\r\n\tWith the discovery of more unconventional heavier crude and alternative hydrocarbon sources, primary upgrading or cracking of the oil into lighter liquid fuel is critical. With increasing concern for environmental sustainability, the regulations on fuel specifications are becoming more stringent. Processing and treating crude oil into a cleaner oil with better quality is equally important. Hence, there has been a relentless and continuous effort to develop new crude upgrading and treating technologies, such as various catalytic systems for more economical and better system performance, as well as cleaner and higher-quality oil.
\r\n
\r\n\tThis edited book aims to provide the reader with an overview of the state-of-the-art technologies of crude oil downstream processing which include the primary and secondary upgrading or treating processes covering desulfurization, denitrogenation, demetallation, and evidence-based developments in this area.
",isbn:"978-1-80356-681-8",printIsbn:"978-1-80356-680-1",pdfIsbn:"978-1-80356-682-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"808b0ddfb3b92e0636ae44a83ef7dbd9",bookSignature:"Dr. Ching Thian Tye",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11542.jpg",keywords:"Crude Oil Properties, Hydrocracking, Catalytic Cracking, Coking, Visbreaking, Thermal Cracking, Hydroprocessing, Hydrodesulfurization, Desulfurization, Denitrogenation, Demetallation, Dearomatization",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 22nd 2022",dateEndSecondStepPublish:"April 19th 2022",dateEndThirdStepPublish:"June 18th 2022",dateEndFourthStepPublish:"September 6th 2022",dateEndFifthStepPublish:"November 5th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Associate professor at the School of Chemical Engineering in Universiti Sains Malaysia and dedicated researcher in fuel-related catalytic process and chemical reaction engineering. 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\n
1. Introduction
\n
Childhood traumatic experiences are known to have strong and lasting consequences on the physical, mental and reproductive health of victims as well as confining them to low mental health in adulthood [1]. A body of researches largely documented the severe and long-lasting effects of the adverse childhood experiences (ACEs) on the biological and psychological development of victims [1, 2], highlighting severe impairments in stress regulation and socio-emotional development. Indeed, early interpersonal traumas expose victims to attachment disorganization and progressive deterioration in the self-worth from the first and most vulnerable stages of a child’s development [3].
\n
Moreover, studies reported a significant odd-ratio for psychiatric disorders in adulthood, including major depression, panic disorder and bulimia nervosa in sexually abused victims [4]. Adults’ at-risk behaviors, such as substance abuse and dependence, are twice as common among victims, compared to the general population [5], and a major risk for sexual behaviors as well as for re-victimization is also largely documented [6–8].
\n
Complex trauma, referring to children’s experiences of multiple traumatic events that occur within the caregiving system [9], has significant long-lasting effects on brain maturation. Structural and functional abnormalities are reported in abused children, namely reduction in the volume of the orbitofrontal cortex and over reactivity of the amygdala [10]. Both areas are of fundamental importance in emotional and stress responses, which display atypical functioning in abused children from the earliest stages of life [11].
\n
Child maltreatment and adverse childhood experiences are a common occurrence. In 2013, 9.1 per 1000 children in the USA known to child protective services (CPS) had been victims of abuse and neglect experiences [12]. In Europe, more than 18 million children are estimated to suffer from maltreatment, as reported by the World Health Organization [13]. In particular, a prevalence of 9.6% for sexual abuse, 22.9% for physical abuse and 29.1% for mental or emotional abuse is reported. In Italy, around 9.5% per 1000 children and adolescents are subject to some form of violence in childhood [14]; the data support the international portrait.
\n
One of the most studied effects of traumatic experiences in childhood is post-traumatic stress disorder (PTSD). Post-traumatic stress disorder is classified as a “trauma and stress-related disorder” in the new Diagnostic and Statistical Manual of Mental Disorders 5 (American Psychological Association, 2013). PTSD represents the most frequent consequence of interpersonal trauma histories [15], with 48–85% of childhood abuse survivors developing PTSD symptoms across life [16, 17].
\n
Despite the fact that studies have mainly analyzed only the stress-related consequences of physical and sexual traumatic experiences, emotional abuse and neglect have also been shown to be associated with the development of PTSD symptoms [18].
\n
The exposure to traumatic experiences is a necessary but not sufficient condition for the development of PTSD. According to Van der Kolk, to consider a linear relationship between early traumatic experiences and adult psychiatric disorders represents an oversimplification [19]; underlying mechanisms and victims’ characteristics involved in the association between traumatic experiences and adult psychopathology is still a matter of on-going study.
\n
Different studies report that psychopathological outcomes of childhood abuse are related to the quality of early attachment relationship. Around 80% of physical and emotional abuses during childhood are perpetrated by parents or close relatives [20], whom are supposed to be the primary and the first external source of emotion and stress regulation. Indeed, the parent-child relationship represents a key feature for the long-term ability of auto-regulation and social support [19, 21].
\n
According to the attachment theory, the quality of early interactions between the caregiver and his/her child determines the child’s immediate emotional response to stress and plays a decisive and lasting role in the latter’s emotion-regulation ability [22–26]. Through the daily over-repetition of the interactive exchanges, a set of internal working models (IWMs) develops and becomes internalized as a patrimony of personal schema of self and of the other. The internal working models enable people to regulate emotions in interactions and to cope with stressful interpersonal situations across the life. These personal schemas are entirely developed during the first years of a child’s life and become relatively stable across the life span. As a consequence, they represent a personal guide influencing interactions and relationships in adulthood [27].
\n
Childhood experiences of abuse and maltreatment constitute a fearful and dangerous developmental environment, in which the intimacy and proximity with the caregiver produce a sense of fear instead of a feeling of “felt security,” thus provoking a disorganization of the attachment system. Indeed, child abuse victims show significantly higher rates of attachment insecurity (70–100%) compared to the general population (30%) [28]. In addition, fearful and angry-dismissive patterns are the most associated with interpersonal traumatic experiences [29].
\n
Furthermore, neglectful caregiving, even in the absence of physical and sexual abuse, denies the child the needed coherent external support. Through the inconsistent and neglectful responses of the caregiver, children develop interpersonal strategies characterized by anxious and/or avoidant behaviors [30].
\n
As a consequence, the adverse childhood experiences shape the interpersonal strategies characterizing adult relationships. In particular, high levels of dependency or avoidance in social relationship as well as insecurity, suspiciousness, isolation, emotional distress and low intimacy in close relationships are reported as a consequence of traumatic experiences [19, 31, 32]. Indeed, the core concept of the attachment theory is that childhood attachment quality constitutes the paradigm for forming the adult romantic relationship [33]. Romantic attachment represents a personal system of beliefs and expectations on the availability and the responsiveness of the partner. It is based on the childhood experiences of being loved and felt security in the relationship with the caregiver [33], and it guides the interactive exchanges between partners. People differently experience and manage intimacy with the partner according to their own early experiences of caregiver’s proximity and responsiveness. In particular, insecure adults are worried of being abandoned or being too close to and dependent on the partner [33]. According to Hazan and Shaver [33], a lack of self-worth and a negative model of self tend to produce anxiety for not being loved and being abandoned; in contrast, a negative view of the other leads to mistrust feelings, expressed by avoidant behaviors and fear of intimacy.
\n
Adult and adolescent victims of abuse have higher attachment insecurity and display more anxiety and/or avoidance in close relationships [15, 34]. In particular, 70% of female victims of sexual abuse have insecure romantic attachments [35]. Lower satisfaction and couple adjustment are also reported in female victims compared to the women who were not abused [34, 36, 37]. In addition, high levels of insecurity in adult attachments and romantic attachments are reported to be associated with increased distress and psychopathology, in particular depression, anxiety, substance abuse and post-traumatic stress disorder [35, 38, 39].
\n
The attachment patterns characterized by insecure or negative IWMs seem to increase the risk of a post-traumatic stress disorder and promote post-traumatic symptoms [38, 40]. In contrast, secure attachment is reported to be a protective factor in adult trauma survivors, moderating the relationship between a traumatic event and the development of PTSD.
\n
Different studies confirm that insecure schema of self and the other generate interpretation biases in interpersonal stressful situations. This mechanism leads to dysfunctional responses characterized by hyper-activation or deactivation of emotion regulation [30, 41]. In particular, the attachment patterns characterized by high levels of anxiety are likely to display hyper-activation of emotional and behavioral response to stress, causing an exaggerated seeking of proximity. In contrast, people with avoidant attachment deactivate the interpersonal strategies of stress response and suppress the search for support [42]. As a consequence, attachment serves as a regulatory system for the stress response; a mental representation of the other’s unresponsiveness during stressful situations can be the mechanism responsible for the increased vulnerability to post-traumatic symptoms [42].
\n
In both PTSD and insecure attachments, there is a lack of security in social and interpersonal contexts. Indeed, people suffering from PTSD report feelings of distrust and a state of anxious apprehension which impedes them from having satisfying interpersonal relationships [43].
\n
As a consequence, both the difficulties in emotion regulation and the lack of interpersonal security represent key variables in association with insecure romantic attachment and post-traumatic stress disorder in victims of childhood traumatic experiences.
\n
Up until now, there are only a few studies investigating the relationship between romantic attachment and the PTSD symptoms in childhood trauma victims. Hence, further studies are needed in order to examine the role played by anxiety and avoidance on the development and the severity of the post-traumatic stress disorder in adult victims of interpersonal traumatic experiences.
\n
Available studies in this field suggest mediating or moderating role for social support, emotion regulation and coping strategies [30]. Few studies showed that romantic attachment styles characterized by high levels of anxiety and avoidance influence the relationship between early traumatic experiences and the development of psychopathology, including post-traumatic stress disorder [44–46]. Another study [47] observed that insecure attachment mediated the relationship between childhood trauma and somatization in adulthood. Other studies [48, 49] reported that adult attachment moderates the association between childhood experiences of abuse and depressive symptoms as well as PTSD in adulthood.
\n
Yet, in other studies [20, 50] it was established that an association between insecure attachment and greater number of PTSD in adult women victims of child sexual abuse exists. Moreover, the ability to maintain closeness in intimate relationships is found to mediate the association between child sexual trauma and global psychological functioning [38].
\n
Finally, all these studies have investigated romantic attachment in clinical samples, while no research has studied the contribution of attachment style to the association between post-traumatic stress disorder and childhood traumatic experiences in a general population [51]. This shortcoming of the available literature represents the starting point for our study.
\n
\n
\n
2. Aims
\n
The present study aims to investigate a nonclinical sample of female students: (1) the prevalence of PTSD in adulthood; (2) the association between reported childhood traumatic experiences and the presence of post-traumatic stress disorders in adulthood and the role played by romantic attachment.
\n
\n
\n
3. Method
\n
The sample is composed by 327 female students from different faculties of the University of Padova: 58.4% from Psychology, 17.1% from Educational Sciences, 9.5% from International Economy, 6.7% from Social Services, 5.2% from Human Rights and Multi-Governance, 1.5% from Communication Strategies, and 1.5% from Engineering.
\n
Complete demographics of the sample are displayed in Table 1.
\n
The participants were recruited on a voluntary basis and were part of a broader study on early traumatic experiences and adult psychological outcomes. All participants signed a consent form and no compensation was given for participation.
\n
\n
3.1. Measures
\n
Participants completed the Childhood Trauma Questionnaire-Short Form, CTQ-SF, [52] in order to assess the presence and severity of childhood traumatic experiences; the Experience in Close Relationship-Revised, ECR-R, [53] for the evaluation of the romantic attachment; and the Post-traumatic Checklist for DSM-5, PCL-5 [54] for the post-traumatic stress disorder diagnosis.
\n
The Childhood Trauma Questionnaire-Short Form (CTQ-SF; Bernstein et al. [52]) is a self-report questionnaire used to assess retrospectively the frequency and severity of different childhood experiences of abuse (emotional, physical, sexual) and neglect (emotional, physical). The short form consists of 28 items, scored on a 5-point (Never True-Very Often True, when growing up) Likert scale. Twenty-five items are equally distributed among five clinical scales: Physical Abuse, Emotional Abuse, Sexual Abuse, Physical Neglect and Emotional Neglect. Three items assess the tendencies of responders to minimize or deny negative childhood experiences, composing the minimization/denial scale. In the present study, the Italian version of CTQ-SF, translated by Petrone and colleagues [55], was administered. The original study of Bernstein [52] demonstrated good internal consistency reliability for each of the CTQ-SF scales, across four heterogeneous clinical and not clinical samples. Cronbach’s α ranged respectively from 0.83 to 0.86 for Physical Abuse, 0.84 to 0.89 for Emotional Abuse, 0.92 to 0.95 for Sexual Abuse; 0.61 to 0.78 for Physical Neglect and 0.85 to 0.91 for Emotional Neglect. In particular, in the community sample the reliability ranged from α = 0.61 for the Physical Neglect to α = 0.92 for the Sexual Abuse. For the Italian version, the CTQ-SF showed reliable psychometrics, with good reliability and confirmed structure validity (Sacchi, Simonelli, in preparation). In the present study, the Cronbach’s α ranged from 0.51 for Physical Neglect to 0.90 for the Sexual Abuse, confirming that Physical Neglect represents the less reliable scale of the self-report.
