surgical Perspective",coverURL:"https://cdn.intechopen.com/books/images_new/11045.jpg"},signatures:"Simona Sobrero, Francesco Leo and Alberto Sandri"},{id:"80875",title:"Pneumothorax: A Concise Review and Surgical Perspective",slug:"pneumothorax-a-concise-review-and-surgical-perspective",totalDownloads:42,totalDimensionsCites:0,doi:"10.5772/intechopen.101049",abstract:"Pneumothorax is the collection of air in pleural cavity, which is commonly due to development of a communication between pleural space and alveolar space (or bronchus) or the atmosphere. In this chapter, we will discuss the various aetiologies of pneumothorax, the differences in their pathophysiology and the implications on the management of the disease. The chapter focusses on the surgical aspects in the management, the revolution brought in by video-assisted thoracoscopic surgery (VATS) and the advancement of the field by introduction of uniportal VATS and robotic-assisted thoracic surgery. The principles of management of catamenial pneumothorax are revisited. The chapter also throws light on the nuances of anaesthesia techniques and the latest developments are outlined. Lastly, a section is dedicated to COVID-19 associated pneumothorax and the approach to its management.",book:{id:"11045",title:"Pleura - A Surgical Perspective",coverURL:"https://cdn.intechopen.com/books/images_new/11045.jpg"},signatures:"Shilpi Karmakar"},{id:"79289",title:"Indwelling Pleural Catheters",slug:"indwelling-pleural-catheters",totalDownloads:86,totalDimensionsCites:0,doi:"10.5772/intechopen.100645",abstract:"Indwelling pleural catheters (IPC) are now being considered worldwide for patients with recurrent pleural effusions. It is commonly used for patients with malignant pleural effusions (MPE) and can be performed as outpatient based day care procedure. In malignant pleural effusions, indwelling catheters are particularly useful in patients with trapped lung or failed pleurodesis. Patients and care givers are advised to drain at least 3 times a week or in presence of symptoms i.e. dyspnoea. Normal drainage timing may lasts for 15–20 min which subsequently improves their symptoms and quality of life. Complications which are directly related to IPC insertion are extremely rare. IPC’s are being recently used even for benign effusions in case hepatic hydrothorax and in patients with CKD related pleural effusions. Removal of IPC is often not required in most of the patients. It can be performed safely as a day care procedure with consistently lower rates of complications, reduced inpatient stay. They are relatively easy to insert, manage and remove, and provide the ability to empower patients in both the decisions regarding their treatment and the management of their disease itself.",book:{id:"11045",title:"Pleura - A Surgical Perspective",coverURL:"https://cdn.intechopen.com/books/images_new/11045.jpg"},signatures:"Yuvarajan Sivagnaname, Durga Krishnamurthy, Praveen Radhakrishnan and Antonious Maria Selvam"},{id:"79221",title:"Surgical Challenges of Chronic Empyema and Bronchopleural Fistula",slug:"surgical-challenges-of-chronic-empyema-and-bronchopleural-fistula",totalDownloads:118,totalDimensionsCites:0,doi:"10.5772/intechopen.100313",abstract:"Chronic empyema has always been a clinical challenge for physicians. There is no standard procedure or treatment to deal with the situation, and multi-modality approach is often necessary. Surgical intervention plays a very crucial role in the treatment of chronic empyema. Since bronchopleural fistula is often seen in chronic empyema patients, therefore it should also be mentioned. In this chapter, the focus will be on the different treatment options, various surgical approaches, and the rationale behind every single modality. Certain specific entity will be included as well, such as tuberculosis infection, post lung resection empyema, and intrathoracic vacuum assisted closure system application. Even with the advancement of technology and techniques, chronic empyema management is still evolving, and we look forward to less traumatic ways of approach with better outcome in the future.",book:{id:"11045",title:"Pleura - A Surgical Perspective",coverURL:"https://cdn.intechopen.com/books/images_new/11045.jpg"},signatures:"Yu-Hui Yang"},{id:"78826",title:"Pneumothorax in Children",slug:"pneumothorax-in-children",totalDownloads:94,totalDimensionsCites:0,doi:"10.5772/intechopen.100329",abstract:"Pneumothorax is a common pleural disease worldwide and is defined as the free accumulation of air between visceral and parietal pleura. Pneumothorax can be spontaneous, iatrogenic, and traumatic. Although it is less common than adults, it is seen in about 1.1–4 per 100,000 per year in the childhood age group. In patients presenting with variable clinic according to the cause of etiology, diagnosis is confirmed on a PA chest radiograph, sometimes a computed tomography may be required. The management of pneumothorax is varying from conservative, over intermediate (chest tube drainage) to invasive methods (video-assisted thoracoscopic surgery—VATS, thoracotomy). Here, we planned to write a chapter that includes a text containing general information about pediatric pneumothorax, algorithms, and visual and clinical cases of the causes of pneumothorax in children, including age, etiology, and treatment approach