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These books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\\n\\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\\n\\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
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IntechOpen and Knowledge Unlatched formed a partnership to support researchers working in engineering sciences by enabling an easier approach to publishing Open Access content. Using the Knowledge Unlatched crowdfunding model to raise the publishing costs through libraries around the world, Open Access Publishing Fee (OAPF) was not required from the authors.
\n\nInitially, the partnership supported engineering research, but it soon grew to include physical and life sciences, attracting more researchers to the advantages of Open Access publishing.
\n\n\n\nThese books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\n\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\n\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
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Acute pancreatitis is an inflammatory condition of the pancreas with a wide spectrum of pathological and clinical manifestations. It ranges from mild and self-limiting condition to severe pancreatitis with multiorgan failure with high mortality [1, 2].
\nIt was one of the most frequent gastrointestinal causes of hospital admissions in the United States with a total of 275,000 admissions in 2009. In the United Kingdom, hospitals serving a population of 300,000–400,000 people admit about 100 cases each year. Patients with severe acute pancreatitis need ICU admission and multidisciplinary team approach for treatment. It increases the health care cost enormously, and those survive will live with pancreatic endocrine and exocrine dysfunction.
\nThis chapter will focus mainly on severe acute pancreatitis.
Acute pancreatitis is an acute inflammatory process of the pancreas. It is an acute condition presenting with abdominal pain and is usually associated with raised pancreatic enzyme levels in the blood or urine as a result of pancreatic inflammation. It is a disorder of the exocrine pancreas and is associated with acinar cell injury with local and systemic inflammatory responses [3].
There is a wide range of classifications for acute pancreatitis. The Revised Atlanta Classification in 2012 classified acute pancreatitis according to the severity of the disease, morphology and temporal relation [1, 3].
\nAcute pancreatitis is classified into three forms based on the severity [3].
\nMild acute pancreatitis, which is characterized by the absence of organ failure and local or systemic complications.
Moderately severe acute pancreatitis, which is characterized by transient organ failure (resolves within 48 hours and without persistent organ failure >48 hours) and/or local or systemic complications.
Severe acute pancreatitis, which is characterized by persistent organ failure that may involve one or multiple organs.
Temporally, two phases of acute pancreatitis are as follows:
\nOnly clinical parameters are important for treatment planning and are determined by the systemic inflammatory response syndrome (SIRS), which can lead to organ failure.
Morphologic criteria based on CT findings combined with clinical parameters determine the care of the patient [4].
Morphologically, there are three types of acute pancreatitis as follows:
\nAcute oedematous (interstitial) pancreatitis
Acute necrotizing pancreatitis
Haemorrhagic
Usually, the necrosis involves both the pancreas and the peripancreatic tissues, less commonly the peripancreatic tissues alone and rarely the pancreatic parenchyma alone [1].
\nThe commonest cause in the western world is gallstones (50%) and alcohol (25%). Rare causes (<5%) include drugs (for example, valproate, steroids, and azathioprine), endoscopic retrograde cholangiopancreatography, hypertriglyceridaemia or lipoprotein lipase deficiency, hypercalcaemia, pancreas divisum and some viral infections (mumps and coxsackie B4). About 10% of patients have idiopathic pancreatitis, where no cause is found [5]. The aetiological factors are enumerated in Table 1.
Aetiology of Acute Pancreatitis | |
---|---|
Methyl alcohol Smoking Organophosphates Scorpion bite, certain spiders, Gila monster lizard | |
Biliary pancreatitis—Cholelithiasis, Biliary sludge Malignancy—pancreatic, ampullary, cholangiocarcinoma Parasitic infections—ascariasis Periampullary diverticulum Penetrating duodenal ulcer, Duodenal obstruction | |
Abdominal trauma—duct disruption | |
Hyperparathyroidism Hypertriglyceridemia Hypercalcaemia Diabetic ketoacidosis End-stage renal failure Pregnancy Post-renal transplant | |
Necrotising vasculitis—SLE, Thrombotic thrombocytopenia Atheroma Shock | |
Vasculitis—SLE, polyarteritis nodosa | |
Corticosteroids, furosemide, tetracyclines, thiazides, oestrogen, valproic acid, Metronidazole, pentamidine, nitrofurantoin, erythromycin, methyldopa, ranitidine 5-ASA/salicylates, azathioprine/6-MP, didanosine, pentamidine, L-asparaginase | |
Post-ERCP pancreatitis Pancreas divisum in some patients Ischaemia, hereditary pancreatitis is a rare familial condition |
Aetiology of acute pancreatitis.
The exact pathogenesis of acute pancreatitis is unknown, and there is an ongoing research at the molecular level. There are many pathophysiological hypothesis put forward to explain the processes. These hypotheses are based on the aetiology and risk factors. The final result of the pathophysiological process is activation of proteolytic enzymes (intra-acinar activation of trypsinogen) leading to breakdown of the junctional barrier between acinar cells and leakage of pancreatic fluid and enzymes into the interstitial space causing autophagy and autodigestion of acinar cells [2, 3]. Diagram 1 depicts the hypothetical aetiopathogenic process of acute pancreatitis.
Aetiopathogenesis of acute pancreatitis.
Three different phases can be seen during the pathogenesis of acute pancreatitis. The first phase is the acinar cell damage and death. The second phase is local inflammation of the pancreas. The third and final phase is the SIRS. The first two phases take place in the pancreas itself, while in the third phase causes the distant organ damage and extrapancreatic symptoms.
\nPancreatic ductal obstruction and hypersecretion have been mentioned as factors that contribute to the initiation of the inflammatory process. Different pathophysiological mechanisms have been proposed for ethanol-induced pancreatitis. Explanations like ethanol-induced direct toxicity to the acinar cell, sphincter of Oddi dysfunction, hypertriglyceridaemia, free oxygen radical formation, and protein deposition within the pancreatic duct, which favours retrograde flow of enzymatic. These processes lead to activation of inflammation and membrane destruction. Newer hypotheses include ischaemia/reperfusion injury and enzymatic co-localisation. Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis: 1–3% develops pancreatitis, probably due duct disruption and enzyme extravasation. Patients at the risk of developing post-ERCP pancreatitis have sphincter of Oddi dysfunction or a history of recurrent pancreatitis, those who undergo sphincterotomy or balloon dilatation of the sphincter.
\nSystemic inflammatory response syndrome (SIRS) due to acute pancreatitis is because of the acinar cell death which releases activated pancreatic enzymes. This sets up a local inflammatory response which then activates systemic inflammatory response by release of cytokines, tumour necrosis factor, activation of immunocytes and the complement system activation [2–5].
Symptoms of acute pancreatitis are sudden onset of severe, persistent epigastric pain with or without radiation to the back. Radiation to the back is seen in about 50% of patients. It may be relieved by sitting or leaning forwards. Some patients complain of right upper quadrant pain. Pain is usually associated with nausea and vomiting.
Signs vary according to the severity of the disease. It ranges from mild epigastric tenderness to a diffusely tender abdomen.
\nTachypnoea, tachycardia, and hypotension may be present. Fever due to inflammatory response. Acute swinging pyrexia suggests cholangitis. Icterus may be seen in biliary pancreatitis. Cullen sign, i.e. ecchymotic discoloration in the periumbilical area and Grey Turner sign, i.e. ecchymotic discoloration along the flanks due bleeding into the fascial planes, but these signs are not specific for acute pancreatitis. Abdominal distension due to ileus, guarding in the upper abdomen, free fluid may elicit shifting dullness. Pleural effusion is present in 10–20% of patients. Acute confusion due to metabolic derangement and hypoxaemia. Tetany is seen in some patient because hypocalcaemia [6, 7]
\nPerforated peptic ulcer, acute myocardial infarction, and cholecystitis should be rule out in differential diagnoses for acute pancreatitis.
Serum amylase and lipase are both elevated in acute pancreatitis. The rise can be within 4–12 hours. The rise of >3 times the normal upper limit is the threshold for the diagnosis of acute pancreatitis [6, 7].
\nIt is an enzyme that hydrolyses the starch. The principal sources of amylase are the pancreas, salivary glands and fallopian tubes. Amylase has a shorter half life of 10 hours and returns to normal within 3–5 days. Hyperamylasaemia is seen in many other conditions. It may be increased in a number of other conditions like intestinal ischaemia and perforation, parotitis and acute renal failure, it is a less specific marker in acute pancreatitis. Its levels begin to rise 6–12 hours after the onset of acute pancreatitis, and they return to normal in 3–5 days. It has a high sensitivity (>90%) but a low specificity (as low as 70%) for the diagnosis of acute pancreatitis. Normal serum amylase level will not exclude acute pancreatitis if the patients present late to hospital [1, 6, 7].
It a pancreatic enzyme that hydrolyses triglycerides. Its level increases within 4–8 hours of the onset and peaks at 24 hours and then returns to normal after 8–14 days. The rise in levels should be >3 times the upper limit of normal. It has excellent sensitivity in acute alcoholic pancreatitis. It is more specific than serum amylase for the diagnosis of acute pancreatitis. It has a sensitivity and specificity of 80–100% for acute pancreatitis. The principal sources of lipase are pancreas. The other sources are the tongue, liver, and intestine. These enzymes are useful in diagnosis of acute pancreatitis, but daily levels of these enzymes add no advantage in management. The levels are not useful in assessment of the severity of pancreatitis or decreasing levels are not marker of improvement. Simultaneous estimation of amylase and lipase levels does not improve accuracy [1, 6, 7].
In other laboratory investigations which help in etiological diagnosis are liver function test and serum triglycerides. Elevated liver enzymes, especially levels alanine transaminase Alanine Aminotransferase (ALT), level >150 U/L, it has a positive predictive value of 85% for gallstones. It will aid in diagnosis of acute biliary pancreatitis. Liver Function Test (LFT) should be done in all patients acute pancreatitis, patients within 24 hours of admission. C reactive Protein (CRP) levels will help in assessment of the severity of the disease process [5–7].
The most commonly used imaging modalities in acute pancreatitis are transabdominal ultrasound, endoscopic ultrasound, dynamic contrast enhanced CT scan and Magnetic Resonance Cholangiopancreatography (MRCP). Imaging studies are not indicated for diagnosing acute pancreatitis as it does not predict disease severity at the time of presentation to emergency department. Imaging studies are indicated when there is diagnostic dilemma due to non-conclusive biochemical tests or because of the severity clinical condition or unexplained MODS, which warrants to rule out other intra-abdominal pathologies like gastrointestinal tract perforation and peritonitis.
\nIt also helps in rule out other conditions during the differential diagnosis of acute pancreatitis. The role of CT scan and magnetic resonance imaging (MRI) lies in the detection of complications of acute pancreatitis, such as pancreatic necrosis, peripancreatic fluid collections or pseudocysts; the presence of these complications can also be used to predict the severity of the disease [6].