\n
\n\n
\n
Age
\n
23.09 (2.98)
\n
\n
\n
Ethnicity
\n
\n
\n
\n
Italian
\n
311 (96.3%)
\n
\n
\n
Marital status
\n
\n
\n
\n
Single
\n
101 (31.1%)
\n
\n
\n
Involved
\n
202 (62.2%)
\n
\n
\n
Living together
\n
15 (4.6%)
\n
\n
\n
Married
\n
6 (1.8%)
\n
\n
\n
Separated/divorced
\n
1 (0.3%)
\n
\n
\n
Widow
\n
0%
\n
\n
\n
Education
\n
\n
\n
\n
College
\n
58 (17.8%)
\n
\n
\n
Professional high school
\n
7 (2.1%)
\n
\n
\n
Bachelor degree
\n
254 (77.9%)
\n
\n
\n
Master degree
\n
4 (1.2%)
\n
\n
\n
Postgraduate degree
\n
2 (0.6%)
\n
\n
\n
PhD
\n
1 (0.3%)
\n
\n\n
Table 1.
Demographics of the sample (N = 327).
\n
The Experiences in Close Relationships Scale-Revised (ECR-R; Fraley et al. [53]; Italian version Calvo, 2008) is a 36-item questionnaire that measures the adult romantic attachment style. Respondents are given a description of a possible attitude toward relationships and asked to rate them on a 7-point Likert scale, ranging from “strongly disagree” to “strongly agree.” The ECR-R contains two subscales that measure orthogonal dimensions of adult romantic attachment: attachment avoidance and attachment anxiety; each dimension is measured by summing 18 items. The ECR-R presented excellent psychometric properties in its Italian version. In the cross-cultural study of Calvo [56], the Cronbach’s α was 0.93 for the avoidance and 0.88 for the anxiety. In the present study, the internal consistency reliability of the ECR-R was α = 0.93 for the attachment avoidance scale and α = 0.90 for the attachment anxiety scale.
\n
The Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5; Weathers et al. [54]) is a 20-item self-report for the assessment of current post-traumatic stress disorder symptoms. The PCL-5 is developed from the PCL, and the 20 items correspond to the 20 symptoms describing the diagnosis of PTSD in the Diagnostic and Statistical Manual for Mental Disorders V version [57]. Since no Italian version for the PCL-5 is currently available, in the present study the original version was translated, using the back-translation method [58]. The 20 items belong to four sub-scales representing different clusters of the diagnosis of post-traumatic stress disorder. The severity of each class of symptoms is obtained by the sum of the scores within each cluster. For a provisional PTSD diagnosis and in order to have cutoff scores for the evaluation of symptoms’ severity, items score 2 (moderately) or higher are considered as symptoms. In particular, the PCL-5 diagnosis requires at least: 1 B item, 1 C item, 2 D items and 2 E items score 2 or higher. Preliminary validation work proposes the overall cutoff point of 38 for the PTSD diagnosis, as “reasonable” http://www.ptsd.va.gov/. The PCL was largely examined, demonstrating excellent psychometric properties [59], while less information is available on PCL-5. Two recent studies demonstrate high internal consistency, with Cronbach’s α of 0.94 and 0.95. In the present study, the internal consistency reliability result scored high for each cluster and for the overall measure. In particular, the overall Cronbach’s α was 0.93.
\n
\n
\n
\n
4. Data analyses
\n
First, means, standard deviations and percentile ranks have been calculated for the distribution of PCL-5 scores, in order to attest the rate of Italian female young students showing current PTSD symptoms above the cutoff point. The PCL-5 provisional diagnosis for PTSD was established following the indication of the National Centre for PTSD http://www.ptsd.va.gov/. Namely, it reflects the DSM-5 diagnostic rules according to which are required: at least 1 item in Cluster B scored above 2 point; at least 1 item in Cluster C above 2; at least 2 items above 2 in Cluster D; and 2 items above 2 in Cluster E.
\n
Second, in order to examine the relationship between childhood traumatic experiences, romantic attachment and current post-traumatic symptoms, correlation analyses have been preliminary done on all dimensions and scales of the three measures. Then, moderation and mediation effects have been studied. The hypotheses are displayed in Figures 1 and 2.
\n
In order to study moderation effects, a hierarchical regression analysis was built, in accordance with Baron and Kenny recommendations [60]. The interaction between predictors and moderators was created by multiplying CTQ-SF five scales and the two dimensions of ECR-R. In the Step 1, predictors (childhood traumatic experiences) and moderators (avoidance and anxiety) were entered for direct effects analyses; in Step 2, variables of the previous step were considered along with the ten interaction variables for moderating effects, as suggested by Frazier and Barron [61].
\n
Figure 1.
Moderation model of childhood traumatic experiences, romantic attachment and PTSD.
Figure 2.
Mediation model of childhood traumatic experiences, romantic attachment and PTSD.
\n
For the mediation effect hypothesized, a path analysis was performed using LISREL 8.8 [62]. PCL-5 total score has been used as dependent variable and the five scales of the CTQ-SF as independent variables. Avoidance and anxiety in romantic attachment have been considered as mediator variables. In a first saturated model, all the five scales of the CTQ-SF were supposed to have both direct and mediated effects on the post-traumatic symptoms. Secondly, from first results, a second model has been performed including the clinical scales of CTQ-SF presenting significant direct and/or mediated effects in the first model.
\n
\n
\n
5. Results
\n
Descriptive statistics of the variables are presented in Table 2.
\n\n
\n
Measures
\n
Means
\n
Standard deviation
\n
Min
\n
Max
\n
\n\n\n
\n
Childhood Trauma Questionnaire-Short Form (CTQ-SF)
\n
\n
\n
Emotional Abuse
\n
6.62
\n
2.601
\n
5
\n
22
\n
\n
\n
Physical Abuse
\n
5.42
\n
1.490
\n
5
\n
19
\n
\n
\n
Sexual Abuse
\n
5.29
\n
1.423
\n
5
\n
17
\n
\n
\n
Emotional Neglect
\n
8.92
\n
3.829
\n
5
\n
24
\n
\n
\n
Physical Neglect
\n
5.67
\n
1.393
\n
5
\n
16
\n
\n
\n
Experience in Close Relationship-Revised(ECR-R)
\n
\n
\n
Avoidance
\n
42.13
\n
18.181
\n
8
\n
99
\n
\n
\n
Anxiety
\n
54.09
\n
18.832
\n
19
\n
118
\n
\n
\n
Post-traumatic Checklist for DSM-5 DSM-5 (PCL-5)
\n
\n
\n
Total PTSD score
\n
18.21
\n
13.699
\n
0
\n
66
\n
\n\n
Table 2.
Descriptive statistics of CTQ-SF, ECR-R, PCL-5 (N = 327).
\n
\n
5.1. Prevalence of PTSD symptoms
\n
Table 3 shows percentile ranks of PCL-5 and the rate of subjects exceeding cutoff point for the overall PTSD measure.
\n\n
\n
Measure (C.O.)
\n
% above C.O.
\n
25th percentile
\n
50th percentile
\n
75th percentile
\n
90th percentile
\n
\n\n\n
\n
PCL-5 total score (38)
\n
9.5
\n
7
\n
15
\n
27
\n
37
\n
\n
\n
Provisional diagnosis (DSM V*)
\n
34.9%
\n
\n\n
Table 3.
PCL-5 percentile scores.
C.O., cutoff.
*The provisional diagnosis is calculated considering: at least 1 item of Cluster B scored above 2 point; at least 1 item of Cluster C above 2;, at least 2 items above 2 in Cluster D and 2 items above 2 in Cluster E.
\n
\n
\n
5.2. Moderating role of romantic attachment
\n
Table 4 presents the hierarchical regression analyses results.
\n
Results from the hierarchical regression analyses showed that PTSD symptoms are significantly predicted using childhood traumatic experiences.
\n
In particular, in the Model 1, both the Emotional Abuse (β = 0.198; p = 0.01) and Emotional Neglect (β = 0.148; p = 0.03) show significant direct effects on PTSD symptoms; moreover, the physical categories of traumatic experiences (abuse and neglect), display negative effects on PTSD, respectively, with β = −0.136; p = 0.03 and β = −0.170; p = 0.01.
\n
As regards the romantic attachment, anxiety shows a direct effect on the post-traumatic stress symptoms, β = 0.286; p = 0.00, while no effects have been found for the avoidance. Globally, the R2 of the first model indicates that childhood traumatic experiences and the romantic attachment account for the 22.7% of PTSD variance.
\n
\n\n
\n
Measures
\n
Model 1
\n
Model 2
\n
\n
\n
\n
β
\n
SE
\n
B
\n
SE
\n
\n\n\n
\n
Step 1
\n
\n
\n
Emotional Abuse
\n
0.198**
\n
0.390
\n
0.262**
\n
0.434
\n
\n
\n
Physical Abuse
\n
−0.136*
\n
0.576
\n
−0.147*
\n
0.649
\n
\n
\n
Sexual Abuse
\n
0.087
\n
0.530
\n
0.083
\n
0.706
\n
\n
\n
Emotional Neglect
\n
0.148*
\n
0.245
\n
0.133
\n
0.257
\n
\n
\n
Physical Neglect
\n
−0.170**
\n
0.631
\n
−0.178**
\n
0.671
\n
\n
\n
Avoidance
\n
0.105
\n
0.044
\n
0.124*
\n
0.046
\n
\n
\n
Anxiety
\n
0.286**
\n
0.042
\n
0.265***
\n
0.044
\n
\n
\n
Step 2
\n
\n
\n
Emotional Abuse × Anxiety
\n
\n
\n
−0.150
\n
1.109
\n
\n
\n
Emotional Abuse × Avoidance
\n
\n
\n
0.058
\n
1.051
\n
\n
\n
Physical Abuse × Anxiety
\n
\n
\n
0.104
\n
1.042
\n
\n
\n
Physical Abuse × Avoidance
\n
\n
\n
−0.025
\n
1.383
\n
\n
\n
Sexual Abuse × Anxiety
\n
\n
\n
0.079
\n
0.964
\n
\n
\n
Sexual Abuse × Avoidance
\n
\n
\n
−0.103
\n
1.287
\n
\n
\n
Emotional Neglect × Anxiety
\n
\n
\n
−0.019
\n
0.972
\n
\n
\n
Emotional Neglect × Avoidance
\n
\n
\n
−0.032
\n
0.989
\n
\n
\n
Physical Neglect × Anxiety
\n
\n
\n
0.094
\n
1.148
\n
\n
\n
Physical Neglect × Avoidance
\n
\n
\n
−0.027
\n
1.174
\n
\n
\n
Intercept
\n
3.835
\n
3.971
\n
3.655
\n
5.110
\n
\n
\n
R2
\n
0.227
\n
0.253
\n
\n\n
Table 4.
Hierarchical regression analyses: direct and moderating effect on PTSD symptoms.
*p < 0.05; **p < 0.01; ****p < 0.001.
\n
In the Model 2, results show no moderating effects of anxiety and avoidance dimensions, with interaction variables presenting no significant weights. Among childhood traumatic experiences, Emotional Abuse (β = 0.262; p = 0.00), Physical Abuse (β = −0.147; p = 0.04) and Physical Neglect (β = −0.178; p = 0.01) remain significant predictors, while Emotional Abuse shows no significant association with post-traumatic symptoms. In particular, Emotional Abuse has a positive effect, while Physical Abuse and Neglects present negative influences. With regard to romantic attachment, in the second model, both anxiety and avoidance display direct significant effects on PTSD overall symptoms, respectively, β = 0.265; p = 0.00 for anxiety and β = −0.124; p = 0.04 for avoidance. The R2 shows that Model 2 accounted a small (2.6%) nonsignificant percentage of additional variance of PTSD.
\n
\n
\n
5.3. Mediating role of romantic attachment
\n
Results of the first saturated model tested show the childhood traumatic experiences to have mainly direct effects on PTSD symptoms’ severity.