of pneumothorax in children.",book:{id:"11045",title:"Pleura - A Surgical Perspective",coverURL:"https://cdn.intechopen.com/books/images_new/11045.jpg"},signatures:"Hatice Sonay Yalçın Cömert"},{id:"78760",title:"Bronchopleural Fistula after Pulmonary Resection: Risk Factors, Diagnoses and Management",slug:"bronchopleural-fistula-after-pulmonary-resection-risk-factors-diagnoses-and-management",totalDownloads:233,totalDimensionsCites:0,doi:"10.5772/intechopen.100209",abstract:"Bronchopleural fistula (BPF) after a pulmonary resection is rare with some of the most life-threatening consequences and a high mortality rate. Contamination of the pleural space resulting in empyema and spillage of the infected fluid into the remaining lung leading to respiratory distress remain the biggest concerns with BPF postoperatively. There are many patient characteristics and risk factors that can be evaluated to decrease the chance of a postoperative BPF. Presentation of BPF can be early or late with the late BPF more difficult to diagnosis and manage. Many options to treat BPF include surgical repair, conservative management, and endoscopic treatment.",book:{id:"11045",title:"Pleura - A Surgical Perspective",coverURL:"https://cdn.intechopen.com/books/images_new/11045.jpg"},signatures:"Kristina Jacobsen"}],onlineFirstChaptersTotal:8},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:108,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:141,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:123,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:22,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:11,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:"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"}}}},{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"}}}}]},series:{item:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403",scope:"Artificial Intelligence (AI) is a rapidly developing multidisciplinary research area that aims to solve increasingly complex problems. In today's highly integrated world, AI promises to become a robust and powerful means for obtaining solutions to previously unsolvable problems. This Series is intended for researchers and students alike interested in this fascinating field and its many applications.",coverUrl:"https://cdn.intechopen.com/series/covers/14.jpg",latestPublicationDate:"July 5th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:9,editor:{id:"218714",title:"Prof.",name:"Andries",middleName:null,surname:"Engelbrecht",slug:"andries-engelbrecht",fullName:"Andries Engelbrecht",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNR8QAO/Profile_Picture_1622640468300",biography:"Andries Engelbrecht received the Masters and PhD degrees in Computer Science from the University of Stellenbosch, South Africa, in 1994 and 1999 respectively. He is currently appointed as the Voigt Chair in Data Science in the Department of Industrial Engineering, with a joint appointment as Professor in the Computer Science Division, Stellenbosch University. Prior to his appointment at Stellenbosch University, he has been at the University of Pretoria, Department of Computer Science (1998-2018), where he was appointed as South Africa Research Chair in Artifical Intelligence (2007-2018), the head of the Department of Computer Science (2008-2017), and Director of the Institute for Big Data and Data Science (2017-2018). In addition to a number of research articles, he has written two books, Computational Intelligence: An Introduction and Fundamentals of Computational Swarm Intelligence.",institutionString:null,institution:{name:"Stellenbosch University",institutionURL:null,country:{name:"South Africa"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:6,paginationItems:[{id:"22",title:"Applied Intelligence",coverUrl:"https://cdn.intechopen.com/series_topics/covers/22.jpg",isOpenForSubmission:!0,editor:{id:"27170",title:"Prof.",name:"Carlos",middleName:"M.",surname:"Travieso-Gonzalez",slug:"carlos-travieso-gonzalez",fullName:"Carlos Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Carlos M. Travieso-González received his MSc degree in Telecommunication Engineering at Polytechnic University of Catalonia (UPC), Spain in 1997, and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. He won the “Catedra Telefonica” Awards in Modality of Knowledge Transfer, 2017, 2018, and 2019 editions, and awards in Modality of COVID Research in 2020.\n\nPublic References:\nResearcher ID http://www.researcherid.com/rid/N-5967-2014\nORCID https://orcid.org/0000-0002-4621-2768 \nScopus Author ID https://www.scopus.com/authid/detail.uri?authorId=6602376272\nScholar Google https://scholar.google.es/citations?user=G1ks9nIAAAAJ&hl=en \nResearchGate https://www.researchgate.net/profile/Carlos_Travieso",institutionString:null,institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"23",title:"Computational Neuroscience",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",isOpenForSubmission:!0,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null},{id:"24",title:"Computer Vision",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",isOpenForSubmission:!0,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. Papakostas has received a diploma in Electrical and Computer Engineering in 1999 and the M.Sc. and Ph.D. degrees in Electrical and Computer Engineering