Transabdominal ultrasound is less sensitive and less useful to visualize the inflamed or necrotic pancreas. The distended abdomen because of the gas-filled bowel obscures the pancreatic view. It cannot assess the extent of necrosis.
\nIt helps in detection of gall stones, which are found in about 50% patients with acute pancreatitis or dilatation of biliary tract secondary to obstruction.
\nOnly indication of US scanning abdomen on presentation to emergency department is to rule out cholelithiasis as a cause for pancreatitis. Transabdominal ultrasound in later stages can help diagnosis of infection and therapeutic intervention-like guiding aspiration [6, 7].
It is a combination of ultrasonography and endoscopic simultaneously. It is comparatively less invasive than endoscopic retrograde cholangiopancreatography (ERCP). It has a high sensitivity when compared to transabdominal ultrasound, especially in detecting the common bile duct microlithiasis and biliary sludge. It has a diagnostic yield of up to 88%. It helps in identifying patients who might benefit from endoscopic retrograde cholangiopancreatography and its therapeutic interventions. The added advantage of endoscopic ultrasonography is that it can be performed beside in unstable ICU patients, pregnant women where CT is contraindicated, and patients with metallic implants where MRCP is contraindicated [6, 7].
Contrast-enhanced computed tomography is the gold standard to detect necrosis and to grade the severity of acute pancreatitis. This imaging modality also helps detecting local complication. CT scan findings range from localized oedema, pancreatic tissue inflammation (Figure 1), necrosis to extensive peripancreatic fluid collections (Figure 2).
Oedematous pancreatitis.
Pancreatitic necrosis.
CT findings of acute pancreatitis are diffuse or segmental enlargement of the pancreas due to interstitial oedema and irregular contour. Contrast non-enhancement represents pancreatic necrosis which is heterogeneous in appearance, peripancreatic fluid collection. Whole pancreatic necrosis is rare, multifocal areas are common. Necrosis is seen seen after 96 hours from the start of symptoms. CT scan performed before 72 hours will underestimate the degree of necrosis. The necrosis pancreas is variable involving the periphery with preservation of the core or involving the head, body, or tail separately or in combination. The outcome depends on the part of the pancreas involved. Necrosis of the entire pancreas has a relatively better outcome when compared to the head of pancreas involvement. Necrosis of the head of pancreas causes obstruction of the pancreatic duct there by an increase in pancreatic duct pressure causing to damage to acinar cells and leakage of destructive enzymes. Necrosis only in the distal portion of the pancreas has a favourable outcome and fewer complications [8]. Figure 2 shows the CT image of pancreatic necrosis.
Haemorrhagic pancreatitis.
Patients in whom the clinical diagnosis is in doubt
Patients with hyperamylasaemia and severe clinical pancreatitis Figure 3 abdominal distension, tenderness, high fever (>39°C), and leucocytosis
Patients with Ranson’s score >3 or the acute physiology and chronic health evaluation (APACHE) II >8
Patients showing lack of improvement after 72 hours of initial therapy,
Acute deterioration following the initial clinical improvement [8].
The modified CT severity index is a modification of the original CT severity index developed by Balthazar and colleagues in 1994. Table 2 enumerates the details of the evaluation of Balthazar’s computed tomography scoring system for acute pancreatitis.
Inflammatory process | Grade | score |
---|---|---|
Normal | A | 0 |
Focal or diffuse enlargement | B | 1 |
Contour irregularity | ||
Inhomogeneous attenuation | ||
Grade B plus peripancreatic haziness/Mottled densities | C | 2 |
Grade B, C plus one ill-defined peripancreatic fluid collection | D | 3 |
Grade B, C plus two ill-defined peripancreatic fluid collection or gas | E | 4 |
Necrosis | ||
None | 0 | 0 |
<30% | 0 | 2 |
50% | 4 | |
>50% | 6 |
Evaluation of Balthzar’s computed tomography scoring system for acute pancreatitis.
0–2: mild
4–6: moderate
8–10: severe.
The two factors that are useful in grading the severity of pancreatitis by CT are the extent pancreatic necrosis and the degree of peripancreatic inflammation. CT finding of necrosis and peripancreatic fluid collection strongly correlates with the complications (morbidity) and mortality [6, 7, 9, 10].
Normal pancreas
Focal or diffuse pancreatic enlargement
Pancreatic gland abnormalities associated with peripancreatic inflammation
Single fluid collection
Two or more fluid collections and/or gas present in or adjacent to the pancreas [10].
Repeat scanning is only indicated if there is any deterioration in clinical condition to rule out/diagnose pancreatic necrosis, abscess or pseudocyst, haemorrhage, or bowel ischaemia or perforation.
Magnetic resonance imaging (MRI) and MRCP are non-invasive imaging modalities. It has several advantages over CT, like no risk from radiation, can detect pancreatic duct continuity and parenchymal changes. It helps diagnose acute pancreatitis and identifying the aetiology of acute pancreatitis. MRI can accurately differentiate between necrotic and non-necrotic tissue.
It is especially useful to visualising the pancreatic duct and detecting lithiasis. MRCP is performed when ERCP has failed. The advantage of MRCP over CT scan is that iodinated contrast agents can be avoided and thereby avoid the risk for acute kidney injury.
\nDisadvantages of MRI and MRCP is transportation of critically ill patients to the MRI suite are limited access to patient during the acquisition of images and longer time to complete the study.
To classify the disease process.
To predict the level of care needed, ICU or HDU for monitoring and supportive care.
To predict the outcome depending the severity of the acute pancreatitis, especially the mortality.
Select patients for specialised interventions as therapy to improve the outcome.
If patients are managed by the nonspecialist clinicians, then the scoring system will help them identify patients who need consultation and transfer to specialist centre.
For comparisons of severity within and between patient series.
In research for rational selection of patients for inclusion in trials.
It helps in intra-, inter-departmental and patient and patient family communication—using the same language.
Severity assessment should be carried out within 48 hours of diagnosis of acute pancreatitis. Patients with a body mass index over 30 are at higher risk of developing complications.
There are various scoring systems in vogue, using the clinical data, laboratory markers and radiological findings to assess and grade the severity of the acute pancreatitis. The scoring systems are of two types: one that correlates clinical features and lab indices and the other being the use of non-specific physiological scoring, namely, APACHE II and III. The commonly used scoring systems are the Ranson’s criteria, Glasgow (Imrie) scoring systems, the APACHE II and III scoring systems (mainly used in ICU), the Simplified acute physiology score, bedside index of severity in acute pancreatitis (BISAP) scoring system, and the CT severity index. None of the scoring systems have a high sensitivity, specificity, positive predictive value or negative likelihood ratio. The scoring systems used at present are often inadequate in patients with severe Acute necrotizing pancreatitis (ANP), which is characterised by rapidly progressive multiple-system organ dysfunction [3, 4, 10].
The Ranson’s criteria were introduced in clinical practice in the early 1970s. It is the most widely used scoring system. Note that, 11 criteria are taken into account. Table 3 enumerates the Ranson’s criteria for assessment severity of acute pancreatitis. They were designed after analysis of 100 patients with alcohol-induced pancreatitis. It makes use of a combination of clinical and biochemical parameters obtained at admission and during the first 48 hours after admission. It reflects the extent of metabolic derangement and estimates the risk for mortality.
|
|
0–2 < 1% 3–4 ≈ 15% 5–6 ≈ 40% >6 ≈ 100% |
Ranson’s criteria for assessment severity of acute pancreatitis.
Drawbacks of the scoring system are that the study was only for alcoholic pancreatitis, do not take into consideration the ongoing treatment and predicts high mortality which is not the case in today’s practice.
\nThe Ranson’s criteria have a sensitivity 74%, specificity 77%, positive predictive value 49% and negative predictive value 91% [3, 4, 10].
A decade after the Ranson’s criteria were introduced, a re-evaluation of those criteria was done and found that the eight of the criteria were most predictive of the severity and outcome. Table 4 enumerates the modified Glasgow criteria (Imrie score) for assessment severity of acute pancreatitis.
|
|
Modified Glasgow criteria (IMRIE SCORE) for assessment severity of acute pancreatitis.
Those eight criteria were renamed as Glasgow criteria or Imrie score. It’s use is limited in Emergency department (ED) as some of the variables are only evaluated at 48 hours. The criteria excluded from the Ranson’s criteria are Lactate dehydrogenase (LDH), base deficit, and fluid deficit, and these were found to be least contributory in assessment of severity and outcome [9, 10].
\nThe Glasgow (Imrie) criteria are valid for both alcohol induced and biliary pancreatitis. A scores 3 or more after 48 hours of presentation indicates severe acute pancreatitis.
It is an acute phase reactant. It should be done after 48 hours of presentation. It can be used both for the assessment of severity and monitoring the progress of the disease. Levels more than 100 mg/L late in the first week after presentation indicate that patient is developing pancreatic necrosis. Procalcitonin will help identifying the pancreatic infection. IL-6, trypsinogen activation peptide, polymorphonuclear elastase, and carboxypeptidase B activation peptide can also be used for assessing the severity and monitoring the progress of the disease, but these are either used as a research tool or not yet routinely available.
\nPersistent high haematocrit is also an indicator of pancreatic necrosis and organ failure. If initial resuscitation is inadequate, then haemoconcentration is not a useful marker [3, 4, 10].
The acute physiology and chronic health evaluation (APACHE) II is (Knaus et al.) used to quantify the severity of the illness in ICU patients. It contains 12 continuous variables, the age and the pre-morbid conditions (which reflect a diminished physiological reserve). Patients with an APACHE II score >8 have severe acute pancreatitis and are likely to develop organ failure. It can be used in monitoring the patient’s response to therapy throughout the patient’s hospital stay unlike Ranson’s and Glasgow, which is assessed in the first 48 hours. Hence, it can assess both the severity and progress/deterioration. Disadvantages being that it is complex to perform and has been evaluated prospectively only in first 24–48 hours after the onset of pancreatitis. In criteria used, factors with most predictive value for mortality include advanced age, presence of renal or respiratory insufficiency and presence of shock. It has a sensitivity of 65%, specificity of 76%, positive predictive value of 43% and negative predictive value of 89%. APACHE III is also been used in predicting the severity of pancreatitis [10].