\n
From the results of the first model, a second path analysis was performed, removing Sexual Abuse and testing the direct effects of Emotional Abuse, Emotional and Physical Neglect. Moreover, in the second model, the effect of Physical Abuse and Emotional Neglect on avoidance and the effect of Physical Neglect on anxiety were tested.
\n
Figure 3.
Results of mediation analyses.
\n
For both models, the overall fit was provided by different goodness-of-fit indices, while the path coefficients estimated the relative effect of one variable on another. The goodness-of-fit indices, following Schermelleh and colleagues [63] recommendations, were: the Non-normed Fit Index (NNFI) and the Comparative Fit Index (CFI), both ranging from 0 to 1 with values close to 1 indicating good fit. The root mean square error of approximation (RMSEA) was considered, following Browne and Cudec [64] indications, that is: ≤0.05 considered as a good fit, between 0.05 and 0.08 as an adequate fit, and between 0.08 and 0.10 as a mediocre fit, whereas values >0.10 are considered not acceptable.
\n
Chi-square of the second model was 6.84 df = 6; p = 0.34. Considering the definition of fit, all indices show a good fit, with NNFI and CFI equal to 1 and RMSEA 0.021.
\n
Path coefficients indicate significant direct and mediating effects. In particular, in the second model, anxiety and avoidance mediate the effect of Emotional Neglect on PTSD (β = 0.12) and avoidance shows a tending to significance mediation of Physical Abuse on PTSD (β = −0.02; p = 0.091).
\n
For the direct effects, Emotional Abuse shows significant direct effect (β = 0.14) on PTSD; Physical Abuse shows no direct influence on PTSD, but a significant negative effect on avoidance (β = −0.15). Emotional Neglect has direct effect on PTSD as well as on avoidance and anxiety, respectively 0.16, 0.34 and 0.27. The Physical Neglect only fits negatively to PTSD symptoms (−0.16).
\n
Results of the mediation analyses are presented in Figure 3.
\n
\n
\n
\n
6. Discussion
\n
The first aim of this study was to explore preliminary descriptive data on the presence of significant post-traumatic symptoms in nonclinical female students attending courses at the University of Padova. Moreover, the purpose of the present study was to analyze the relationship between childhood experiences of interpersonal traumas and the presence of current post-traumatic stress disorder symptoms in an Italian sample of students. More precisely, this study tested whether romantic attachment is a significant moderator and/or mediator in the relationship between traumatic experiences and current PTSD symptoms.
\n
\n
6.1. PTSD prevalence
\n
The first objective of the study was to provide preliminary descriptive data on PTSD in Italian female students. Although university students are considered high functioning samples, results highlight that around 10% of female students attending courses at the University of Padova exceed the cutoff point indicating a potential for the presence of post-traumatic symptoms. A high percentage of them, 34.9%, satisfy DSM-5 criteria for a provisional clinical diagnosis of post-traumatic stress disorder. This result supports the on-going investigations to assess long-term effects of childhood adverse experiences as well as other factors influencing post-traumatic manifestations.
\n
\n
\n
6.2. Moderating effect
\n
With regard to the study of a moderating effect played by anxiety and avoidance, the aim of the study was to observe whether the long-term effects of childhood traumatic experiences can be altered, namely increased, under two different conditions: higher levels of anxiety in close relationship and higher levels of avoidance of intimacy. Our results do not support this hypothesis.
\n
In the hierarchical regression, no interaction between traumas and romantic attachment significantly predicted the severity of post-traumatic symptoms. As a consequence, the present study suggests that romantic attachment is not a significant moderator in the association between childhood traumatic experiences and PTSD in adulthood. This result is in line with a recent study on the moderating role of partner emotional support and negative interaction [65], in which authors found no moderation and observed that the stress buffering theory does not explain the role of social support in distress. Our results may confirm that couple attachment does not buffer the effect of childhood trauma on post-traumatic symptoms in adulthood. However, the authors [65] suggest that further investigations should run both moderation and mediation analyses in order to have different functional understanding on the role of social support variables.
\n
A previous study [50] found a moderation of the quality of romantic relationship on the association between sexual abuse experience and depression. However, methodological limitations linked to sampling and measure may account for the absence of the same result in our study.
\n
Direct effects show that both anxiety and avoidance represent significant predictors of PTSD. Moreover, when all conditions are controlled, students with higher levels of emotional abuse present higher PTSD symptoms, confirming the centrality of the emotion dysregulation in the expression of post-traumatic symptoms.
\n
The physical abuse and neglect both show direct negative effects on PTSD. This result is not immediate to understand and claims for further analyses. As a consequence, functional approaches overcome the limit of descriptive interpretations of results. Finally, the variance explained by predictors and moderators suggests that other variables could be involved as independent predictors as well as significant moderators.
\n
\n
\n
6.3. Mediating effect
\n
Results of the path analyses show that different forms of childhood traumatic experiences present different relationship with current post-traumatic symptoms: some forms of trauma show a direct influence on PTSD, while others are independent or have a combination of direct and indirect effects.
\n
First, our results highlight that the inability to manage intimacy and closeness in romantic relationships leads to a severity of emotional neglect and ultimately, the development of post-traumatic symptoms in adulthood. Moreover, emotional abuse and emotional neglect display direct influences on PTSD.
\n
These results allow two considerations. First, emotional components of trauma appear to have the greatest direct and mediated influences on PTSD. In particular, a possible explanation is that emotional traumas damage or compromise the development of affect regulation in infancy; such early impairment lasts into adulthood and exposes victims to a major risk of maladaptive response in stressful situations. Moreover, the emotional abuse appears to impede interpersonal affect regulation, with victims presenting higher levels of anxiety and avoidance in romantic attachment and then greater PTSD.
\n
Emotional abuse and neglect experiences are mainly expressed in chronic familiar contexts, including ignoring the child, being constantly absent, blaming, humiliating and constantly criticizing the child. These repeated experiences produce a negative self-worth and a sense of guilt which are symptoms of complex PTSD. Moreover, emotional neglect involves showing no emotions in interactive exchanges with the child which leads to extreme difficulties in recognizing self- and other-emotions. This mechanism damages the development of reliable internal model of self and other, making victims more vulnerable to high levels of anxiety and avoidance in intimate relationship.
\n
Second, the mediation of the relationship between emotional neglect and PTSD is provided by both anxiety and avoidance in romantic attachments. It is possible to suppose that previous levels of stress, due to traumatic repetitive experiences, like the inaccessibility of emotional support, can be reactivated by the vulnerability in the relationship, such as a perceived threat of abandonment. As a consequence, this mechanism might encourage people to read interpersonal minor stressors, quarrel and separations as trigger for high levels of stress, which, on the other hand, exposes hidden PTSD symptomatology. According to Van der Kolk [21], abused and maltreated children may show biases in the interpretation of interpersonal situations, quickly seeing the changes in voice tone and facial expression as a threat; consequently, they rapidly shift from the stimuli to a defensive reaction. In adulthood, this consolidated experience produces the internal perception of stress, even in neutral situation of fight or discussion in close relationships. The repetition of such mechanism produces dysregulation of emotion and hyper-arousal, characteristics of PTSD, as a response to non-stressing stimulus. A previous study shows that adult victims of childhood traumatic experiences are more likely to react with a deeper affective and physiological dysregulation to a harmless situation, compared to adult victims of a traumatic experience in adulthood [20].
\n
A more controversial result is given by the negative influence of both physical abuse and neglect on post-traumatic stress disorder. Other investigations previously attested the ambiguous role of the dismissing pattern of attachment (characterized by greater avoidance) in association with PTSD. Moreover, this pattern appears to be less frequent in female samples. The two elements related to our study may affect the results. However, a possible interpretation of the results may also include that the negative emotions characterizing avoidance in romantic attachment may result in increase in emotional forms of trauma; physical abuse and neglect may have different long-terms effects, less connected with emotion regulation and PTSD. Physically abused subjects may have developed different defensive mechanisms reducing avoidance and PTSD. Further studies in this field are needed to reach a clearer interpretation.
\n
Finally, the present study suggests that further investigations should consider the role of other independent predictors and other possible mediators, reported by literature, in the expression of post-traumatic symptoms and in the long-terms effects of physical interpersonal traumatic experiences.
\n
\n
\n
6.4. Limitations
\n
The present study has some limitations. First, for a broader and more complete understanding of the variables involved in the relationship between childhood traumas and post-traumatic symptoms, the measures of childhood experiences, attachment and psychological outcomes should include interviews and different kinds of assessment. Indeed, the present results are totally produced based on self-report measures. Second, the measure of traumatic experiences is retrospective and participants are female students; further studies should be done with clinical subjects to evaluate, in clinical or high risk groups, the role of attachment on their symptomatology. Moreover, participants were all Italians; hence, the external validity is so far limited. Another limit is due to the lack of other psychopathological outcomes which might impact on the different roles played by anxiety and/or avoidance on different psychopathologies.
\n
However, even if methodological shortcomings of the present results do not allow clear interpretations on the role that romantic attachment may play in determining adult post-traumatic symptomatology, one of the strength of the study lays in the opportunity to describe, in a functional framework, the relationship between childhood experiences and adult post-traumatic symptomatology. Indeed, the study of both moderation and mediation overcome limits linked with descriptive models.
\n
\n
\n
\n
7. Conclusion
\n
In conclusion, the present study provides interesting results on the relationship between childhood traumatic experiences, romantic attachment and post-traumatic stress disorder, considering both the limited number of investigations involving nonclinical samples and the novelty of the application of a functional approach.
\n
In particular, the results of the present study point out the role of emotional forms of trauma in later psychopathology and well-being, evidencing the role of severe impairment of early emotional regulation on stress and socio-emotional development.
\n
The present results might be considered in a clinical framework, pointing to some aspects which should be included and focused on in the intervention with adults experiencing post-traumatic stress disorder as a result of the connection with a childhood history of abuse. From this study, we discover the role of anxiety and avoidance in close relationship as features to include in the clinical work with female victims presenting PTSD in adulthood.
\n
In particular, programs of intervention should consider focusing on affect and interpersonal regulatory skills and implement strategies addressing the work on fear of abandonment as well as on avoidance of intimacy, in order to boost more adaptive coping skills to face stressful situations. Namely, reducing the negative self-believes and/or other-believes which lead to dependence on or avoidance of the other people may reduce their hyper sensibility to stressful situation and their avoidance of negative emotion. Both features characterize affect dysregulation, interpersonal disturbance and negative self-concept typical of complex PTSD. Finally, results about the presence of PTSD among female students suggest the need for further studies and screening in general populations.