in 2002 and 2007, respectively, from the Democritus University of Thrace (DUTH), Greece. Dr. Papakostas serves as a Tenured Full Professor at the Department of Computer Science, International Hellenic University, Greece. Dr. Papakostas has 10 years of experience in large-scale systems design as a senior software engineer and technical manager, and 20 years of research experience in the field of Artificial Intelligence. Currently, he is the Head of the “Visual Computing” division of HUman-MAchines INteraction Laboratory (HUMAIN-Lab) and the Director of the MPhil program “Advanced Technologies in Informatics and Computers” hosted by the Department of Computer Science, International Hellenic University. He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. Dr Ventura also holds the positions of Affiliated Professor at Virginia Commonwealth University (Richmond, USA) and Distinguished Adjunct Professor at King Abdulaziz University (Jeddah, Saudi Arabia). Additionally, he is deputy director of the Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI) and heads the Knowledge Discovery and Intelligent Systems Research Laboratory. He has published more than ten books and over 300 articles in journals and scientific conferences. Currently, his work has received over 18,000 citations according to Google Scholar, including more than 2200 citations in 2020. In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. 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He is the author of several scientific articles, book chapters, and books.",institutionString:"University of Hassan II Casablanca",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"7",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"University of Hassan II Casablanca",institutionURL:null,country:{name:"Morocco"}}},equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7060",title:"Gingival Disease",subtitle:"A Professional Approach for Treatment and Prevention",coverURL:"https://cdn.intechopen.com/books/images_new/7060.jpg",slug:"gingival-disease-a-professional-approach-for-treatment-and-prevention",publishedDate:"October 23rd 2019",editedByType:"Edited by",bookSignature:"Alaa Eddin Omar Al Ostwani",hash:"b81d39988cba3a3cf746c1616912cf41",volumeInSeries:4,fullTitle:"Gingival Disease - A Professional Approach for Treatment and Prevention",editors:[{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",institutionURL:null,country:{name:"India"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7572",title:"Trauma in Dentistry",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7572.jpg",slug:"trauma-in-dentistry",publishedDate:"July 3rd 2019",editedByType:"Edited by",bookSignature:"Serdar Gözler",hash:"7cb94732cfb315f8d1e70ebf500eb8a9",volumeInSeries:3,fullTitle:"Trauma in Dentistry",editors:[{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",institutionURL:null,country:{name:"Turkey"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7139",title:"Current Approaches in Orthodontics",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7139.jpg",slug:"current-approaches-in-orthodontics",publishedDate:"April 10th 2019",editedByType:"Edited by",bookSignature:"Belma Işık Aslan and Fatma Deniz Uzuner",hash:"2c77384eeb748cf05a898d65b9dcb48a",volumeInSeries:2,fullTitle:"Current Approaches in Orthodontics",editors:[{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"6668",title:"Dental Caries",subtitle:"Diagnosis, Prevention and Management",coverURL:"https://cdn.intechopen.com/books/images_new/6668.jpg",slug:"dental-caries-diagnosis-prevention-and-management",publishedDate:"September 19th 2018",editedByType:"Edited by",bookSignature:"Zühre Akarslan",hash:"b0f7667770a391f772726c3013c1b9ba",volumeInSeries:1,fullTitle:"Dental Caries - Diagnosis, Prevention and Management",editors:[{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",institutionString:"Gazi University",institution:{name:"Gazi University",institutionURL:null,country:{name:"Turkey"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},subseriesFiltersForPublishedBooks:[{group:"subseries",caption:"Prosthodontics and Implant Dentistry",value:2,count:3},{group:"subseries",caption:"Oral Health",value:1,count:6}],publicationYearFilters:[{group:"publicationYear",caption:"2022",value:2022,count:3},{group:"publicationYear",caption:"2020",value:2020,count:2},{group:"publicationYear",caption:"2019",value:2019,count:3},{group:"publicationYear",caption:"2018",value:2018,count:1}],authors:{paginationCount:229,paginationItems:[{id:"318170",title:"Dr.",name:"Aneesa",middleName:null,surname:"Moolla",slug:"aneesa-moolla",fullName:"Aneesa Moolla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/318170/images/system/318170.png",biography:"Dr. Aneesa Moolla has extensive experience in the diverse fields of health care having previously worked in dental private practice, at the Red Cross Flying Doctors association, and in healthcare corporate settings. She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\r\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\r\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Orthodontist, Assoc Prof in the Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. 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We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. 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