BISAP score is a beside scoring system with fewer variables than Ranson’s criteria. The data sued in scoring are the basic data recorded during the time of admission or taken from the first 24 hours of the patient’s evaluation. Table 5 enumerates the criteria of bedside index of severity in acute pancreatitis (BISAP) score for assessment severity of acute pancreatitis. It is a prognostic scoring system that predicts the mortality, whereas Ranson’s score predicts persistent organ failure. BISAP scores have the advantages over Ranson’s and Glasgow scores of being calculated within 24 hours of admission, use fewer variables. BISAP score is higher in patients having SIRS, in older patients and in patients with altered mental status. It has the disadvantage that it cannot easily distinguish transient from persistent organ failure [3, 4, 10].
Bedside index of severity in acute pancreatitis (BISAP) score | ||
---|---|---|
Scores | ||
1 | 0 | |
BUN >25 mg/dL (8.9 mmol/L) | >25 mg% | <25 mg% |
Abnormal mental status with a Glasgow coma score <15 | Present | Absent |
Evidence of SIRS (systemic inflammatory response syndrome) | 2/4 | Absent |
Patient age | >60 years old | <60 years old |
Imaging study reveals pleural effusion | Present | Absent |
Bedside index of severity in acute pancreatitis (BISAP) score for assessment severity of acute pancreatitis.
Patients with a score of zero predict a mortality of less than 1 whereas patients with a score of 5 predict a mortality rate of 22%. The way forward may be to use a combination of the Ranson’s score, the radiological scoring systems and a descriptive organ failure score such as the sepsis-related organ failure assessment.
Management of acute pancreatitis should be aggressive and begins early in the emergency department once the diagnosis is made. Initial resuscitation can affect the outcomes of acute pancreatitis significantly.
\nThe treatment can be divided into three major parts as follows:
\nICU admission and management
Treatment of the local complications
ICU/HDU admission is needed in patients with severe acute pancreatitis for close monitoring, organ support, and follow up. It is difficult to decide which patient is a candidate for ICU/HDU admission at the time of presentation. There is a lack of early and adequate predictors of impending organ dysfunction. But the patients present with signs of organ dysfunction like hypotension, respiratory insufficiency, coagulopathy (including Disseminated intravascular coagulation (DIC), and acute kidney injury are definite candidates for ICU/HDU admission. Other than organ dysfunction patients with severe metabolic derangements like hyperglycaemia, severe hypocalcaemia and patients with comorbidities like heart failure, chronic kidney disease where the acute on chronic organ dysfunction may develop are the candidates for ICU admission [10]
Monitoring a patient with acute severe pancreatitis can be divided into the following:
\nMonitoring of vital signs: Heart rate, blood pressure, respiratory rate, oxygen saturation, urinary output and level of consciousness
Biochemical evaluation of organ function: Blood gases, lactic acid, renal function test, coagulation profile, haematocrit, blood glucose and serum electrolyte levels, especially calcium, magnesium, and liver function test. These test may alert impending organ dysfunction, improvement or worsening of the organ function
Development of local complications like pancreatic necrosis and infection, which are associated with increased morbidity and mortality.\n
Pancreatic necrosis is detected by contrast enhanced CT scan
Pancreatic infection needs repeated contrast enhanced CT scan with CT/US guided fine needle aspiration
Intra-abdominal pressure (IAP): Intra-abdominal hypertension (IAH) is related to the development of complications, especially necrosis and infection, bowel oedema. High IAP is one indication for intervention like aspiration or surgery [6, 7, 10].
Hypotension is one of the most common presentations with acute pancreatitis. It is a sign of impending organ dysfunction. The hypotension is due to the third space loss secondary to the inflammatory response, this contributes to hypoperfusion and end organ perfusion dysfunction. Aggressive fluid resuscitation and rapid restoration of intravascular volume are the main stay of the treatment. It requires several liters of fluids. Both crystalloids and colloids can be used as resuscitation fluids. There is no evidence that colloids have any added benefit over crystalloids. Among the crystalloid, use of 0.9% sodium chloride is to be avoided. As it causes hyperchloraemic metabolic acidosis, which is associated with renal impairment, infections and activation of trypsinogen in a pH-dependent manner. Lactated Ringer’s solution is a cystalloid, it is a balanced salt solution, It is fluid of choice it has been found to be less incidence of SIRS compared to normal saline. Both under resuscitation as well as over resuscitation can lead to adverse outcomes, hence very close monitoring is recommended. Over resuscitation can lead interstitial oedema, bowel oedema, Acute respiratory distress syndrome (ARDS) which can lead to organ dysfunction. Monitoring of fluids status should be done by physical examination (clinical condition, vital signs and urine output), volume responsiveness and dynamic parameters by sonography or invasive or semi invasive haemodynamic parameters. Metabolic indicators like serial measurements of blood urea nitrogen and haematocrit [11, 12].
Pleuropulmonary abnormalities are commonly associated with pancreatitis, respiratory dysfunction is rarely seen at the time of presentation to Emergency department (ED) but usually develops after fluid resuscitation. It manifests as acute lung injury or acute respiratory distress syndrome. It is one of the major components of multiple organ system dysfunction syndromes. Other manifestations are bilateral infiltrates, pleural effusion, pulmonary hypertension, and decreased thoracic compliance [11, 12].
\nPatients with acute severe pancreatitis should be monitored closely for early detection of failure. Respiratory support usually initiated by supplemental oxygen and mechanical ventilation is often required depending on the severity of respiratory dysfunction. Nasogastric decompression will decrease the distension and improve the compliance and prevent aspiration. Non-invasive ventilation is poorly tolerated in most of the patients because of abdominal distension and reduced functional residual capacity, careful selection of patient is warranted. Non-invasive ventilation is good choice to start with as it may avoid endotracheal intubation. Acute lung injury and Acute respiratory distress syndrome (ARDS) secondary to acute severe pancreatitis is similar to any other condition using lung protective strategies. Pleural effusion may need ultrasound-guided drainage. Good analgesia will help in chest physiotherapy, early physiotherapy will prevent atelectasis and related complications [11, 12].
Pain is one of the symptoms of acute severe pancreatitis. It causes discomfort and heightened sympathetic activity, impairment of oxygenation due to restriction of abdominal wall movement. Effective analgesia can be provided by the use of opioids and parenteral route, i.e. intravenous route is the preferred route. Analgesia may improve pulmonary dysfunction. In the past, morphine was supposed to exacerbate acute pancreatitis by promoting contraction of the sphincter of Oddi and increase pressure in the sphincter of Oddi dysfunction, but there is no good supportive evidence. Another modality of pain management is use of drugs like local anaesthetics through in epidural route [13, 14].
Acute pancreatitis is a catabolic and hypermetabolic pathophysiological condition. This disease process increases protein demand and the calorie requirements. This altered metabolic state is further deranged by poor oral intake due to pain, ileus or partial obstruction of the duodenum from pancreatic oedema. There are increased protein losses locally in the retroperitoneum due to inflammation and through pancreatic fistulae. These features may be compounded by the pre-existing malnutrition, e.g. in alcohol abuse [11, 12, 13].
\nIf malnutrition and a prolonged negative nitrogen balance are not taken care, it may result in poor pancreatic healing, increased risk of infection, impaired immunity, gut dysfunction leading to translocation of bacteria. Nutritional care and therapy along with other therapeutics measures will results in faster recovery and better outcome.
\nFeeding during severe acute pancreatitis may be challenging. The questions to address during the initiation of the nutritional support are when? How? and what?
\nEarlier concept of feeding in acute pancreatitis: the pathogenesis of pancreatitis is assumed to be perpetuation of premature enzymatic activation. ‘Resting the pancreas’ the approach to avoid stimuli to exocrine secretion from the pancreas was thought to be most physiological method to treat the pancreatitis. Hence, parenteral nutritional was the preferred option to avoid stimulation of the inflamed pancreatic gland. The other hypothesis is that systemic inflammatory response syndrome is caused by the absorption of the pancreatic endotoxins and ultimately leads to multiorgan failure. If the gut mucosal barrier is maintained, then it reduces the absorption of endotoxin. The present concept of nutritional support in acute pancreatitis: the preferred route of nutritional support is ‘enteral route’, it should be initiated as early as possible within 24–48 hours of presentation. Parenteral route is second choice, especially if the presentation is severe and it is unlikely to start oral intake within the next 5–7 days. The advantages of the enteral feeding are improved gut blood flow, maintenance of mucosal integrity and barrier function there by reduction in microbial translocation and pancreatic infection, and better glycaemic control, avoidance of central venous access-related complications are benefits of enteral nutrition. There benefits are translated in lower incidence of infections, multiorgan failure and outcome, i.e. mortality and length of stay when compared to parenteral nutrition [11–13].
If nutritional support is supplemented by the enteral route, then it is usually delivered by tube feeding. There is a controversy about nasogastric versus nasojejunal feeding. But there is not much evidence to support any one over the other. Though traditionally nasojejunal feedings (to be delivered distal to the ligament of Treitz) have been preferred with the concept of less stimulation of the exocrine pancreas, cholecystokinin (CCK) cells that are present in the distal third part of the duodenum get stimulated when food passing through duodenum. It releases CCK that stimulates the pancreas and increased volume of pancreatic enzymes and bicarbonate secretion. This may worsen the course of the disease. Nasogastric tube feedings have now been shown to as safe as the jejunal feeding. Nasogastric insertion can be at bedside. Fluoroscopy endoscopic (endoscopically placed guide wire) and specialist help is not needed. With the Nasogastric (NG) feeding, the standard precautions of aspiration like elevation of head end of bed should be followed.
\nThe indication for nasojejunal feeds is when patients cannot tolerate gastric feeding due to ileus and slow bowel transit time. Nasojejunal (NJ) tube placement needs fluoroscopy, endoscopic, and specialist help. NJ tube may get displaced back into the stomach. Prokinetics and right-lateral positioning pass the tube through the into-duodenum. The correct positioning of the tube should be ascertained regularly by radiography [2, 7, 13].
No specific enteral nutrition supplement or immunonutrition formulation had any advantage. Low fat formulas with medium-chain triglycerides should be used enteral because it helps in better assimilation by direct absorption into the portal vein as there is lipase deficiency.
The common complications are metabolic and splanchnic. They are as follows:
\nHypertriglyceridemia is usually due to overfeeding. Monitor serum triglyceride level and titrate fat content.
\nInfection is common in pancreatic necrosis, it occurs in approximately 40–70% of patients. Infection causes an increase in morbidity and mortality. There are various theories proposed for the mechanisms of infection in severe acute pancreatitis, namely bacterial translocation from the colon, via the biliary tree, especially in biliary pancreatitis, bacterial migration through the pancreatic duct from the lumen of the duodenum and haematogenous spread from bacteraemia due to other causes like infected central venous lines [5, 9, 10].