\n
\n\n',keywords:"childhood traumatic experiences, romantic attachment, post-traumatic stress disorder, mediating effect, moderating effect",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/52375.pdf",chapterXML:"https://mts.intechopen.com/source/xml/52375.xml",downloadPdfUrl:"/chapter/pdf-download/52375",previewPdfUrl:"/chapter/pdf-preview/52375",totalDownloads:1986,totalViews:570,totalCrossrefCites:3,totalDimensionsCites:3,totalAltmetricsMentions:0,impactScore:2,impactScorePercentile:77,impactScoreQuartile:4,hasAltmetrics:0,dateSubmitted:"November 25th 2015",dateReviewed:"August 25th 2016",datePrePublished:null,datePublished:"November 2nd 2016",dateFinished:"September 13th 2016",readingETA:"0",abstract:"Childhood traumatic experiences are known to have strong and durable effects on physical, mental and reproductive health. One of the most studied consequences of childhood trauma is the post-traumatic stress disorder (PTSD). The present study aims to investigate in a community sample of Italian female students: (1) the prevalence of PTSD; (2) the association between reported childhood traumatic experiences and the presence of PTSD in adulthood and the role played by the romantic attachment (anxiety, avoidance) on the relationship between childhood traumatic experiences and PTSD symptoms. Three hundred and twenty-seven female Italian students (mean age = 23.09 years; SD = 2.98) of the University of Padova participated in the study. Participants have been tested on childhood traumatic experiences (Childhood Trauma Questionnaire-Short Form, CTQ-SF); romantic attachment (Experience in Close Relationship-Revised, ECR-R) and post-traumatic stress disorder (Post-traumatic Stress Disorder Checklist for DSM-5, PCL-5). Results show that PTSD symptoms are significantly predicted by the experiences of emotional abuse and neglect. Moreover, anxiety and avoidance play a significant role in the relationship between the emotional forms of traumatic experiences and the current presence of PTSD symptoms. Clinical implications for the treatment of PTSD patients with history of interpersonal trauma are discussed.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/52375",risUrl:"/chapter/ris/52375",book:{id:"5272",slug:"a-multidimensional-approach-to-post-traumatic-stress-disorder-from-theory-to-practice"},signatures:"Alessandra Simonelli and Chiara Sacchi",authors:[{id:"105986",title:"Prof.",name:"Alessandra",middleName:null,surname:"Simonelli",fullName:"Alessandra Simonelli",slug:"alessandra-simonelli",email:"alessandra.simonelli@unipd.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"University of Padua",institutionURL:null,country:{name:"Italy"}}},{id:"183026",title:"Ph.D. Student",name:"Chiara",middleName:null,surname:"Sacchi",fullName:"Chiara Sacchi",slug:"chiara-sacchi",email:"chr.sacchi@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Aims",level:"1"},{id:"sec_3",title:"3. Method",level:"1"},{id:"sec_3_2",title:"3.1. Measures",level:"2"},{id:"sec_5",title:"4. Data analyses",level:"1"},{id:"sec_6",title:"5. Results",level:"1"},{id:"sec_6_2",title:"5.1. Prevalence of PTSD symptoms",level:"2"},{id:"sec_7_2",title:"5.2. Moderating role of romantic attachment",level:"2"},{id:"sec_8_2",title:"5.3. Mediating role of romantic attachment",level:"2"},{id:"sec_10",title:"6. Discussion",level:"1"},{id:"sec_10_2",title:"6.1. PTSD prevalence",level:"2"},{id:"sec_11_2",title:"6.2. Moderating effect",level:"2"},{id:"sec_12_2",title:"6.3. Mediating effect",level:"2"},{id:"sec_13_2",title:"6.4. Limitations",level:"2"},{id:"sec_15",title:"7. Conclusion",level:"1"}],chapterReferences:[{id:"B1",body:'Cicchetti D, Toth SL. Child maltreatment. 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Journal of Traumatic Stress. 2000;13:321–332. doi:10.1023/A:1007752719557'},{id:"B36",body:'Rumstein-McKean O, Hunsley J. Interpersonal and family functioning of female survivors of childhood sexual abuse. Clinical Psychology Review. 2001;21:471–490. doi:10.1016/S0272-7358(99)00069-0'},{id:"B37",body:'Testa M, Van Zile-Tamsen C, Livingston JA. Childhood sexual abuse, relationship satisfaction, and sexual risk taking in a community sample of women. Psychology of Women Quarterly. 2005;29:345–352. doi:10.1037/0022-006X.73.6.1116'},{id:"B38",body:'Muller RT, Lemieux KE. Social support, attachment, and psychopathology in high risk formerly maltreated adults. Child Abuse and Neglect. 2000;24:883–900. doi:10.1016/S0145-2134(00)00150-2'},{id:"B39",body:'Fowler JC, Allen JG, Oldham JM, Frueh BC. Exposure to interpersonal trauma, attachment insecurity, and depression severity. 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Department of Developmental Psychology and Socialization, University of Padova, Padova, Italy
Department of Developmental Psychology and Socialization, University of Padova, Padova, Italy
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1. Introduction
Stroke was previously assumed to occur in developed countries only, as the third leading cause of death and is responsible for 5.5 million deaths every year [1, 2] However, it is actually uncommon to be found in Southeast Asian countries [3, 4, 5] or other countries with low and middle income [6].
Stroke is the primary cause of death and disability in the world, whose cost needed for post-stroke treatment and care is quite pricey. In 2016, stroke was the second leading cause of death globally (5.5 million deaths) after ischemic heart disease [2]. In South Asian countries including India, Pakistan, and Bangladesh, as well as developing countries in Southeast Asia, such as Cambodia, Indonesia, Laos, and Malaysia, the stroke incidence is increasing. However, since these developing countries do not have inadequate health facilities, the mortality rate caused by this disease is high and the number of persons with disabilities caused by this disease also increases [3, 7, 8, 9].
Stroke is the leading cause of death in adults. The death caused by stroke is predicted to increase twice in the next 30 years [10]. A previous research project carried out by Carandang (2006) discovered that approximately 62% of all stroke cases were atherothrombotic infarcts [11]. Meanwhile, according to Puthenpurakal [12] about 85% of stroke cases are ischemic stroke or infarct stroke, while the remaining (15%) are hemorrhagic stroke. Global data issued in 2016 also gave similar results, in which 84.4% of stroke incidence were ischemic stroke [2]. Stroke with ischemic health diseases (IHD) was the leading cause of deaths attributable to tobacco use as a risk factor [13].
According to Basic Health Research (RISKESDAS) that was conducted in Indonesia in 2007, it was revealed that stroke was the leading cause of death by 15.4% [14]. In the age group of 45 to 54 years old, stroke is the leading cause of death in urban areas and in men. Meanwhile, in the age group of 55 to 64 years old, this disease is the leading cause of death in both urban and rural areas as well as in both male and female [14]. Martini et al. [15] revealed that 76% of stroke incidence in a hospital that has been a tertiary referral in the last 10 years was ischemic stroke or infarct stroke. Furthermore, there was also an increase of stroke incidence in 2013 compared to 2007, which was 12.1 and 8.3% [14, 16]. Meanwhile, the stroke incidence in 2018 was 10.9 per mile [17].
Previous study carried out by Pinto et al. showed that hypertension was commonly found in lacunar infarct stroke and large artery atherosclerosis in diabetic patients [18]. Therefore, it indicates that hypertension is a co-factor that determines lacunar stroke in diabetic patients. This is in accordance with the statement made by Harry Keen three decades ago that both high blood glucose level and high blood pressure damage blood vessels, especially the small blood vessels (microvascular). Meanwhile, research conducted by Kisella et al. [19] claimed that hypertension comorbidity was not a significant risk factor for the stroke infarct incidence in African Americans (OR = 1.3 95% confidence interval [CI]: 0.9–1.7), yet it was a significant risk factor for the infarct stroke incidence in Caucasian people (OR = 1.6, 95% CI: 1.4–1.9). About 35–42% of all infarct stroke incidences in both African Americans and Caucasians are related to diabetes alone or in combination between diabetes and hypertension. The risk of stroke in hypertension was 1.46 (95% CI: 1.07–1.99) as the sole risk factor [20]. Hypertension is the most common risk factor found in Asia 1 [3, 4, 21, 22]. Data from one of the community-based surveys in Indonesia, which is Sleman Health and Demographic Surveillance System (HDSS) in 2016, found a high prevalence of stroke that was related to the increasing age, hypertension, and diabetes mellitus [9].
When diabetes mellitus (DM) is the sole factor, then DM also increases the risk of infarct stroke [23, 24]. Furthermore, the risk of infarct stroke is 2.5 (95% CI: 2.0–3.2) in all types of DM. According to the type of diabetes mellitus, the risk of infarct stroke is 7.9 times (95% CI: 5.1–12.2) in DM type 1 and 3.0 times (95% CI: 2.6–3.4) in DM type 2. Meanwhile, based on the duration of suffering from DM type 2, infarct stroke risk increases by 1.7 times when the duration of illness is less than 5 years and 3.2 times when the duration of illness is within 10–14 years [25]. Diabetes patients have a higher risk ([OR] 1.33, 95% CI: 1.18–1.5) of suffering from ischemic stroke than hemorrhagic stroke (OR 0.72, 95% CI: 0.6–0.877). In addition, the combination of infarct stroke and DM affects younger people more than infarct stroke without DM. The risk of infarct stroke is more common in white DM patients [26]. According to research conducted by Kaarisalo et al. [27], infarct stroke has a tendency to occur more frequently in people with impaired glucose tolerance (GTG) than in people with normal blood glucose levels, although the difference was not significant [28]. In addition, several studies have estimated that approximately 20–33% of hospitalized patients with acute stroke have diabetes [29, 30]. This is strengthened by the results of the research conducted at General Hospital of Haji Adam Malik Medan Indonesia that diabetes had a relationship with the prevalence of stroke (p < 0.05). The risk of stroke was 1.34 times higher in diabetes than those without diabetes [30].
Stroke can occur in all age groups but mostly occurs at the age above 55 years old; thus, age is a strong determinant of infarct stroke incidence [9, 31, 32, 33]. Many factors cause stroke. An individual may have more than one risk factor, whether the risk factor is a risk factor that is supported by strong evidence (level of evidence A) or less strong evidence (level of evidence C), or whether these risk factors can be modified or cannot be modified, or whether these risk factors are controlled or not.
High blood glucose level can cause complications on blood vessels such as microangiopathy (eye, kidney, and nerve disorders) and macroangiopathy (stroke and heart problems). If the blood glucose is excessive, then glucose will bind to proteins, including blood vessel wall cells. These bonds will damage the structure and function of blood vessels. The damage or complications that occur cannot be reversed and the process can only be stopped or slowed down [34]. Furthermore, hyperglycemia increases oxidative stress, which causes pathological processes in diabetic complications. Overproduction of reactive oxygen species (ROS) induced by hyperglycemia will activate five pathogenic pathways that contribute to endothelial dysfunction and diabetes complications, and those are (1) polyol pathway; (2) the increase of formation of advanced glycation end products (AGEs); (3) the increase of receptor expression for AGEs; (4) activation of protein kinase C isoforms; and (5) over-activity of the hexamine pathway. Vasculopathy that is induced by chronic hyperglycemia also results in accelerated atherosclerosis in diabetes. Therefore, a higher prevalence and incidence of cardiovascular disease including stroke are common in the diabetic patients [35, 36]. Improper diabetes control also increases the short- and long-term morbidity and mortality associated with stroke and significantly increases the recurrent risk of stroke [35].
Based on the doctor diagnosis, the prevalence of diabetes in Indonesia population has increased from 2007 to 2018. This can be seen from the results of Basic Health Research (RISKESDAS) [16], which increased from 1.5% in 2007 to 2.0% in 2018. Such condition shows that serious problems still occur related to unresolved diabetes. Meanwhile, the prevalence based on the age increased from 2007 to 2018. In this case, the age category was divided into seven groups and the highest prevalence was shown by the age group of above 55 years old and this figure was related to insulin resistance.
Age is a risk factor for diabetes [37]. Based on the results of the research aforesaid, the older age group suffers from DM more. The increasing prevalence of DM that includes metabolic diseases at the old age can be directly related to the aging process or indirectly through several other DM risk factors such as central obesity, mitochondrial dysfunction, FFA and lipid metabolism disorders, inflammation, cell dysfunction, insulin resistance, and metabolic syndrome (Figure 1) [38]. The purpose of this study is to find the factor that increases the risk of infarct stroke related to the blood glucose level of Indonesian people.
Figure 1.
Prevalence of diabetes mellitus among people age 15 years old and over in Indonesia.
2. Food consumption in Indonesia
Indonesia is the third largest sugar consumer in Asia after India and China. Indonesian people consumption of sugar is slightly higher (5%) than the total energy and when combined with the sugar contained in beverages such as soft drinks, the content will be even higher [39].
Basic Health Research (RISKESDAS) that was conducted in 2018 showed that there were 40.1 and 60.27% of Indonesian people at the age of above 3 years old who consumed sweet foods and beverages once a day [40]. Meanwhile, previous research in 2007 and 2013 found that the consumption of sweet foods was still quite high, although it decreased from 65.2 to 53.1%.
In this case, children at the age group of 3–9 years old have the highest percentage (above 50%) of consuming sweet foods once a day. Furthermore, about 98.4% of Indonesian teenagers at the age of 13–18 years old consumed nutritious foods including fruits and vegetables insufficiently (<400 g/day) [41]. The prevalence of overweight in Indonesia is the highest among adults by 8% of men and 29% of women suffering from central obesity [42]. Therefore, concern needs to be provided to the quality of community diet needs and energy adequacy, especially among teenagers and children who need nutritional intake in the growth process.
Basic Health Research (RISKESDAS) in 2007, 2013, and 2018 was conducted concerning the food consumption pattern of Indonesian people as presented in Figure 2. The prevalence of sweet foods and drinks consumption once a day was 65.2% in 2007, which then decreased to 53.1% in 2013. Furthermore, the consumption of sweet food for once a day also decreased to 40.1% in 2018, yet the consumption of sweet beverages once a day increased to 61.27%. In addition, the consumption of soft drinks or carbonated drinks was 2.2% (Figure 3) [14, 16, 17, 40].
Figure 2.
The percentage of population aged 10 years and older to consume unhealthy food ≥1 per day in Indonesia in 2007 and 2013.
Figure 3.
Unhealthy food consumption based on Basic Health Research (RISKESDAS) 2007, 2013, and 2018.
Several other studies have also revealed that Indonesian adults insufficiently consumed protein, fruits, and vegetables, but consumed fast food and sodium excessively [41]. Another study that has been conducted in Central Java, Indonesia, also showed that dietary patterns were associated with increased consumption of soft drinks, snacks, and various animal products [43]. Another study was further conducted in Jakarta showing that the daily food consumption of the observed population reached 1868–2334 g/capita/day. The total intake of added sugar in the different groups of respondents ranged between 34.9 and 45.9 g/capita/day, with the highest values observed in school-age boys. Total salt intake ranged from 5.46 to 7.43 g/capita/day, while fat intake reached 49.0–65.1 g/capita/day. One of the main food sources that contribute to salt and fat intake is street food and fast-food restaurants [44].
3. Data and analysis
The population involved is those who suffered from infarct stroke and were treated at RSUD Dr. Soetomo. The population source was hospital-based because, to obtain data on stroke incidence, it must be based on a doctor’s diagnosis, not based on the results of interviews. Case samples were infarct stroke incidences, which were taken by consecutive sampling from the case population with several inclusion criteria, including (1) aged 40 years and above, (2) male and female, (3) normal consciousness (GCS 4 5 6), and (4) willing to participate in the research (proven by informed consent). Meanwhile, the exclusion criteria were (1) having family comorbidity of stroke, (2) previous heart disease (proven by being hospitalized with a diagnosis of heart disease), and (3) aphasia. Furthermore, the sampling was carried out in the Neurology Inpatient Ward of RSUD Dr. Soetomo in Surabaya, Indonesia.
Based on the calculation, there were 79 samples obtained from each group. In this research, there were 82 samples for each group; thus, there were 164 samples involved. Data collection was carried out through several stages. The first stage is conducting direct examination of research subjects to obtain a diagnosis of infarct stroke (based on clinical signs, symptoms, and CT scan images) when the respondent arrived at the hospital. Second stage is examining the blood sugar, by collecting venous blood through taking 3 μl of serum added by 200 μl of reagent 1 and 200 μl of reagent 2, then incubated for 10 minutes, and read at wavelengths of 600 and 505 nm. The examination method used is the enzymatic method, which is the hexokinase method. This method was chosen because it has good precision and accuracy and is a referential method [45]. Casual blood sugar and HBA1C examinations were carried out no later than 24 h after the respondents entered the nervous room [46]. After that, the respondents were required to fast for at least 10 h to check the fasting blood sugar in the next day. Then, respondents were asked to eat rice (the menu provided by the hospital) and 2 h after eating, and their blood was taken for blood sugar examination 2-h postprandial for cases. During the controls, casual blood sugar and HBA1C tests were carried out before the interview, and then, respondents were asked to fast for at least 10 h before having their blood drawn the next day for fasting blood sugar checks. After the blood was taken, respondents were asked to eat rice, side dishes, and drink sweet tea equivalent to 600 to 650 calories. The respondents’ blood was then taken again 2 h after eating for blood sugar examination 2-h postprandial. The examination results were categorized according to the American Diabetes Association (ADA) criteria and percentiles based on the average of these examination results.
This research employed a research instrument in the form of a questionnaire to obtain data on age, gender, blood sugar, medical history, which is diabetes mellitus. A computerized (CT) scan of the head was further conducted as the gold standard to determine the diagnosis of infarct stroke and to check serum sugar and cholesterol levels using the Hitachi 912 autoanalyzer.
4. Results and discussion
4.1 Results
4.1.1 Casual blood glucose according to infarct stroke status
The results showed that the average casual blood glucose (CBG) was 148.57 mg/dl with the lowest CBG level was 66 mg/dl and the highest CBG was 535 mg/dl. Based on the Kolmogorov–Smirnov normality test, p-value obtained was 0.000 indicating that the distribution of CBG data did not show a normal distribution. Therefore, CBG was classified according to the percentile method as follows:
Group I: CBG < 87 mg/dl
Group II: CBG 87 to 224 mg/dl
Group III: CBG > 224 mg/dl
The mean value of CBG in the infarct stroke was 186 mg/dl with a standard deviation of 14 mg/dl. Meanwhile, the mean value of CBG in the non-stroke group was 111 mg/dl with a standard deviation of 65 mg/dl.
This casual blood glucose (CBG) was categorized based on the American Diabetes Association (ADA) 2010 criteria [46]. The percentile method is shown in Table 1. Based on Table 1, there were only 4.9% of respondents who had CBG of 87 mg/dl in the infarct stroke group. Meanwhile, in the non-stroke group, almost 30% of respondents had CBG of 87 mg/dl. Furthermore, according to the criteria of percentile method, there were 28% of respondents who had CBG 224 mg/dl in the infarct stroke group and 4.9% of respondents with CBG 224 mg/dl in the non-stroke group. Furthermore, according to the ADA criteria, almost 50% of infarct stroke incidence had CBG levels of 140 mg/dl and above. On the other hand, 90.3% of non-stroke incidences had CBG level of less than 140 mg/dl..
Disease
Casual blood glucose
Number
Percentage
Infarct stroke
ADA criteria
<140 mg/dl 140–199 mg/dl > = 200 mg/dl
42 13 27
51.2 15.9 32.9
Percentile method
<87 mg/dl 87–224 mg/dl >224 mg/dl
4 55 23
4.9 67.1 28.0
Not stroke
ADA criteria
<140 mg/dl 140–199 mg/dl > = 200 mg/dl
74 2 6
90.3 2.4 7.3
Percentile method
<87 mg/dl 87–224 mg/dl >224 mg/dl
24 54 4
29.3 65.9 4.9
Table 1.
Distribution of casual blood glucose (CBG) of the respondents based on the infarct stroke status according to the American Diabetes Association (ADA) 2010 criteria and percentile method.
4.1.2 Fasting blood glucose based on infarct stroke status
Fasting blood glucose (FBG) was categorized based on American Diabetes Association (ADA) 2010 criteria and percentile method as presented in Table 2. The fasting blood glucose (FBG) variable had an average fasting blood glucose level (FBG) of 114.07 mg/dl with the lowest fasting blood glucose level was 65 mm Hg, while the highest fasting blood glucose was 329 mg/dl. Based on the Kolmogorov–Smirnov normality test, the p-value obtained was 0.000, indicating that the distribution of GDP data did not show a normal distribution. Therefore, FBG was classified according to the percentile method as follows:
Disease
Fasting blood glucose
Number
Percentage
Infarct stroke
ADA criteria
<110 mg/dl 110–125 mg/dl > = 126 mg/dl
37 12 33
45.1 14.6 40.2
Percentile method
<80 mg/dl 80–159 mg/dl >159 mg/dl
4 54 24
4.9 65.9 29.3
Not stroke
ADA criteria
<110 mg/dl 110–125 mg/dl > = 126 mg/dl
71 5 6
86.6 6.1 7.3
Percentile method
<80 mg/dl 80–159 mg/dl >159 mg/dl
19 61 2
23.2 74.4 2.4
Table 2.
Fasting blood glucose (FBG) of the respondents based on the infarct stroke status according to the American Diabetes Association (ADA) 2010 criteria and percentile method.
Groups I: FBG < 80 mg/dl
Groups II: FBG 80 to 159 mg/dl
Groups III: FBG > 159 mg/dl
The average fasting blood glucose (FBG) in the infarct stroke group was 134 mg/dl with a standard deviation of 54 mg/dl, while in the non-stroke group it was 94 mg/dl with a standard deviation of 33 mg/dl.
According to ADA 2010 criteria, in the stroke-infarction group, there were 40.2% of respondents had a FBG level of 126 mg/dl or more, 14.6% of respondents had a FBG of 110 to 125 mg/dl, and 45.1% of respondents had a FBG 110 mg/dl. Meanwhile, in the non-stroke group, most respondents (86.6%) had a FBG of 110 mg/dl and only 7.3% of respondents had a FBG of 126 mg/dl or more. Furthermore, according to the percentile method, in terms of the infarct group, 29.3% of respondents had a FBG level of 159 mg/dl and only 4.9% of respondents had a FBG level of 80 mg/dl, while the remaining (65.9%) had a FBG level of 80 to 159 mg/dl. Meanwhile, in the non-stroke group, as many as 23.2% of respondents had a FBG of 80 mg/dl, only 2.4% had a FBG of more than 159 mg/dl, and 74.4% of the respondents had a FBG of 80 to 159 mg/dl.
4.1.3 Blood glucose of 2-h postprandial according to the infarct stroke status
The mean value of blood glucose of 2-h postprandial (BG2PP) was 144.32 mg/dl with the lowest blood glucose levels of 2-h postprandial was 68 mg/dl, while the highest was 483 mg/dl. Based on the Kolmogorov–Smirnov normality test, the p-value obtained was 0.000 indicating that the distribution of BG2PP data did not show a normal distribution. Therefore, BG2PP was classified according to the percentile method as follows:
Group I: BG2PP < 94 mg/dl
Group II: BG2PP 94 to 207 mg/dl
Group III: BG2PP > 207 mg/dl
The mean blood glucose of 2-h postprandial (BG2PP) in the infarct stroke group was 165 mg/dl with a standard deviation of 70 mg/dl, while in the non-stroke group was 124 mg/dl with a standard deviation of 62 mg/dl.
The blood glucose of 2-h postprandial (BG2PP) was categorized based on the American Diabetes Association (ADA) criteria 2010 and the percentile method as presented in Table 3.
Disease
Blood glucose of 2 hours post-prandial
Number
Percentage
Infarct stroke
ADA criteria
<140 mg/dl 140–199 mg/dl > = 200 mg/dl
44 15 23
53.7 18.3 28.0
Percentile method
<94 mg/dl 94–207 mg/dl >207 mg/dl
11 51 20
13.4 62.2 24.4
Not stroke
ADA criteria
<140 mg/dl 140–199 mg/dl > = 200 mg/dl
69 7 6
84.1 8.5 7.3
Percentile method
<94 mg/dl 94–207 mg/dl >207 mg/dl
21 55 6
25.6 67.1 7.3
Table 3.
Blood glucose of 2 hours post-prandial (BG2PP) of the respondents based on the infarct stroke status according to the American Diabetes Association (ADA) 2010 criteria and percentile method.
According to the ADA criteria 2010, in terms of infarct stroke, there were 28% of respondents who had a BG2PP level of 200 mg/dl or more, 18.3% of respondents had a BG2PP level of 140 to 200 mg/dl, and 53.7% of respondents had a BG2PP level of 140 mg/dl. On the other hand, in terms of the non-stroke group, most of the respondents (84.1%) had a BG2PP level of 140 mg/dl and only 7.3% of respondents had a BG2PP level of 200 mg/dl or more. Meanwhile, according to the percentile method in the stroke-infarction group, there were 62.2% of respondents which had a BG2PP level of 94–207 mg/dl and 24.4% of respondents with BG2PP level of 207 mg/dl. Meanwhile, in the non-stroke group, there were 25.6% of respondents, which had a BG2PP level of 94 mg/dl, 67.1% of respondents had 94 to 207 mg/dl, and only 7.3% of respondents had a BG2PP level of more than 207 mg/dl.
4.1.4 Hemoglobin glycated (HBA1c) according to the infarct stroke status
Variable of glycated hemoglobin (HBA1C) level obtained the mean value of 6.37%. The lowest HBA1C level was 3.5%, while the highest was 11.6%. Based on the Kolmogorov–Smirnov normality test, the p = value obtained was 0.011, indicating that the HBA1C data distribution did not show a normal distribution. Therefore, HBA1C was classified according to the percentile method as follows:
Group I: HBA1C < 6.1%
Group II: HBA1C ≥ 6.1%
The mean value of HBA1C level in the stroke infarct group was 7.07% with a standard deviation of 1.40%. Meanwhile, the mean value in the non-stroke group was 5.74% with a standard deviation of 0.97%. Furthermore, the HBA1C levels were categorized according to the American Diabetes Association (ADA) criteria 2010 and the percentile method as described in Table 4.
Disease
HBA1C level
Number
Percentage
Infarct stroke
ADA criteria
< 6.0% > = 6.0%
27 55
32.9 67.1
Percentile method
< 6.1% > = 6.1%
30 52
36.6 63.4
Not Stroke
ADA criteria
< 6.0% > = 6.0%
53 29
64.6 35.4
Percentile method
< 6.1% > = 6.1%
55 27
67.1 32.9
Table 4.
Hemoglobin glycated (HBA1C) level of the respondents based on the infarct stroke status according to the American Diabetes Association (ADA) 2010 criteria and percentile method.
According to the ADA criteria 2010, in the infarct stroke group, there were 67.1% of respondents who had HBA1C level of 6% or more, while the remaining obtained HBA1C level less than 6%. On the other hand, in the non-stroke group, most (64.6%) of the respondents obtained HBA1C level of less than 6%, while 35.4% respondents had HBA1C level of 6% or more.