\nProphylactic antibiotics in severe acute pancreatitis have been a topic of debate in the last 4–5 decades. Pancreatic necrosis more than 30% increases the chances of infection. The right choice of antibiotics is very important, those which have high penetration into pancreatic tissue. Carbapenems are both broad spectrum and excellent pancreatic penetration properties. Other antibiotics, which penetrate well in the pancreatic tissue, are cephalosporin, ureidopenicillins, fluoroquinolones, metronidazole and imipenem. Aminoglycosides have a poor penetration ability. Patients with mild pancreatitis do not benefit from antibiotics. In a meta-analysis by Sharma et al. [16], use of prophylactic antibiotics has shown mortality benefit in patients with Acute necrotizing pancreatitis (ANP) confirmed by contrast-enhanced CT (21–12.3%). Ref. [15, 16] prophylactic antibiotics use has not shown to decrease the need for interventional and surgical management but no effect on mortality.
Fungal infection in severe acute pancreatitis is associated with high morbidity and mortality.
\nIt has been noted that the incidence depends on the severity of the disease, extent of necrosis and use of broad spectrum antibiotic administration. Prophylactic use of fluconazole has shown to be effective in decreasing the morbidity but not the mortality [10].
The presence of non-viable tissue in the pancreatic parenchyma, which is detected by the non-enhancement on the contrast-enhanced CT, is called as pancreatic necrosis. It can be focal or diffuse with associated peripancreatic involvement. It can be sterile necrosis or get infected in approximately 70% of the cases. The diagnosis of infection of the necrotic pancreas is difficult. Infected necrosis is diagnosed in the patients who show no signs of improvement, signs of sepsis (leukocytosis and fever are confounded by the SIRS), worsening of clinical condition, especially after improvement. The lab data to confirm the infection of the necrotic pancreatic tissue are not reliable. Biomarker like CRP is usually high in severe acute pancreatitis, but procalcitonin can be used as a marker, but still it is not specific because in patients who are critically ill, there are other infection like Central Line-associated Bloodstream Infection (CLABSI), Ventilator-Associated Event (VAE) (Ventilator-Associated pneumonia (VAP)), Catheter-associated Urinary Tract Infections (CAUTI), etc. wherein procalcitonin is raised.
\nThe best method to confirm the diagnosis of infected pancreatic necrosis is CT/US guided fine needle aspiration, Gram’s staining, and culture. Multiple samples from all pockets should be taken or sampling needs to be repeated. Pancreatic abscess is a collection of pus in close proximity to pancreatic necrosis, which develops as a local infection of the necrotic pancreatic tissue after severe acute pancreatitis.
Sterile pancreatic necrosis is usually managed conservatively (non-operatively). Earlier in the 1990s, all necrotic pancreatitis use to undergo necrosectomy. Surgical intervention in sterile pancreatic necrosis may increase the risk of infection and thereby an increase in the mortality. Patients with sterile pancreatic necrosis need close observation for evidence of infection. In selected patients with extensive necrosis may need surgical intervention if they do not improve for more than 6–8 weeks [3, 8, 11, 12].
Infected necrotic pancreatitis requires debridement and there is a consensus on surgical intervention in such cases. There is still a controversy about the best approach for debridement of the infected necrotic pancreatic tissue.
\nThe aim of the intervention is removal of the infected necrotic substance. To achieve this goal, there are several techniques suggested. It ranges from drainage, debridement, lavage laparoscopy to laparotomy and packing.
Anterior
Retroperitoneal
This can be done when there are infected fluid collections or pus. It will be difficult to drain if it is just infected necrotic tissue or fluid/pus is too viscous. It has to be done CT/US guided and needs expertise. Complications are rare in expert hands. Usual complications with percutaneous drainage are bleeding, viscous perforation, fistula formation and super infection [3, 11, 12].
Minimally invasive
Open surgical
These procedures can be performed transperitoneal or retroperitoneal which is decided on the location of necrosis and collections. Some patients need multiple sitting and planned relaparotomies. The open surgical approach carries higher risk of morbidity and mortality when compared to laparoscopic technique. There is higher risk of bleeding, perforation multiple organ failure, enterocutaneous fistula, incisional hernia, and new-onset diabetes mellitus [13, 14]
There is very few or nothing to do for the etiological management other than biliary pancreatitis. The treatments depend on the severity of the pancreatitis. In severe pancreatitis, there is no role of surgery. Surgery increases the morbidity and mortality. ERCP (endoscopic retrograde cholangiopancreatography) with sphincterotomy is indicated in patients with acute cholangitis. This will help in decreasing the pressure in pancreatic duct and lessens the severity of the disease. ERCP with sphincterotomy decreases the morbidity but not the mortality [13, 14].
Change in dietary habits and consumption of balance diet will prevent the gall stone formation, earlier cholecystectomy will prevent the recurrence of pancreatitis. Regular exercise, avoiding the high caloric intake, regular use of low fat diet will control the serum triglyceride levels and early introductions of statins will help in preventing the hyperlipidaemia associated pancreatitis. Moderation in alcohol intake will reduce the incidence of alcoholic pancreatitis [13, 14].
Breast cancer begins in the late 20s, but the mammary glands are well developed in the 20s and 30s, making initial diagnosis by X-ray mammography, which is a general examination, difficult. There is an ultrasonic diagnostic device (US) as an alternative method, but the reliability of the diagnosis depends on the skill of the inspector, the reproducibility of the data is poor, and continuous tomographic images cannot be obtained [1]. On the other hand, magnetic resonant image (MRI) and positron emission tomography (PET) are not candidates for examination equipment because of their large scale, long examination time, and high cost. Microwave imaging (MI) has a stronger contrast between soft tissues than X-rays and ultrasound. MI is not exposed to radiation, and has the characteristics of being small in scale and inexpensive. However, there are problems to be solved and it has not yet been put into practical use.
There are two types of MI, scattering tomography (ST), which solves the inverse scattering problem and reconstructs the relative permittivity and conductivity distribution in the breast, and confocal imaging (CI), which reconstructs the scattered power distribution [2]. In principle, the former can reconstruct the shape of intramammary tissue and is suitable as a diagnostic device. However, the inverse scattering problem is a non-linear ill-posed problem with more unknowns (relative permittivity / conductivity distribution in the breast) than the number of equations (measurement data), and is susceptible to modeling, manufacturing, and measurement errors. The latter has been clinically imaged by several research groups, including the author, and strong scattering has been confirmed around the cancer [3, 4, 5, 6]. However, even in breasts without lesions, meaningless scattered images (artifacts) appear due to multiple reflections in the breast, so how to identify the presence or absence of cancer is an issue.
In recent years, as a third method, research on near field holographic imaging (NFHI), which can reconstruct the shape of intramammary tissue, is also in progress [7, 8]. Since the principle of image reconstruction of NFHI is based on the principle of Fourier transform, the time required for image reconstruction is short. However, there are still problems that a huge amount of observation data is required to increase the resolution and that images cannot be reconstructed correctly with high-contrast objects.
In this chapter, we first explain the electrical properties of breast tissue, which is the basis of MI, based on large-scale measurement data [9]. Next, the basic device configuration of MI, three imaging algorithms, and the features of CI, ST, and NFHI are described. Next, we will introduce the equipment that implements these algorithms and the experimental results. Finally, the issues of MI and future prospects will be described.
Living tissue has different electrical properties depending on the tissue, and when electromagnetic waves are incident, reflection occurs at the boundary. The basis of MI is to detect reflections that occur at tissue boundaries. This section describes the electrical properties of breast tissue.
Living tissue is a lossy dielectric, and when an electromagnetic wave is incident, its wavelength is shortened and propagates while being attenuated. When an electromagnetic wave having a main polarization in the x-axis direction propagates in the z-axis direction through a dielectric having a loss, the electric field at an arbitrary distance z is expressed by the following equation.
Here,
Here, c0 is the speed of light propagating in the vacuum, and
The dielectric material with loss is represented by the complex permittivity.
It can be seen that the imaginary part of the complex permittivity changes with frequency. By the way, it is known that the real part of the complex permittivity of a living body changes depending on the frequency. The property of such a material is called dispersibility. The complex relative permittivity of dispersible materials can be modeled by the following equation [10].
The curve of the complex relative permittivity represented by Eq. (5) is called the Debye model. Figure 1 shows the result of measuring the complex relative permittivity of the mammary gland tissue by the probe method [11] (solid line) and the approximate curve (dotted line) modeled by Eq. (5). Here,
Complex dielectric constant of glandular tissue and approximation by Debye model.
The electrical constants of breast tissue can be measured using a dielectric probe [9, 11]. Ref. [11] shows that a cylindrical region with a depth of 1.5 mm and a radius of 3.75 mm is required to achieve a measurement error of 10% using a 2.2 mm diameter dielectric probe. In our study, we measure the complex permittivity of breast tissue using a 2.2 mm diameter dielectric probe in the dielectric measurement kit Keysight 85070E and a vector network analyzer, E5071C. The measurement range is 1–8 GHz.
In recent year, since breast cancer is often detected at an early stage, the size of the tumors removed by surgery has become smaller. To investigate the minimum required volume of a specimen, the dielectric constant was measured by placing ketchup in containers of various volumes. Ketchup is readily available and has about the same electrical constant as cancer. The container, apart from the petri dish, was created using a 3D printer. The material of the container is ABS resin. Figure 2 illustrates the appearance of the container and measurement system.
(a) Containers of various volumes, petri dish 1×1×0.5 cm, 0.5×0.5×0.5 cm container. (b) Measurement equipment for complex permittivity.
In the preliminary measurement using ketchup, for a container measuring 0.5 × 0.5 × 0.5 cm, an error of 3% occurred with respect to the measurement result of the petri dish. However, in a container measuring 1 × 1 × 0.5 cm, the error reduces to 1% or lower. We selected the 1 × 1 × 0.5 cm container for analysis. Samples removed by surgery were cut into fats, mammary glands, and cancerous tumor tissues. Each tissue was placed in a container and the probe was pressed downwards to measure the complex permittivity. Figure 3 shows a photograph of the tissue put in a container.
Tissue samples.
During the breast cancer surgery performed at Aichi Medical University from May 2018 to July 2020, breast tissue specimens were collected from 140 patients who consented to the specimen collection [9]. Table 1 shows the number of samples and the average age of the patients classified by case. Here, mammary gland tissues of the highest possible density were collected from every patient.