According to the percentile method, in the infarct stroke group, there were 63.4% of respondents who had HBA1C level of 6.1% or more, while the remaining 36.6% of respondents had HBA1C level of less than 6.1%. On the other hand, in the non-stroke group, there were 67.1% of respondents who had HBA1C level of less than 6.1%, while the remaining 32.9% of respondents had HBA1C level of 6.1% or more.
4.2 Discussion
Based on the results that have been described above, it was discovered that the variable of blood glucose in the stroke infarct group was higher than the non-stroke group’s. The mean value of casual blood glucose (CBG) in the infarct stroke group was 186 mg/dl, while the mean value of CBG in the non-stroke group was 111 mg/dl. Meanwhile, the fasting blood glucose (FBG) level in the infarct stroke group was 134 mg/dl, while in the non-stroke group it was 94 mg/dl. Furthermore, the blood sugar of 2-h postprandial (BG2PP) in the infarct stroke group was 165 mg/dl, while in the non-stroke group it was 124 mg/dl. These results supported the results of previous research conducted by Berger et al. [47] in which the FBG level in the stroke group was higher than in the non-stroke group, which was 106.1 mg/dl and 101.1 mg/dl, respectively.
Furthermore, another previous research project carried out by Boden-Albala et al. [48] revealed that the increase of FBG levels caused the risk of ischemic stroke also increased by 2.7 (95% CI: 2.0–3.8). In addition, it was reported that FBG level of 126 mg/dl to less than 150 mg/dl had a 5.1 (95%CI: 2.8–9.3) risk of ischemic stroke, while if the FBG level is 150 mg/dl, it had a risk of 3.3 (95%CI: 2.2–4.8).
Blood glucose level examination is an examination carried out to determine a definite diagnosis of diabetes mellitus. If the American Diabetes Association (ADA) 2010 criteria were used to determine the diagnosis of diabetes mellitus, the blood sugar level of 2-h post-prandial obtained that 28% of respondents have diabetes mellitus. This percentage figure is higher than the figure obtained from the research performed by O’Donnel et al. [49], in which 21% of ischemic stroke cases had diabetes mellitus. The results of this study are in accordance with previous studies that diabetes mellitus is a factor that increases the risk of ischemic stroke with a risk of 2.2 (95% CI: 1.9–2.6) [28] and a high risk of 1.78 (95% CI: 1.32–2.42) [50] while based on the gender, it was 2.27 (95% CI: 2.24–2.29) for men and 2.15 (95% CI: 2.13–2.17) for women [50, 51].
Other epidemiological studies have shown that diabetes is a risk factor for either ischemic stroke or infarct stroke or hemorrhagic stroke [30]. For example, findings from the Emerging Risk Factors Collaboration showed that the hazard ratio (HR) with diabetes was 2.27 (95% CI: 1.95–2.65) for ischemic stroke or infarct stroke, 1.56 (95% CI: 1.19–2.05) for hemorrhagic stroke, and 1.84 (95% CI: 1.59–2.13) for unclassified stroke [28, 52]. A cohort study was conducted in Taiwan, obtaining that the stroke incidence with and without diabetes was 10.1 and 4.5 per 1000 person-year, respectively. During the follow-up, diabetic patients had an increased risk of stroke (adjusted hazard ratio 1.75; 95%CI: 1.64–1.86) than those without diabetes. The relationship between diabetes and stroke risk was significant in both genders and all age groups [22].
In the glycated hemoglobin variable (HBA1C), the average HBA1C in the infarct stroke group was higher than the non-stroke group, which was 7.07 and 5.74%, respectively. Elevated glycated hemoglobin (HBA1C) was an independent predictor of cardiovascular disease with a risk of 1.06 (95%CI: 1.02–1.11) [53]. In addition, the high HBA1C level (>10.7%) was strongly related to stroke [47]. Diabetes is the most important risk factor for ischemic stroke either with diabetes mellitus alone or in combination between diabetes mellitus and hypertension [22, 29, 54]. Another study showed that the ischemic stroke group had significantly higher HBA1C levels (5.9 ± 2.9% vs. 5.5 ± 1.6%) compared with the control group, while HBA1C was a significant determinant of stroke (p < 0.05). HBA1C was also significantly higher in the diabetic group compared with the non-diabetic (7.6 ± 2.1 vs. 6.1 ± 2.3) (p < 0.05) (7.6 ± 2.1 vs. 6.1 ± 2.3) (p < 0.05) [55].
In the current research, the blood glucose variable is a variable, which is strongly related to the incidence of infarct stroke because the highest consumption of carbohydrates in Indonesia is rice (1433 kcal/person/day), corn (228 kcal/person/day), and cassava (161 kcal/person/day) based on data from FAO. Based on the glycemic index, rice and corn have a high glycemic index (GI), which is more than 85 [56]. This causes a large glucose load on the body causing a relative insulin deficiency. As a result, not all glucose can be converted into glycogen, resulting in excessive glucose in the blood, causing hyperglycemia.
Blood glucose level is a valid indicator of the risk of infarct stroke. This is proven when blood sugar variable consisting of casual blood sugar, fasting blood sugar, blood sugar of 2-h postprandial, and HBA1C were analyzed together with the other variables (multivariable analysis). It was revealed that the four variables of blood sugar level showed the greatest validity coefficients based on confirmatory factor analysis, as shown in Table 5.
Variable
Validity
Reliability
coefficient
p-value
coefficient
p-value
Cigarette smoke exposure
0.16
0.05
0.97
0.00
History of hypertension
0.27
0.00
0.93
0.00
History of diabetes
0.73
0.00
0.46
0.00
History of hiperurisemia
0.17
0.00
0.97
0.00
Systolic blood pressure
0.50
0.00
0.75
0.00
Diastolic blood pressure
0.46
0.00
0.79
0.00
Casual blood glucose
0.93
0.00
0.13
0.00
Fasting blood glucose
0.97
0.00
0.05
0.00
Two hours post-prandial blood glucose
0.93
0.00
0.14
0.00
HBA1C
0.70
0.00
0.52
0.00
Total cholesterol
0.20
0.02
0.96
0.00
HDL cholesterol
0.17
0.04
0.97
0.00
Table 5.
The coefficient of validity (λ), reliability (δ) and t-value of each variable compromising the infarct stroke risk index (IRSI) of type a on the final stage of confirmatory factor analysis.
5. Conclusion
In Indonesia, it was revealed that stroke was the leading cause of death by 15.4% in 2007. A study conducted in the tertiary hospital revealed that 76% of stroke incidence in the last 10 years was ischemic stroke or infarct stroke. Another study showed that high prevalence of stroke was related to the increasing age, hypertension, and diabetes mellitus. The risk of stroke was 1.34 times higher in diabetes than those without diabetes.
In the current research, the blood glucose variable is a variable that is strongly related to the incidence of infarct stroke associated with the highest consumption of carbohydrates such as rice that is consumed three times a day in Indonesia, whereas it has a high glycemic index compared with other carbohydrate sources, as well, due to the lifestyle of the Indonesian people who like to eat sweet foods and drink sweet beverages. Therefore, education about food selection should be a priority in the effort to prevent infarct stroke and diabetes mellitus in Indonesia.
Efforts to prevent diabetes mellitus and infarct stroke should be considered since there is an emergence of COVID-19 disease, which has a worsening course and high fatality rate in people with comorbidities such as diabetes mellitus and stroke.
Acknowledgments
The author (Santi Martini) is thankful to author’s supervisor when taking doctoral program, and Prof. Dr. Moh. Hasan Machfud (neurolog) and Prof. Dr. Joewono Soeroso (internist) for giving knowledge about stroke and the risk factors.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"infarct stroke, cerebrovascular disease, blood glucose, diabetes, tobacco use, Indonesia",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/80005.pdf",chapterXML:"https://mts.intechopen.com/source/xml/80005.xml",downloadPdfUrl:"/chapter/pdf-download/80005",previewPdfUrl:"/chapter/pdf-preview/80005",totalDownloads:53,totalViews:0,totalCrossrefCites:0,dateSubmitted:"August 23rd 2021",dateReviewed:"November 8th 2021",datePrePublished:"February 15th 2022",datePublished:null,dateFinished:"January 12th 2022",readingETA:"0",abstract:"Stroke is the primary cause of death in adults. It is predicted that the death caused by stroke will increase twice in the next 30 years. In Indonesia, stroke is one of the diseases of the circulatory system, which has been taking the first place of causing death since 2007. Indonesia has rice as the main type of daily food consumed, which has higher glycemic index than other sources. This study aims to find the risk of blood glucose level that determines the incidence of infarct stroke. There were 164 patients enrolled in this study, 82 patients in each stroke and not stroke group. The blood examination is using the enzymatic method, which is the hexokinase method. The results of research revealed that indicators of high blood glucose level were found in infract stroke incidence, including casual blood glucose, fasting blood glucose, 2-h postprandial blood glucose, and glycated hemoglobin. These four indicators were found in a higher level in the infarct stroke than the non-stroke group. Other epidemiological studies have shown that diabetes is a risk factor for stroke. Therefore, education about food selection should be a priority in the effort to prevent infarct stroke and diabetes mellitus in Indonesia.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/80005",risUrl:"/chapter/ris/80005",signatures:"Santi Martini, Hermina Novida and Kuntoro",book:{id:"10782",type:"book",title:"Cerebrovascular Diseases - Elucidating Key Principles",subtitle:null,fullTitle:"Cerebrovascular Diseases - Elucidating Key Principles",slug:null,publishedDate:null,bookSignature:"Dr. Patricia Bozzetto Ambrosi",coverURL:"https://cdn.intechopen.com/books/images_new/10782.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-83962-701-9",printIsbn:"978-1-83962-700-2",pdfIsbn:"978-1-83962-702-6",isAvailableForWebshopOrdering:!0,editors:[{id:"221787",title:"Dr.",name:"Patricia",middleName:null,surname:"Bozzetto Ambrosi",slug:"patricia-bozzetto-ambrosi",fullName:"Patricia Bozzetto Ambrosi"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Food consumption in Indonesia",level:"1"},{id:"sec_3",title:"3. Data and analysis",level:"1"},{id:"sec_4",title:"4. Results and discussion",level:"1"},{id:"sec_4_2",title:"4.1 Results",level:"2"},{id:"sec_4_3",title:"Table 1.",level:"3"},{id:"sec_5_3",title:"Table 2.",level:"3"},{id:"sec_6_3",title:"Table 3.",level:"3"},{id:"sec_7_3",title:"Table 4.",level:"3"},{id:"sec_9_2",title:"4.2 Discussion",level:"2"},{id:"sec_11",title:"5. Conclusion",level:"1"},{id:"sec_12",title:"Acknowledgments",level:"1"},{id:"sec_15",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Gorelick PB. The global burden of stroke: Persistent and disabling. Lancet Neurology. 2019;18(5):417-418. DOI: 10.1016/S1474-4422(19)30030-4'},{id:"B2",body:'Johnson CO et al. Global, regional, and national burden of stroke, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurology. 2019;18(5):439-458. 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Division of Epidemiology, Faculty of Public Health, Universitas Airlangga, Indonesia
Division of Biostatistics, Faculty of Public Health, Universitas Airlangga, Indonesia
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UK Research and Innovation (former Research Councils UK (RCUK) - including AHRC, BBSRC, ESRC, EPSRC, MRC, NERC, STFC.) Processing charges for books/book chapters can be covered through RCUK block grants which are allocated to most universities in the UK, which then handle the OA publication funding requests. It is at the discretion of the university whether it will approve the request.)
UK Research and Innovation (former Research Councils UK (RCUK) - including AHRC, BBSRC, ESRC, EPSRC, MRC, NERC, STFC.) Processing charges for books/book chapters can be covered through RCUK block grants which are allocated to most universities in the UK, which then handle the OA publication funding requests. It is at the discretion of the university whether it will approve the request.)
Wellcome Trust (Funding available only to Wellcome-funded researchers/grantees)
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Osseointegration",slug:"dental-implant-surface-enhancement-and-osseointegration",totalDownloads:18676,totalCrossrefCites:38,totalDimensionsCites:99,abstract:null,book:{id:"179",slug:"implant-dentistry-a-rapidly-evolving-practice",title:"Implant Dentistry",fullTitle:"Implant Dentistry - A Rapidly Evolving Practice"},signatures:"S.Anil, P.S. Anand, H. Alghamdi and J.A. Jansen",authors:[{id:"25232",title:"Prof.",name:"Sukumaran",middleName:null,surname:"Anil",slug:"sukumaran-anil",fullName:"Sukumaran Anil"},{id:"28373",title:"Prof.",name:"John",middleName:null,surname:"Jansen",slug:"john-jansen",fullName:"John Jansen"},{id:"77058",title:"Dr.",name:"Seham",middleName:null,surname:"Alyafei",slug:"seham-alyafei",fullName:"Seham Alyafei"},{id:"82073",title:"Dr.",name:"Subhash",middleName:null,surname:"Narayanan",slug:"subhash-narayanan",fullName:"Subhash Narayanan"}]},{id:"18415",doi:"10.5772/16936",title:"Osseointegration and Bioscience of Implant Surfaces - Current Concepts at Bone-Implant Interface",slug:"osseointegration-and-bioscience-of-implant-surfaces-current-concepts-at-bone-implant-interface",totalDownloads:12502,totalCrossrefCites:16,totalDimensionsCites:42,abstract:null,book:{id:"179",slug:"implant-dentistry-a-rapidly-evolving-practice",title:"Implant Dentistry",fullTitle:"Implant Dentistry - A Rapidly Evolving Practice"},signatures:"Mustafa Ramazanoglu and Yoshiki Oshida",authors:[{id:"26726",title:"Prof.",name:"Yoshiki",middleName:null,surname:"Oshida",slug:"yoshiki-oshida",fullName:"Yoshiki Oshida"},{id:"29841",title:"Prof.",name:"Mustafa",middleName:null,surname:"Ramazanoglu",slug:"mustafa-ramazanoglu",fullName:"Mustafa Ramazanoglu"}]},{id:"18426",doi:"10.5772/18746",title:"Factors Affecting the Success of Dental Implants",slug:"factors-affecting-the-success-of-dental-implants",totalDownloads:17474,totalCrossrefCites:9,totalDimensionsCites:35,abstract:null,book:{id:"179",slug:"implant-dentistry-a-rapidly-evolving-practice",title:"Implant Dentistry",fullTitle:"Implant Dentistry - A Rapidly Evolving Practice"},signatures:"Carlos Nelson Elias",authors:[{id:"32438",title:"Prof.",name:"Carlos",middleName:null,surname:"Elias",slug:"carlos-elias",fullName:"Carlos Elias"}]},{id:"18414",doi:"10.5772/17512",title:"Dental Implant Surfaces – Physicochemical Properties, Biological Performance, and Trends",slug:"dental-implant-surfaces-physicochemical-properties-biological-performance-and-trends",totalDownloads:13080,totalCrossrefCites:5,totalDimensionsCites:30,abstract:null,book:{id:"179",slug:"implant-dentistry-a-rapidly-evolving-practice",title:"Implant Dentistry",fullTitle:"Implant Dentistry - A Rapidly Evolving Practice"},signatures:"Ahmed M. Ballo, Omar Omar, Wei Xia and Anders Palmquist",authors:[{id:"19042",title:"Dr.",name:"Wei",middleName:null,surname:"Xia",slug:"wei-xia",fullName:"Wei Xia"},{id:"28549",title:"Dr.",name:"Ahmed",middleName:"M.",surname:"Ballo",slug:"ahmed-ballo",fullName:"Ahmed Ballo"},{id:"81291",title:"Dr.",name:"Omar",middleName:null,surname:"Omar",slug:"omar-omar",fullName:"Omar Omar"},{id:"81292",title:"Dr.",name:"Anders",middleName:null,surname:"Palmquist",slug:"anders-palmquist",fullName:"Anders Palmquist"}]},{id:"18417",doi:"10.5772/18309",title:"Implant Stability - Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA",slug:"implant-stability-measuring-devices-and-randomized-clinical-trial-for-isq-value-change-pattern-measu",totalDownloads:13176,totalCrossrefCites:8,totalDimensionsCites:19,abstract:null,book:{id:"179",slug:"implant-dentistry-a-rapidly-evolving-practice",title:"Implant Dentistry",fullTitle:"Implant Dentistry - A Rapidly Evolving Practice"},signatures:"Jong-Chul Park, Jung-Woo Lee, Soung-Min Kim and Jong-Ho Lee",authors:[{id:"31057",title:"Prof.",name:"Jong-Ho",middleName:null,surname:"Lee",slug:"jong-ho-lee",fullName:"Jong-Ho Lee"},{id:"48351",title:"Prof.",name:"Jong-Chul",middleName:null,surname:"Park",slug:"jong-chul-park",fullName:"Jong-Chul Park"},{id:"83313",title:"Dr.",name:"JungWoo",middleName:null,surname:"Lee",slug:"jungwoo-lee",fullName:"JungWoo Lee"}]}],mostDownloadedChaptersLast30Days:[{id:"18432",title:"Clinical Complications of Dental Implants",slug:"clinical-complications-of-dental-implants",totalDownloads:56478,totalCrossrefCites:2,totalDimensionsCites:5,abstract:null,book:{id:"179",slug:"implant-dentistry-a-rapidly-evolving-practice",title:"Implant Dentistry",fullTitle:"Implant Dentistry - A Rapidly Evolving Practice"},signatures:"Su-Gwan Kim",authors:[{id:"27797",title:"Prof.",name:"Su-Gwan",middleName:null,surname:"Kim",slug:"su-gwan-kim",fullName:"Su-Gwan Kim"}]},{id:"47927",title:"Miniscrew Applications in Orthodontics",slug:"miniscrew-applications-in-orthodontics",totalDownloads:4697,totalCrossrefCites:0,totalDimensionsCites:2,abstract:null,book:{id:"4548",slug:"current-concepts-in-dental-implantology",title:"Current Concepts in Dental Implantology",fullTitle:"Current Concepts in Dental Implantology"},signatures:"Fatma Deniz Uzuner and Belma Işık Aslan",authors:[{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan"},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner"}]},{id:"50308",title:"Antibiotics in Implant Dentistry",slug:"antibiotics-in-implant-dentistry",totalDownloads:2369,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Antibiotics have been recommended either as an extended treatment for several days or as a single antibiotic prophylaxis dose since the development of dental implant osseointegration technique in the 1970s. It is also performed as part of surgical protocol during the peri-operative phase in the treatment of peri-implantitis. To date, there is a lack of scientific evidence regarding the additive effect of antibiotics in the treatment of dental implant. This has thus left the clinician with inconclusive recommendations, leading to increase antibiotic prescription. With this increase, the development of antibiotic resistance is becoming a threat to modern healthcare that requires revisiting of current indications and implementation of rational treatment strategies. Therefore, more studies are needed to assess the benefit of antibiotic prescription and whether it is safe to refrain from its use.",book:{id:"5185",slug:"dental-implantology-and-biomaterial",title:"Dental Implantology and Biomaterial",fullTitle:"Dental Implantology and Biomaterial"},signatures:"Dalia Khalil, Bodil Lund and Margareta Hultin",authors:[{id:"179031",title:"Dr.",name:"Dalia",middleName:null,surname:"Khalil",slug:"dalia-khalil",fullName:"Dalia Khalil"},{id:"185113",title:"Dr.",name:"Bodil",middleName:null,surname:"Lund",slug:"bodil-lund",fullName:"Bodil Lund"},{id:"185114",title:"Dr.",name:"Margareta",middleName:null,surname:"Hultin",slug:"margareta-hultin",fullName:"Margareta Hultin"}]},{id:"47915",title:"Rationale for Dental Implants",slug:"rationale-for-dental-implants",totalDownloads:3076,totalCrossrefCites:0,totalDimensionsCites:2,abstract:null,book:{id:"4548",slug:"current-concepts-in-dental-implantology",title:"Current Concepts in Dental Implantology",fullTitle:"Current Concepts in Dental Implantology"},signatures:"Ilser Turkyilmaz and Gokce Soganci",authors:[{id:"171984",title:"Associate Prof.",name:"Ilser",middleName:null,surname:"Turkyilmaz",slug:"ilser-turkyilmaz",fullName:"Ilser Turkyilmaz"}]},{id:"18430",title:"An Important Dilemma in Treatment Planning: Implant or Endodontic Therapy?",slug:"an-important-dilemma-in-treatment-planning-implant-or-endodontic-therapy-",totalDownloads:6264,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"179",slug:"implant-dentistry-a-rapidly-evolving-practice",title:"Implant Dentistry",fullTitle:"Implant Dentistry - A Rapidly Evolving Practice"},signatures:"Funda Kont Cobankara and Sema Belli",authors:[{id:"28846",title:"Dr.",name:"Funda",middleName:null,surname:"Kont Çobankara",slug:"funda-kont-cobankara",fullName:"Funda Kont Çobankara"},{id:"75862",title:"Prof.",name:"Sema",middleName:null,surname:"Belli",slug:"sema-belli",fullName:"Sema Belli"}]}],onlineFirstChaptersFilter:{topicId:"998",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81595",title:"Prosthetic Concepts in Dental Implantology",slug:"prosthetic-concepts-in-dental-implantology",totalDownloads:25,totalDimensionsCites:0,doi:"10.5772/intechopen.104725",abstract:"This chapter will address evidence-based prosthetic concepts in dental implantology as well as clinical evidence with focus on appropriate logic and technical skills. Those prosthetic factors are as just important as surgical factors, and long-term success can only be achieved if both of those factors are considered, respected, and strictly followed from planning to prosthetic phase of treatment. This chapter will deal with materials selection for prosthetic part, shape, size, and design of supracrestal parts of abutments and their influence on soft tissue and bone stability around dental implants. Furthermore, one of most important decisions is about choosing the proper way of retention: screw- vs. cement-retained restorations, and it will be discussed in detail. Additionally, emergence profile and its function in soft tissues adaptation and adhesion to different prosthetic materials also have important role in long-term success of dental implant restorations.",book:{id:"10808",title:"Current Concepts in Dental Implantology - From Science to Clinical Research",coverURL:"https://cdn.intechopen.com/books/images_new/10808.jpg"},signatures:"Ivica Pelivan"},{id:"80500",title:"Novel Dental Implants with Herbal Composites: A Review",slug:"novel-dental-implants-with-herbal-composites-a-review",totalDownloads:49,totalDimensionsCites:0,doi:"10.5772/intechopen.101489",abstract:"Missing a permanent tooth is a miserable condition faced by a common man. A tooth decay, periodontitis, mechanical trauma, or any systemic complications lead to such a complication. These bone defects when left untreated lead to severe resorption of the alveolar bone. A proper dental filling with an appropriate bone substitute material could prevent such resorption and paves a way for subsequent implant placement. Dental implants are considered as the prime option by dentists to replace a single tooth or prevent bone resorption. A variety of bone substitutes are available differ in origin, consistency, particle size, porosity, and resorption characteristics. Herbal composites in dentistry fabricated using biphospho-calcium phosphate, casein, chitosan, and certain herbal extracts of Cassia occidentalis, Terminalia arjuna bark, Myristica fragans also were reported to possess a higher ossification property, osteogenic property and were able to repair bone defects. C. occidentalis was reported to stimulate mineralization of the bone and osteoblastic differentiation through the activation of the PI3K-Akt/MAPKs pathway in MC3T3-E1 cells of mice. This implant proved better osteoconductivity and bioactivity compared to pure HAP and other BCP ratios. Terminalia Arjuna was also worked in the incorporation in the graft to enhance the osteogenic property of the implant and gave good results. Another implant bone graft was synthesized containing BCP, biocompatible casein, and the extracts of Myristica fragans and subjected to in vitro investigations and the results revealed the deposition of apatite on the graft after immersing in SBF and also the ALP activity was high when treated with MG-63 cells, NIH-3 T3, and Saos 2 cell lines. This study indicates that the inclusion of plant extract enhances the osteogenic property of the graft. Thus, these novel dental implants incorporated with herbal composites evaluated by researchers revealed an enhanced bone healing, accelerates osseointegration, inhibits osteopenia, and inhibits inflammation. This application of herbal composite inclusion in dentistry and its applications has a greater potential to improve the success rate of dental implants and allows the implications of biotechnology in implant dentistry.",book:{id:"10808",title:"Current Concepts in Dental Implantology - From Science to Clinical Research",coverURL:"https://cdn.intechopen.com/books/images_new/10808.jpg"},signatures:"Gopathy Sridevi and Seshadri Srividya"},{id:"78320",title:"Implant-Retained Maxillary and Mandibular Overdentures - A Solution for Completely Edentulous Patients",slug:"implant-retained-maxillary-and-mandibular-overdentures-a-solution-for-completely-edentulous-patients",totalDownloads:66,totalDimensionsCites:0,doi:"10.5772/intechopen.99575",abstract:"The main goal of modern removable prosthodontics is to restore the normal appearance, function, esthetics and speech in each completely edentulous patient. However, if all teeth are missing in a patient, it becomes very complicated to achieve it using traditional protocols. Therefore, implants were introduced into removable prosthodontics to ensure better retention and stability of the conventional dentures. In case of a large amount of bone missing in the jaw it is necessary to ensure the functioning of the dentures constructing various additional stabilizing and retentive prosthodontic solutions on the osseointegrated implants. Numerous types of attachment systems have been used recently for relating implant-retained overdentures to underlying implants: basically splinting (various bar shape designs) and non-splinting attachments (various ball type attachment, magnet attachment, telescopic coping systems). Indications for their use depend on the surgical and prosthodontic factors such as