Histological classification | Patient | Tumor | Gland | Fat | Age (years) | |
---|---|---|---|---|---|---|
Invasive ductal carcinoma | Tuble forming | 7 | 6 | 6 | 6 | 59.6 |
Solid | 38 | 35 | 23 | 36 | 63.3 | |
Scirrhous | 64 | 52 | 46 | 58 | 61 | |
Others | 9 | 8 | 6 | 9 | 59.9 | |
Special | Invasive lobular carcinoma | 4 | 4 | 4 | 4 | 63.6 |
Mucinous carcinoma | 6 | 6 | 4 | 5 | 66.8 | |
Others | 5 | 0 | 5 | 5 | 49.4 | |
Mixed connective tissue and epithelial tumors | Fibroadenoma | 5 | 5 | 4 | 2 | 31.1 |
Phyllodes tumor | 2 | 2 | 0 | 1 | 54.2 | |
Total | 140 | 118 | 98 | 126 | 60.3 |
Number of samples taken out by surgery.
In recent years, there have been many stage 0 and stage 1 (tumors less than 2 cm) surgery, and it has not been possible to collect tumor tissues that can withstand measurement from all patients. X-ray mammography findings of mammary gland density revealed that nearly half of the patients had dense mammary glands. Due to the disappearance of mammary gland tissue at an older age, it was not possible to obtain mammary gland tissue that could be used for measurement from all patients.
Invasive ductal carcinoma accounts for 84%, of which more than half are scirrhous type. Fibroadenoma is more common in young women, with a minimum age of onset of 15 in this study. Five patients in their 30s with invasive ductal carcinoma account for 4% of all patients with invasive ductal carcinoma. All of the patients were at stage 2. Women in their 30s are not eligible for breast cancer screening in Japan. When cancer grows, it is said that necrosis and calcification occur in the center of the cancer. X-ray mammography detects this calcification. In the pathological findings, there were necrosis in 6 cases and calcification in 11 cases.
Figure 4 shows a typical example of the complex relative permittivity of the sample measured using the measurement system shown in Figure 2. The measurement result that we expect is that the relative permittivity of tumor tissue is considerably higher than that of mammary tissue, as shown in Figure 4a. However, as shown in Figure 4b, there were 8 cases in the scirrhous type and 1 case in the solid type in which the relative permittivity of the mammary gland tissue was higher than that of the tumor tissue. The reason for the opposite properties may be that, as noted in the Ref. [13], not all areas of the tumor sample are filled with tumor tissue.
(a) Measurement example of the complex permittivity, solid tubular carcinoma (Age 49, dense breast). (b) Measurement example of the complex permittivity, Scirrhous carcinoma (Age 49, dense breast).
Table 2 shows the average of relative permittivity εr and conductivity σ of tumor and mammary gland at 1.6 GHz by pathology. On average, the relative permittivity of cancer is 17.5% higher than that of mammary gland tissue, and the conductivity is 16.2% higher.
Histological classification | Tumor | Mammary gland | |||
---|---|---|---|---|---|
εr | σ [S/m] | εr | σ [S/m] | ||
Invasive ductal carcinoma | Tuble forming | 60.5 | 1.66 | 50.1 | 1.4 |
Solid | 58.6 | 1.59 | 49.8 | 1.39 | |
Scirrhous | 58.9 | 1.65 | 52.4 | 1.47 | |
Others | 59.6 | 1.63 | 41.6 | 1.15 | |
Special | Invasive lobular carcinoma | 58.4 | 1.63 | 43.0 | 1.19 |
Mucinous carcinoma | 65.3 | 1.93 | 45.9 | 1.3 | |
Others | — | — | 53.4 | 1.5 | |
Mixed connective tissue and epithelial tumors | Fibroadenoma | 62.7 | 1.74 | 60.2 | 1.73 |
Phyllodes tumor | 61.7 | 1.61 | — | — | |
Total | 59.5 | 1.65 | 50.6 | 1.45 |
Averaged permittivity and conductivity.
Fibroadenoma has the lowest contrast between the relative permittivity and conductivity of cancer and mammary gland. Fibroadenoma is common in women in their teens and 20s, has well-defined lump boundaries, and is often classified as a benign tumor. The disease is not a tumor, but is made up of an excessive amount of normal cells (anaplasia), so there is almost no difference in contrast with the mammary gland. Among the invasive cancers, tumors that are said to be a special type have a large contrast between the mammary gland and the cancer, and good detection by microwave imaging can be expected. The scirrhous type is the most common type of invasive ductal carcinoma, but the contrast between the relative permittivity and the conductivity of the cancer and mammary gland tissue is 12%, which is relatively small. Therefore, MI requires the ability to identify objects with a contrast of about 10%.
Table 3 shows the average Debye parameters for tumor and mammary gland by pathology. The Debye parameter is a parameter considering dispersibility (frequency characteristic). Relaxation time τ does not differ significantly between tumor tissue and mammary gland tissue. This is an important prior knowledge of ST for solving the inverse scattering problem [14]. Among the Debye parameters, ε∞ has an extremely high contrast between cancer and mammary gland. By utilizing this feature, it will become easy to distinguish between the mammary gland and cancer in microwave imaging.
Histological classification | Tumor | Mammary gland | |||||||
---|---|---|---|---|---|---|---|---|---|
ε∞ | Δε | σs | ε∞ | Δε | σs | ||||
Invasive ductal carcinoma | Tuble forming | 5.63 | 55.9 | 0.94 | 11.6 | 1.25 | 49.7 | 0.77 | 11.5 |
Solid | 3.91 | 55.5 | 0.90 | 11.2 | 1.56 | 49.0 | 0.81 | 10.7 | |
Scirrhous | 4.59 | 55.2 | 0.95 | 11.4 | 0.59 | 52.5 | 0.85 | 10.5 | |
Others | 3.39 | 57.0 | 0.97 | 10.3 | 1.81 | 40.4 | 0.64 | 10.3 | |
Special | Invasive lobular carcinoma | 5.28 | 53.9 | 0.97 | 11.0 | −0.45 | 44.0 | 0.70 | 9.9 |
Mucinous carcinoma | −1.76 | 66.2 | 0.98 | 10.3 | −4.71 | 47.0 | 0.68 | 9.8 | |
Others | — | — | — | — | −1.88 | 55.9 | 0.90 | 9.7 | |
Mixed connective tissue and epithelial tumors | Fibroadenoma | 1.46 | 61.8 | 0.96 | 11.1 | 1.99 | 56.3 | 0.96 | 11.8 |
Phyllodes tumor | −0.45 | 63.0 | 0.89 | 10.3 | — | — | — | — | |
total | 3.87 | 56.3 | 0.94 | 11.2 | 0.64 | 50.5 | 0.81 | 10.6 |
Debye parameters.
Figure 5 is a plot showing the relationship between relative permittivity εr and conductivity σ of breast tissue at 1.6 GHz, It shows that there is a strong correlation between εr and σ. This is also important priori information for ST to solve the inverse scattering problem [15].
Linear relationship between relative permittivity and conductivity.
This chapter gives an overview of the configuration of an imaging device using microwaves and the algorithm for reconstructing images. The details of the reconstruction algorithm are omitted due to space limitations. For details of the reconstruction algorithm, refer to the related literature.
Figure 6 shows the hardware configuration of the MI system. Multiple antennas are placed around the object. One antenna is selected to transmit electromagnetic waves, and all antennas including the antenna used for transmission receive and record scattered waves from the imaging target. The observation data group Xnn (n = 1, .., N) is collected by changing the antenna used for transmission one after another. The first digit of the subscript of Xnn indicates the transmission condition number, and the second digit indicates the reception condition number. When transmitting and receiving using 18 antennas, N = 18 and 18 × 18 = 324 observation data groups can be obtained. If multiple signals are received at the same time, the hardware configuration becomes complicated, so a changeover switch is used for time-division reception. A commercially available vector network analyzer (VNA) can be used as the transmitter / receiver. Since short pulses are equivalent to wideband frequency sweep signals, VNA can be used even with radars that use pulses.
Hardware of the MI system.
Table 4 shows typical image reconstruction methods.
CI | NFHI | MT | |
---|---|---|---|
Reconstructed Image | Scattered power distribution | Reflection coefficients distribution | Complex permittivity distribution |
Reproduction of tissue shape | Impossible | Possible | Possible |
Processing time | Short | Very short | Long |
Installation | Easy | difficult | difficult |
Problems | • Identification of abnormal tissue | • Means for acquiring a large amount of observation data.• Investigating the effects of multiple reflections between objects | • Accuracy / resolution• Establishment of calibration method. • Design of high sensitivity antenna |
Reference | [3, 4, 5, 6, 16, 17, 18, 19] | [7, 8, 20] | [14, 15, 21, 22, 23, 24, 25, 28] |
Image reconstruction method.
The principle of image reconstruction of CI is the same as that of ultrasonic diagnostic equipment. That is, while shifting the focal point set in the imaging region, the magnitude of the scattered wave at the focal point is calculated and the magnitude distribution is visualized. Electromagnetic waves are more attenuated in the body than ultrasonic waves, and objects embedded in the high contrast tissue cannot accurately reproduce the tissue image due to the multiple reflections. Reconstructed images of breasts of breast cancer patients have been reported by the author and several other research institutes [3, 4, 5, 6]. In all reports, large reflection images were observed around the cancer, but the shape and size of the cancer could not be accurately reconstructed. In addition, meaningless images are reconstructed even in cancer-free breasts. Doctors make a diagnosis from the reconstructed image, but it is not possible to make an accurate diagnosis because the tissue shape is not accurately reconstructed.
NFHI reconstructs the reflection coefficients’ distribution in the imaging region, and the reconstructed image reflects the shape of the tissue [20]. Since the image reconstruction is based on the Fourier transform of the spatial region, the reconstruction time is extremely short and real-time display will be possible. The problem is that the resolution is governed by the sampling theorem, so a huge amount of observation data is required to obtain a high-definition reconstructed image, and it is difficult to realize a practical data acquisition system. For example, in order to obtain a spatial resolution of 2 mm, observation data for each 2 mm is required on the projection surface of the imaging region, and observation data at 2500 positions is required assuming an observation surface of 100 mm × 100 mm. Data can be acquired by mechanical scanning of the antenna, but the observation time will be significantly longer. If the antenna is an array to save time, 2500 transmitters and receivers are required, which increases the cost and limits the aperture length of one antenna to 2 mm or less. In this case, millimeter waves should be used, but the attenuation is extremely large in the body, which is not practical. Another issue is that the currently proposed 3D reconstruction algorithm does not take into account the effects of multiple reflections within the imaging region, making reconstructed images of object with a large size or a complicated structure difficult.
Research by the authors has shown that NFMI can, in principle, reconstruct the tissue image precisely [8]. In addition, Manitoba University has developed an experimental device that collects observation data by moving up and down while mechanically rotating two wideband horns, and showed that it can detect foreign matter in the phantom even in the air interface between the phantom and the antenna [7]. However, clinical imaging with NFMI has not yet been reported.
In ST, which solves the inverse scattering problem, the complex permittivity distribution in the imaging region is reconstructed and the structure shape can be reproduced. However, the processing time is long because it is necessary to repeat the full-wave electromagnetic field analysis. In our research, even workstations with the latest GPUs take hours for a single analysis and days for image reconstruction. The biggest problem is that the phenomenon of radio wave propagation in the imaging region cannot be faithfully reproduced on a computer. It is extremely difficult to completely match the results of experiments with computer simulations that model microwave equipment with current numerical analysis technology for electromagnetic waves. The key to the realization of this technology is how to calibrate the experimental results and match them with the computer simulation. In this method, the breast is treated as a set of small hexahedrons or tetrahedra (called voxels), and the complex permittivity of each voxel is estimated. To improve the resolution is to make the voxels smaller, and the number of complex permittivity to be estimated increases on the order of the third power. In the inverse scattering problem, the governing equations are Born approximated and solved by replacing them with linear simultaneous equations, but this is an ill-posed problem with many unknowns (complex dielectric constant of each voxel) with respect to the number of equations. In this case, the reconstructed image looks like a defocused photograph because the sudden change in contrast between voxels cannot be reproduced. In addition, a highly sensitive antenna that can capture small changes in the complex permittivity of small voxels is required.
A group at Dartmath University has prototyped an imaging device with a structure in which 18 monopoles are submerged together with the breast in a matching fluid, and is performing clinical imaging [21]. The monopole array is moved up and down to acquire several observation data. For the imaging algorithm, forward analysis by Discrete Dipole Assumption (DDA) and inverse analysis by iterative method are adopted. Reconstructed images of scattered mammary glands accurately capture the location and size of the cancer, but the results of imaging the dense breast are not shown, and it seems that they have not reached the stage of practical use.
This section introduces the MI device and imaging results developed by the author. Only the equipment using CI was performed up to clinical imaging, but the equipment of ST and NFHI is in the stage of basic experiment.
A schematic diagram and photographs of the developed microwave mammography equipment are shown in Figure 7 [5]. The equipment comprised a sensor, an aspirator, an antenna switch, a network analyzer, a PC for control, and a workstation (WS) for data processing.
(a) Schematic diagram of the microwave mammography. (b) Overview of the microwave mammography. (c) Overview of the sensor.
Figure 8 shows the concept of the proposed sensor. It consists of several stacked patch antennas fed by the slot. The number of antennas depends on the breast size. The antennas are embedded in a cup made by Sumitomo Electric Industries, Ltd., the material of which has almost the same electromagnetic parameters as those of the adipose tissue (εr = 6.3, σ = 0.15, 6 GHz). The elements are designed so as to match impedance over the bandwidth of 4 to 9 GHz when the aperture touches the breast. When the pressure in the sensor is reduced by the aspirator, the breast is fixed to the inside of the sensor. Therefore, we need not know the breast shape for the image reconstruction process.
(a) Sensor (longitudinal section). (b) Sensor (6-element). (c) Sensor (18 element). (d) Sensor (30-element).
As shown in Figure 8, we prepared three different sensor types for various breast sizes: a 30-element sensor with a diameter of 13 cm and a depth of 5.4 cm (large), a 18-element sensor with a diameter of 10 cm and a depth of 4 cm (middle), and a 6-element sensor with a diameter of 8 cm and a depth of 2 cm (small).
The antenna switch selects one or two antennas connected to the input/output port of the network analyzer (Agilent E5071C), and can correspond with the three sensor types. It consists of 42 single port double transfer (SPDT) switches and 6 single port 6 transfer (SP6T) switches. The total insertion loss is less than 5 dB at 6.5 GHz, and the peak amplitude and phase deviation are less than 0.2 dB and 10°, respectively. The antenna switch and network analyzer are automatically controlled by the PC.
The size of the microwave mammography equipment is 600 (width) × 600 (length) × 500 (height) mm. It is designed to align and connect lengthwise with a bed in the consulting room. Before inspection, a sensor with the proper size must be selected. Using a transparent cup that has the same size as the sensor on the breast and then by decompressing, one can confirm that the breast touches all elements by observation. Then, patient lies facedown on the bed and places her breast in the sensor and suction begins. S11 when the breast is placed in the sensor is compared with S11 when no breast is present. If S11 is not sufficiently reduced, an alarm is activated. In this case, the inspector aligns the position or inclination of the sensor. The inspection time is approximately 5, 30, and 200 s for 6, 18, and 30 sensor elements, respectively. An array rotation technique was used for artifact removal [16]. Additional inspection when the sensor is mechanically rotated by 20° was carried out.
We imaged the breasts of an elderly woman with fatty tissue. Referring MRI Image shown in Figure 9a, her right breast is infected with early breast cancer of 9 mm in diameter at lower inside near the chest wall, while no pathological changes can be seen in her left breast. In this case, boundary of the cancer is comparatively clear, and it isolates from the fibro-glandular tissue.
(a) MRI image of the right breast with cancer and healthy left breast. (b) Imaging results by the microwave mammography (right breast). (c) Imaging results by the microwave mammography.
Figure 9b shows the imaging results using microwave mammography. In this case, the small-sized sensor was used. The reflection strength is normalized by the peak reflection field where it is generated around the cancer. Then, areas where the back-scattered energy is more than 80% of the peak scattered power are shown. In addition, estimated position and size from MRI image are shown as green circle. We can see a large scattering near the cancer.
Six breast cancer patients were clinically imaged and a strong scattering image was confirmed around the cancer. The location of the cancer can also be detected by confocal imaging. However, if the cancer is large, its shape cannot be reproduced. In the experiment, the scattering intensity distribution is standardized by the peak value of the response in the breast with the cancer with the largest scattering power. For this reason, the scattering intensity in cancer-free breasts is low. However, assuming cancer screening, it is predicted that scattered images will appear in such standardized processing because of the difference in mammary gland density between the left and right breasts even without cancer. In addition to cancer, the breast has other diseases such as cysts and mastitis. The cyst is a bag of water, and it is predicted that a scattered image stronger than that of cancer will appear. Since it is necessary for medical devices to be able to accurately reproduce the shape of cancer and to distinguish between cancer and diseases such as cysts, the use of tumor markers in Ref. [17] is a realistic solution for confocal imaging.
Since UWB radar could not reconstruct diagnostic images with the tissue structure, we are working on scattering tomography to solve the inverse scattering problem. A simple imaging sensor with a printed board dipole inserted in a dielectric block was prototyped and evaluated. However, if the rough position and size of the target were not used as preliminary knowledge, a reconstructed image with sufficient quality could be not obtained [5]. This was due to a modeling error issue as well as a lack of sensitivity. It was necessary to investigate a highly sensitive antenna with a structure with small modeling error.
In [24], the evaluation results of radar imaging using a circular array with a structure in which a folded quasi self- complementary antenna (FQSCA) composed of a printed board is pressed vertically against a cylindrical dielectric block containing the target are demonstrated. We evaluated the image reconstruction of an image sensor constructed by pressing FQSCA against a rectangular dielectric block by computer simulation compared with a printed dipole. As a result, it was found that the imaging sensor using FQSCA has higher image reconstruction capability than the printed dipole.
In this section, high sensitivity with FQSCA is first confirmed by computer simulation using the sensor structure in [22]. Next, FQSCA is applied to a sensor for clinical imaging, and it is confirmed that high-quality diagnosis image is reconstructed using a numerical phantom.
Figure 10 shows the image sensor and phantom used in the computer simulation [25]. Figure 10a shows an imaging sensor in which two printed board dipoles arranged in an inverted L shape are inserted on the side of a dielectric block. Figure 10b shows an image sensor with a structure in which two FQSCAs arranged in an inverted L shape are pressed against the side surface of a dielectric block.
(a) Simulated imaging sensor (printed dipole). (b) Simulated imaging sensor (FQSCA).
In this model, an imaging area of 40×40×40 mm is provided in the center of the dielectric block. The imaging area is modeled by cubic voxels with a side length of 10 mm or 5 mm. The number of voxels in the imaging area is 64 when the resolution is 10 mm and 512 when the resolution is 5 mm. In the image reconstruction using one frequency, the number of observation data is 8C2 = 28, so it is an ill-posed problem with unknowns greater than the number of equations for any resolution. The distance between the imaging area and the antenna is 30 mm. The relative permittivity and conductivity of the dielectric block are 6.5 and 0.036 S/m.
Figure 11 shows photographs of the printed board dipole and FQSCA. The printed board dipole is mounted on a substrate with a thickness of 0.8 mm, relative dielectric constant of 3.8, and tanδ = 0.003. FQSCA is mounted on a substrate with a thickness of 1.6 mm, relative permittivity of 4, and tanδ = 0.011.
(a) Printed dipole. (b) FQSCA.
In order to evaluate image reconstruction quantitatively, the voxel number of the imaging area is determined as shown in Figure 12. As shown in Figure 12, the target of relative permittivity 39.6 and conductivity 1 S/m is set to 8 voxels in the center of the imaging area. The algorithm used for reconstruction is Distorted Born Iterative Method (DBIM) [14], the forward problem is solved with CST-Studio Suite [26], and the inverse problem is solved with MATLAB [27]. The frequency used for image reconstruction is 1.85 GHz for printed dipoles and 1.5 GHz for FQSCA. These are the frequencies of the lowest resonance point of each antenna.
Voxel number.
Figure 13 shows the results of reconstruction of the dielectric constant after 10 iterations assuming a resolution of 10 mm. Both the printed dipole and FQSCA show good reconstruction results. Note that the reconstruction result of the conductivity is omitted due to space limitations, but a reconstruction result equivalent to the relative dielectric constant has been confirmed.
(a) Reconstructed relative permittivity (resolution of 10 mm, printed dipole is used). (b) Reconstructed relative permittivity (resolution of 10 mm, FQSCA is used).
Figure 14 shows the results of reconstruction of the relative permittivity after 10 iterations, assuming a resolution of 5 mm, a relative permittivity of 39.6, and a conductivity of 1 S/m for only one voxel. Targets cannot be detected with printed dipoles, but targets can be detected with FQSCA.
(a) Reconstructed relative permittivity (resolution of 5 mm, printed dipole is used). (b) Reconstructed relative permittivity (resolution of 5 mm, FQSCA is used).
Figure 15 shows the appearance of an imaging sensor for clinical trials using FQSCA and a breast modeled with hexahedral voxels. In this sensor, six FQSCA are arranged on the side of a 140×140×50 mm dielectric block, and 12 FQSCA are arranged on the upper surface with different polarization.
(a) Imaging sensor for clinical test. (b) Breast model.