the number and position of the implants, the amount of free intermaxillary space and the type and size of the overdentures. Different indications, types of the overdentures and the attachment systems will be discussed in this chapter.",book:{id:"10808",title:"Current Concepts in Dental Implantology - From Science to Clinical Research",coverURL:"https://cdn.intechopen.com/books/images_new/10808.jpg"},signatures:"Dubravka Knezović Zlatarić, Robert Ćelić and Hrvoje Pezo"},{id:"79724",title:"Implant Stability Quotient (ISQ): A Reliable Guide for Implant Treatment",slug:"implant-stability-quotient-isq-a-reliable-guide-for-implant-treatment",totalDownloads:60,totalDimensionsCites:0,doi:"10.5772/intechopen.101359",abstract:"Implant stability is a prerequisite for successful dental implants and osseointegration. To determine the status of implant stability, continuous monitoring in an objective and qualitative manner is important. To measure implant stability two different stages are there: Primary and secondary. Primary implant stability at placement is a mechanical phenomenon that is related to the local bone quality and quantity, the type of implant and placement technique used. Primary stability is checked from mechanical engagement with cortical bone. Secondary stability is developed from regeneration and remodeling of the bone and tissue around the implant after insertion and affected by the primary stability, bone formation and remodeling. Implant stability is essential for the time of functional loading. Classical benchmark methods to measure implant stability were radiographs or microscopic analysis, removal torque, push-through and pull-through but due to lack of feasibility, time consumption and ethical reasons other methods have been propounded over period of time like measurement of implant torque, model analysis and most important ISQ which has the ability to monitor osseointegration and the life expectancy of an implant. ISQ is a valuable diagnostic and clinical tool that has far-reaching consequences on implant dentistry and this article throws light on advanced and reliable methods of assessing ISQ.",book:{id:"10808",title:"Current Concepts in Dental Implantology - From Science to Clinical Research",coverURL:"https://cdn.intechopen.com/books/images_new/10808.jpg"},signatures:"Gaurav Gupta"},{id:"79817",title:"Peri-Implant Soft Tissue Augmentation",slug:"peri-implant-soft-tissue-augmentation",totalDownloads:128,totalDimensionsCites:0,doi:"10.5772/intechopen.101336",abstract:"The peri-implant soft tissue (PIS) augmentation procedure has become an integral part of implant-prosthetic rehabilitation. Minimal width of keratinized mucosa (KM) of 2 mm is deemed necessary to facilitate oral hygiene maintenance around the implant and provide hard and soft peri-implant tissue stability. PIS thickness of at least 2 mm is recommended to achieve the esthetic appearance and prevent recessions around implant prosthetic rehabilitation. The autogenous soft tissue grafts can be divided into two groups based on their histological composition—free gingival graft (FGG) and connective tissue graft (CTG). FGG graft is used mainly to increase the width of keratinized mucosa while CTG augment the thickness of PIS. Both grafts are harvested from the same anatomical region—the palate. Alternatively, they can be harvested from the maxillary tuberosity. Soft tissue grafts can be also harvested as pedicle grafts, in case when the soft tissue graft remains attached to the donor site by one side preserving the blood supply from the donor region. Clinically this will result in less shrinkage of the graft postoperatively, improving the outcome of the augmentation procedure. To bypass the drawback connected with FGG or CTG harvesting, substitutional soft tissue grafts have been developed.",book:{id:"10808",title:"Current Concepts in Dental Implantology - From Science to Clinical Research",coverURL:"https://cdn.intechopen.com/books/images_new/10808.jpg"},signatures:"Marko Blašković and Dorotea Blašković"},{id:"79611",title:"Growth Factors and Dental Implantology",slug:"growth-factors-and-dental-implantology",totalDownloads:103,totalDimensionsCites:0,doi:"10.5772/intechopen.101082",abstract:"Normal healing procedure of bone involves various sequential events to develop bone and bridge the bone -to- bone gap. When this healing occurs with a metal (titanium) fixture on one side, it is called as osseointegration. After extensive studies on this topic, it is found that this procedure occurs in presence of various biologic constituents that are spontaneously released at the site. Thus, to accelerate normal healing after implant placement and make results more predictable, it has been proposed to use these autologous factors in the osteotomy site. Since it is the beginning of a new revolution in dental implantology, right now it is essential to analyze all possible combinations of host conditions, bone quality and quantity and bio factors being used. This can definitely be a boon for the patients with compromised systemic or local conditions.",book:{id:"10808",title:"Current Concepts in Dental Implantology - From Science to Clinical Research",coverURL:"https://cdn.intechopen.com/books/images_new/10808.jpg"},signatures:"Deeksha Gupta"}],onlineFirstChaptersTotal:17},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:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:106,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:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"June 29th, 2022",hasOnlineFirst:!0,numberOfOpenTopics:4,numberOfPublishedChapters:318,numberOfPublishedBooks:32,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},subseries:[{id:"14",title:"Cell and Molecular Biology",keywords:"Omics (Transcriptomics; Proteomics; Metabolomics), Molecular Biology, Cell Biology, Signal Transduction and Regulation, Cell Growth and Differentiation, Apoptosis, Necroptosis, Ferroptosis, Autophagy, Cell Cycle, Macromolecules and Complexes, Gene Expression",scope:"The Cell and Molecular Biology topic within the IntechOpen Biochemistry Series aims to rapidly publish contributions on all aspects of cell and molecular biology, including aspects related to biochemical and genetic research (not only in humans but all living beings). We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics include, but are not limited to: Advanced techniques of cellular and molecular biology (Molecular methodologies, imaging techniques, and bioinformatics); Biological activities at the molecular level; Biological processes of cell functions, cell division, senescence, maintenance, and cell death; Biomolecules interactions; Cancer; Cell biology; Chemical biology; Computational biology; Cytochemistry; Developmental biology; Disease mechanisms and therapeutics; DNA, and RNA metabolism; Gene functions, genetics, and genomics; Genetics; Immunology; Medical microbiology; Molecular biology; Molecular genetics; Molecular processes of cell and organelle dynamics; Neuroscience; Protein biosynthesis, degradation, and functions; Regulation of molecular interactions in a cell; Signalling networks and system biology; Structural biology; Virology and microbiology.",annualVolume:11410,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"79367",title:"Dr.",name:"Ana Isabel",middleName:null,surname:"Flores",fullName:"Ana Isabel Flores",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRpIOQA0/Profile_Picture_1632418099564",institutionString:null,institution:{name:"Hospital Universitario 12 De Octubre",institutionURL:null,country:{name:"Spain"}}},{id:"328234",title:"Ph.D.",name:"Christian",middleName:null,surname:"Palavecino",fullName:"Christian Palavecino",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000030DhEhQAK/Profile_Picture_1628835318625",institutionString:null,institution:{name:"Central University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"186585",title:"Dr.",name:"Francisco Javier",middleName:null,surname:"Martin-Romero",fullName:"Francisco Javier Martin-Romero",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSB3HQAW/Profile_Picture_1631258137641",institutionString:null,institution:{name:"University of Extremadura",institutionURL:null,country:{name:"Spain"}}}]},{id:"15",title:"Chemical Biology",keywords:"Phenolic Compounds, Essential Oils, Modification of Biomolecules, Glycobiology, Combinatorial Chemistry, Therapeutic peptides, Enzyme Inhibitors",scope:"Chemical biology spans the fields of chemistry and biology involving the application of biological and chemical molecules and techniques. In recent years, the application of chemistry to biological molecules has gained significant interest in medicinal and pharmacological studies. This topic will be devoted to understanding the interplay between biomolecules and chemical compounds, their structure and function, and their potential applications in related fields. Being a part of the biochemistry discipline, the ideas and concepts that have emerged from Chemical Biology have affected other related areas. This topic will closely deal with all emerging trends in this discipline.",annualVolume:11411,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",institutionString:null,institution:{name:"Ondokuz Mayıs University",institutionURL:null,country:{name:"Turkey"}}},editorThree:null,editorialBoard:[{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",fullName:"Abdulsamed Kükürt",profilePictureURL:"https://mts.intechopen.com/storage/users/219081/images/system/219081.png",institutionString:null,institution:{name:"Kafkas University",institutionURL:null,country:{name:"Turkey"}}},{id:"241413",title:"Dr.",name:"Azhar",middleName:null,surname:"Rasul",fullName:"Azhar Rasul",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRT1oQAG/Profile_Picture_1635251978933",institutionString:null,institution:{name:"Government College University, Faisalabad",institutionURL:null,country:{name:"Pakistan"}}},{id:"178316",title:"Ph.D.",name:"Sergey",middleName:null,surname:"Sedykh",fullName:"Sergey Sedykh",profilePictureURL:"https://mts.intechopen.com/storage/users/178316/images/system/178316.jfif",institutionString:null,institution:{name:"Novosibirsk State University",institutionURL:null,country:{name:"Russia"}}}]},{id:"17",title:"Metabolism",keywords:"Biomolecules Metabolism, Energy Metabolism, Metabolic Pathways, Key Metabolic Enzymes, Metabolic Adaptation",scope:"Metabolism is frequently defined in biochemistry textbooks as the overall process that allows living systems to acquire and use the free energy they need for their vital functions or the chemical processes that occur within a living organism to maintain life. Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. Thus all studies on metabolism will be considered for publication.",annualVolume:11413,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",fullName:"Anca Pantea Stoian",profilePictureURL:"https://mts.intechopen.com/storage/users/243049/images/system/243049.jpg",institutionString:null,institution:{name:"Carol Davila University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"203824",title:"Dr.",name:"Attilio",middleName:null,surname:"Rigotti",fullName:"Attilio Rigotti",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institutionString:null,institution:{name:"Pontifical Catholic University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"300470",title:"Dr.",name:"Yanfei (Jacob)",middleName:null,surname:"Qi",fullName:"Yanfei (Jacob) Qi",profilePictureURL:"https://mts.intechopen.com/storage/users/300470/images/system/300470.jpg",institutionString:null,institution:{name:"Centenary Institute of Cancer Medicine and Cell Biology",institutionURL:null,country:{name:"Australia"}}}]},{id:"18",title:"Proteomics",keywords:"Mono- and Two-Dimensional Gel Electrophoresis (1-and 2-DE), Liquid Chromatography (LC), Mass Spectrometry/Tandem Mass Spectrometry (MS; MS/MS), Proteins",scope:"With the recognition that the human genome cannot provide answers to the etiology of a disorder, changes in the proteins expressed by a genome became a focus in research. Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. The Proteomics topic aims to attract contributions on all aspects of MS-based proteomics that, by pushing the boundaries of MS capabilities, may address biological problems that have not been resolved yet.",annualVolume:11414,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null,editorialBoard:[{id:"72288",title:"Dr.",name:"Arli Aditya",middleName:null,surname:"Parikesit",fullName:"Arli Aditya Parikesit",profilePictureURL:"https://mts.intechopen.com/storage/users/72288/images/system/72288.jpg",institutionString:null,institution:{name:"Indonesia International Institute for Life Sciences",institutionURL:null,country:{name:"Indonesia"}}},{id:"40928",title:"Dr.",name:"Cesar",middleName:null,surname:"Lopez-Camarillo",fullName:"Cesar Lopez-Camarillo",profilePictureURL:"https://mts.intechopen.com/storage/users/40928/images/3884_n.png",institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",institutionURL:null,country:{name:"Mexico"}}},{id:"81926",title:"Dr.",name:"Shymaa",middleName:null,surname:"Enany",fullName:"Shymaa Enany",profilePictureURL:"https://mts.intechopen.com/storage/users/81926/images/system/81926.png",institutionString:"Suez Canal University",institution:{name:"Suez Canal University",institutionURL:null,country:{name:"Egypt"}}}]}]}},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/267499",hash:"",query:{},params:{id:"267499"},fullPath:"/profiles/267499",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()