Figure 16a shows 3D distribution of permittivity and conductivity of the numerical breast phantom. Figure 16b shows the reconstructed 3D distribution of permittivity and conductivity. The resolution is 4 mm and the frequency used is 1.5GHz. Circles indicate the cancer site. With the proposed sensor, mammary gland structure and cancer shape can be accurately reconstructed. The quality factor [28] evaluated by the complex dielectric constant was 0.96.
(a) Set relative permittivity distribution. (b) Set conductivity. (c) Reconstructed relative permittivity distribution. (d) Reconstructed conductivity distribution.
The sensor shown in Figure 15 was prototyped and mounted on the system shown in Figure 7. Figure 17 shows the prototype ST. The transmission characteristics of the antenna were measured with nothing in the cup that holds the breast, but as expected, they do not match the analysis results of CST Studio Suite. Therefore, we plan to adapt the measurement results to the simulation results by calibration based on the measurement of the reference object in [23], and proceed to clinical imaging.
(a) Sensor for the manufacturing model. (b) Overview of the manufacturing model.
First, we confirm by computer simulation that NFHI can reconstruct intramammary tissue. Next, a simple image system is constructed and experimental verification is performed.
Computer simulations were performed to confirm that NFHI can reconstruct intramammary tissue. Figure 18 shows the simulation model, and Table 5 shows the simulation conditions. Similar to X-ray mammography imaging, imaging is performed with a model in which the breast is sandwiched between two glass plates and two antennas move on a plane at the same time. In order to obtain a resolution of 2 mm, the scattering parameters are acquired while the two antennas move in 2 mm steps on a plane of 100 × 50 mm. The frequency band used is 20.4-26GHz and the frequency step is 100 MHz. The antenna is a dipole antenna with a resonance frequency of 23.2 GHz. Figure 19 shows the original tissue image and the reconstructed image. The reconstructed image faithfully reproduces the original image.
Simulation model.
Frequency (GHz) | 20.4 ∼ 26 | |
Scanning range (mm) | x-axis | −50 ∼ 50 |
y-axis | 0 ∼ 50 | |
z-axis | −10 ∼ 30 | |
Scanning step (mm) | 2 | |
CO | size(mm) | 2 × 2 × 2 |
permittivity | 25 | |
Conductivity{S/m} | 0.75 |
Simulation conditions.
Original image (left) and reconstructed image (right).
Figure 20 shows the appearance and system diagram of the imaging system used in the experiment. Table 6 summarizes the measurement conditions.
(a) Overview of the NFHI system. (b) System configuration of NFHI system.
Frequency (GHz) | 8.5 ∼ 12.5 | |
Scanning range (mm) | xy- plane | 100 ∼ 100 |
z-axis | −10 ∼ 30 | |
Scanning step (mm) | xy-plane | 2 |
z-axis | 10 | |
CO(mm) | 10 × 10 × 5 |
Measurement conditions.
The antennas are the commercially available primary feeds for Communication Satellite (CS) broadcast reception shown in Figure 21, and two antennas are arranged at intervals of 15 cm above and below, and can be scanned on the xy plane by an automatic stage. The imaging table is a celluloid plate with a thickness of 2 mm and 150 × 150 mm, and the height in the z-axis (vertical) direction can be adjusted by the z-axis stage. The outputs of the two CS antennas are connected to the input / output ports of the vector network analyzer, and the data of S11, S21, S12, and S22 are measured while changing the relative positions of the antenna and the object. The calibration object (CO) is glycerin (relative permittivity: 4.042, dielectric loss tangent: 1.021 (10 GHz)) filled with a 10×10×5 mm ABS resin container in Figure 20a. The complex permittivity of glycerin was measured by the equipment described in Section 2.2.
Feed antenna for communication satellites broadcast.
The CO was placed in the center of the imaging table, and the S-parameters of the CO were measured in 10 mm steps in the range of −10 mm to 30 mm on the z-axis. Next, the pork was placed on the imaging table at the position of z = 10 mm as shown in Figure 22b, and the S parameter was measured. In order to acquire the scattering component, the S-parameters of the background were measured at the positions of 10 mm steps of −10 mm to 30 mm on the z-axis, and this was subtracted from the S-parameters of the object. Figure 23 shows a reconstructed image. It can be seen that the position and shape of the pork and the contrast between the lean and white meat are reproduced.
(a) Calibration object (CO) on the imaging table. (b) Pork placed on the imaging table.
(a) Original image. (b) Reconstructed image.
Bright spots may appear in the reconstructed image due to measurement error. This is because the measurement data on the xy plane has a measurement error corresponding to white noise. That is, when the white noise is inverse Fourier transformed, it becomes an impulse. In this case, the median filter used in image processing is effective. Take out a part of the measurement data (for example, 9×9 data) measured at the grid points every 2 mm on the xy plane, find the median value, and use this as the measurement result of the center position of the 9×9 data. This process eliminates the bright spots caused by noise and improves the quality of the reconstructed image.
The breakthroughs required to put MI-based diagnostic imaging equipment into practical use are summarized below.
CI
How to extract only the scattered wave of the target (lesion) in the living body?
Reference [18] attempts to characterize breast cancer using all currently conceivable methods such as principal component analysis, independent component analysis, and kurtosis analysis. TR-MUSIC is applied to image reconstruction to improve the resolution. Clinical trial equipment has been developed and clinical trials have begun. In [19], the scattering response when the shape of the target (cancer) changes are analyzed and extraction of the characteristics of the cancer is tried. In the future, it is thought that the development of technology to determine the presence or absence of cancer by giving a response signal to artificial intelligence will progress [29].
ST
Improvement of simulation technology: It is required to develop a numerical analysis method that matches the experiment and the simulation result, a sensor that has a structure that easily matches the simulation result, or to establish a calibration technology. It is also expected to speed up forward analysis using cloud computing and supercomputers.
NFHI
It is necessary to proceed with the development of high-density sensing technology to ensure the resolution, and to find a measure in which the Born approximation can be applied in the biometric environment.
This work was supported by grants-in-aid for Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology of Japan.
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On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. 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Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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Almost all the parts of this plant, that are, fruit, leaves, flower bud, trunk, and pseudo-stem, can be utilized. This chapter deals with the fiber extracted from the pseudo-stem of the banana plant. It discusses the production of banana pseudo-stem fiber, which includes plantation and harvesting; extraction of banana pseudo-stem fiber; retting; and degumming of the fiber. It also deals with the characteristics of the banana pseudo-stem fiber, such as morphological, physical and mechanical, durability, degradability, thermal, chemical, and antibacterial properties. Several potential applications of this fiber are also mentioned, such as the use of this fiber to fabricate rope, place mats, paper cardboard, string thread, tea bags, high-quality textile materials, absorbent, polymer/fiber composites, etc.",book:{id:"7544",slug:"banana-nutrition-function-and-processing-kinetics",title:"Banana Nutrition",fullTitle:"Banana Nutrition - Function and Processing Kinetics"},signatures:"Asmanto Subagyo and Achmad Chafidz",authors:[{id:"257742",title:"M.Sc.",name:"Achmad",middleName:null,surname:"Chafidz",slug:"achmad-chafidz",fullName:"Achmad Chafidz"},{id:"268400",title:"Mr.",name:"Asmanto",middleName:null,surname:"Subagyo",slug:"asmanto-subagyo",fullName:"Asmanto Subagyo"}]},{id:"69568",title:"Water Quality Parameters",slug:"water-quality-parameters",totalDownloads:9909,totalCrossrefCites:12,totalDimensionsCites:32,abstract:"Since the industrial revolution in the late eighteenth century, the world has discovered new sources of pollution nearly every day. So, air and water can potentially become polluted everywhere. Little is known about changes in pollution rates. The increase in water-related diseases provides a real assessment of the degree of pollution in the environment. This chapter summarizes water quality parameters from an ecological perspective not only for humans but also for other living things. According to its quality, water can be classified into four types. Those four water quality types are discussed through an extensive review of their important common attributes including physical, chemical, and biological parameters. These water quality parameters are reviewed in terms of definition, sources, impacts, effects, and measuring methods.",book:{id:"7718",slug:"water-quality-science-assessments-and-policy",title:"Water Quality",fullTitle:"Water Quality - Science, Assessments and Policy"},signatures:"Nayla Hassan Omer",authors:null},{id:"40180",title:"Plant Tissue Culture: Current Status and Opportunities",slug:"plant-tissue-culture-current-status-and-opportunities",totalDownloads:66452,totalCrossrefCites:43,totalDimensionsCites:89,abstract:null,book:{id:"3568",slug:"recent-advances-in-plant-in-vitro-culture",title:"Recent Advances in Plant in vitro Culture",fullTitle:"Recent Advances in Plant in vitro Culture"},signatures:"Altaf Hussain, Iqbal Ahmed Qarshi, Hummera Nazir and Ikram Ullah",authors:[{id:"147617",title:"Dr.",name:"Altaf",middleName:null,surname:"Hussain",slug:"altaf-hussain",fullName:"Altaf Hussain"}]},{id:"66996",title:"Ethiopian Common Medicinal Plants: Their Parts and Uses in Traditional Medicine - Ecology and Quality Control",slug:"ethiopian-common-medicinal-plants-their-parts-and-uses-in-traditional-medicine-ecology-and-quality-c",totalDownloads:4059,totalCrossrefCites:6,totalDimensionsCites:10,abstract:"The main purpose of this review is to document medicinal plants used for traditional treatments with their parts, use, ecology, and quality control. Accordingly, 80 medicinal plant species were reviewed; leaves and roots are the main parts of the plants used for preparation of traditional medicines. The local practitioners provided various traditional medications to their patients’ diseases such as stomachaches, asthma, dysentery, malaria, evil eyes, cancer, skin diseases, and headaches. The uses of medicinal plants for human and animal treatments are practiced from time immemorial. Stream/riverbanks, cultivated lands, disturbed sites, bushlands, forested areas and their margins, woodlands, grasslands, and home gardens are major habitats of medicinal plants. Generally, medicinal plants used for traditional medicine play a significant role in the healthcare of the majority of the people in Ethiopia. The major threats to medicinal plants are habitat destruction, urbanization, agricultural expansion, investment, road construction, and deforestation. Because of these, medicinal plants are being declined and lost with their habitats. Community- and research-based conservation mechanisms could be an appropriate approach for mitigating the problems pertinent to the loss of medicinal plants and their habitats and for documenting medicinal plants. Chromatography; electrophoretic, macroscopic, and microscopic techniques; and pharmaceutical practice are mainly used for quality control of herbal medicines.",book:{id:"8502",slug:"plant-science-structure-anatomy-and-physiology-in-plants-cultured-in-vivo-and-in-vitro",title:"Plant Science",fullTitle:"Plant Science - Structure, Anatomy and Physiology in Plants Cultured in Vivo and in Vitro"},signatures:"Admasu Moges and Yohannes Moges",authors:[{id:"249746",title:"Ph.D.",name:"Admasu",middleName:null,surname:"Moges",slug:"admasu-moges",fullName:"Admasu Moges"},{id:"297761",title:"MSc.",name:"Yohannes",middleName:null,surname:"Moges",slug:"yohannes-moges",fullName:"Yohannes Moges"}]},{id:"29764",title:"Underlying Causes of Paresthesia",slug:"underlying-causes-of-paresthesia",totalDownloads:192987,totalCrossrefCites:3,totalDimensionsCites:7,abstract:null,book:{id:"1069",slug:"paresthesia",title:"Paresthesia",fullTitle:"Paresthesia"},signatures:"Mahdi Sharif-Alhoseini, Vafa Rahimi-Movaghar and Alexander R. Vaccaro",authors:[{id:"91165",title:"Prof.",name:"Vafa",middleName:null,surname:"Rahimi-Movaghar",slug:"vafa-rahimi-movaghar",fullName:"Vafa Rahimi-Movaghar"}]}],onlineFirstChaptersFilter:{topicId:"2",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81769",title:"Biological Control of Agricultural Insect Pests",slug:"biological-control-of-agricultural-insect-pests",totalDownloads:0,totalDimensionsCites:0,doi:"10.5772/intechopen.104464",abstract:"Pests are highly responsible for heavy crop losses and reduced food supplies, poorer quality of agricultural products, economic hardship for growers and processor. Generally, chemical control methods are practiced for their control which is neither always economical nor effective and may have associated unwanted health, safety and environmental risks. However, to meet the challenge of feeding to the ever increasing human population, an efficient, economical and environment friendly disease control methods are requisites. In this regard, biological control may be an effective means of reducing or mitigating the pests and pest effects through the use of natural enemies. Biological control is an environmentally sound which involves the use of beneficial microorganism to control plant pathogens and diseases they cause. Therefore, in this chapter we will provide a comprehensive account of this environmental friendly approach for effectively management of plant diseases. This chapter will also accentuate the development of biological control agents for practical applications and the underlying mechanism. The contents in the chapter will be beneficial and advantageous to all those working in academia or industry related to crop protection.",book:{id:"11015",title:"Insecticides",coverURL:"https://cdn.intechopen.com/books/images_new/11015.jpg"},signatures:"Mrinalini Kumari, Atul Srivastava, Shyam Babu Sah and Subhashini Sini"},{id:"82474",title:"Vitamin D Deficiency in Childhood Obesity: Behavioral Factors or Altered Metabolism?",slug:"vitamin-d-deficiency-in-childhood-obesity-behavioral-factors-or-altered-metabolism",totalDownloads:3,totalDimensionsCites:0,doi:"10.5772/intechopen.105819",abstract:"Obesity childhood is related to vitamin D deficiency, but the mechanisms for this association still remain questionable. We hypothesized that behavioral factors would be decisive in reducing the body content of vitamin D in patients with obesity. A cross-sectional clinical and analytical study (calcium, phosphorus, calcidiol, and parathyroid hormone) was carried out in a group of 377 patients with obesity (BMI-DS >2.0), 348 patients with severe obesity (BMI-DS >3.0), and 411 healthy children. The place of residence was categorized as urban or rural. Vitamin D status was defined according to the US Endocrine Society criteria. The prevalence of vitamin D deficiency was significantly higher (p < 0.001) in severe obesity (48.6%) and obesity groups (36.1%) than in the control group (12.5%). Vitamin D deficiency was more frequent in severe obesity and obesity groups living in urban areas than in those living in rural areas (not in the control group). The patients with obesity living in urban residence did not present significant seasonal variations in vitamin D deficiency throughout the year in contrast to those patients with obesity living in rural residence. These findings suggest that the most probable mechanism for vitamin D deficiency in children and adolescents with obesity, rather than altered metabolic, is the behavioral factors (sedentary lifestyle and lack of adequate sunlight exposure).",book:{id:"11639",title:"Vitamin D Deficiency - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11639.jpg"},signatures:"Teodoro Durá-Travé and Fidel Gallinas-Victoriano"},{id:"82475",title:"Pharmacological Efficacy and Mechanism of Vitamin D in the Treatment of “Kidney-Brain” Disorders",slug:"pharmacological-efficacy-and-mechanism-of-vitamin-d-in-the-treatment-of-kidney-brain-disorders",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.105820",abstract:"Accumulating evidences have shown that serum 25-hydroxyvitamin D concentrations were inversely correlated with the incidence or severity of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and that vitamin D deficiency might be associated with an increased susceptibility to many of the complications accompanied by COVID-19, such as disorders in kidney and brain. Our previous experimental studies demonstrated that vitamin D and its analogs could protect from kidney diseases, neuroinflammation, and musculoskeletal disorders such as osteoporosis and muscle atrophy, through the suppressive effects on overactivation of the renin-angiotensin system (RAS) in tissues. Moreover, we published a review describing the therapeutic effects of traditional Chinese medicine (TCM) for organ injuries associated with COVID-19 by interfering with RAS. In the TCM principle “Kidney dredges brain,” this chapter will emphasize the potential preventive and therapeutic effects of vitamin D on both renal injuries and central nervous system disorders in COVID-19 patients and further elucidate the pharmacological effects with underlying mechanisms of vitamin D in “Kidney-Brain” disorders.",book:{id:"11639",title:"Vitamin D Deficiency - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11639.jpg"},signatures:"Jia-Li Zhang, Yong-Jun Wang and Yan Zhang"},{id:"82217",title:"Sustainable Management Plans in Fisheries and Genetic Tools: An Overview of the Challenge in Invertebrates’ Fisheries at the Central Area of the Southern Bay of Biscay, Spain",slug:"sustainable-management-plans-in-fisheries-and-genetic-tools-an-overview-of-the-challenge-in-inverteb",totalDownloads:4,totalDimensionsCites:0,doi:"10.5772/intechopen.105353",abstract:"The fishing and aquaculture sectors are an important source of development around the globe. In Asturias (Spain), the diversity and richness of the fishing grounds of the Cantabrian Sea favored the historical settlement of a large number of communities closely linked to the marine environment and fishing resources, forming an integral part of the region’s cultural and natural heritage. However, aquatic ecosystems are facing, nowadays, important threats from anthropogenic activities. To address these problems and avoid their impact on fishing activities, it is essential to know the ecological and genetic status of the species. Despite this, the application of genetic tools is still incipient in many species of commercial interest; however, its use can help to generate data that allow better regulation and fisheries planning. Here, the use of genetic markers and educational strategies in the management of some shellfish species of great commercial and cultural value in Asturias are reviewed. Moving toward sustainable fisheries management is a priority that can only be achieved through R + D + i, educational strategies, and the development and implementation of a regional strategy oriented toward the sustainable management and exploitation.",book:{id:"10748",title:"Fishery",coverURL:"https://cdn.intechopen.com/books/images_new/10748.jpg"},signatures:"Marina Parrondo, Lucía García-Florez, Eduardo Dopico and Yaisel J. Borrell"},{id:"82466",title:"Low-Alcohol and Nonalcoholic Wines: Production Methods, Compositional Changes, and Aroma Improvement",slug:"low-alcohol-and-nonalcoholic-wines-production-methods-compositional-changes-and-aroma-improvement",totalDownloads:4,totalDimensionsCites:0,doi:"10.5772/intechopen.105594",abstract:"Nonalcoholic wine (NW) has attracted the interest of winemakers and researchers in recent years, mainly due to the increasing market share of NW (≤ 1% alcohol by volume), the health risks associated with the consumption of wine, the global trend toward healthier lifestyles, and the uncompromising cardioprotective effects of NW. NW can be produced using several methods, particularly, dealcoholization of wines, which is mainly achieved by physical dealcoholization methods. However, the dealcoholization of wine has two major drawbacks. The first drawback is legal since the laws vary according to each country. The second disadvantage is technical since it is difficult to dealcoholize a wine while maintaining its original organoleptic characteristics. Both the aromatic qualities (volatile composition) and taste (sensory characteristics) of the dealcoholized wine (DW) tend to worsen the greater the decrease in its alcoholic strength. This makes the resulting wine have a different flavor and aroma. Improvement of the aroma of DW after dealcoholization could help wine producers limit undesirable effects and increase consumer acceptance. This chapter is focused on the popular techniques used in wine dealcoholization, their impact on the phenolic composition, volatile composition, sensory characteristics, and the state-of-the-art methods of improving the aroma profile of DW.",book:{id:"11622",title:"Recent Advances in Grapes and Wine Production - New Perspectives to Improve the Quality",coverURL:"https://cdn.intechopen.com/books/images_new/11622.jpg"},signatures:"Teng-Zhen Ma, Faisal Eudes Sam and Bo Zhang"},{id:"82452",title:"Temperature Based Agrometeorology Indices Variability in South Punjab, Pakistan",slug:"temperature-based-agrometeorology-indices-variability-in-south-punjab-pakistan",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.105590",abstract:"Climate change has a major impact on crop yield all over the world. Pakistan is one of the major affected countries by climate change. The agrometeorology indices were determined for the South Punjab region, which is a hot spot for climate change and food security. This region is rich in agriculture, but crop yield relationship is estimated with agrometeorology indices (AMI). Temperature stress (33°C), average diurnal temperature range (12°C), Average accumulative growing degree days (1303°C), phototemperature (27°C) and nyctotemperature (21°C) indices were determined for Multan. The variation in diurnal temperature was found at 0.39 for Bahawalpur region and similar variation was observed in growing degree days, which is 0.11 more than the diurnal temperature range. The extreme of these indices which influence the crop yield was found in May and June. The cropping period from sowing to harvest varied due to climate change and cause to decrease in the yield of the crop. The indices are regarded as crop performance indicators. So, policymakers and agricultural scientists should take necessary measures to mitigate such kinds of challenges.",book:{id:"11341",title:"Challenges and Opportunity in Agrometeorology",coverURL:"https://cdn.intechopen.com/books/images_new/11341.jpg"},signatures:"Muhammad Saifullah, Muhammad Adnan, Muhammad Arshad, Muhammad Waqas and Asif Mehmood"}],onlineFirstChaptersTotal:557},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:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"23",title:"Education and Human Development",doi:"10.5772/intechopen.100360",issn:null,scope:"
\r\n\tEducation and Human Development is an interdisciplinary research area that aims to shed light on topics related to both learning and development. This Series is intended for researchers, practitioners, and students who are interested in understanding more about these fields and their applications.
",coverUrl:"https://cdn.intechopen.com/series/covers/23.jpg",latestPublicationDate:"June 25th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:0,editor:{id:"280770",title:"Dr.",name:"Katherine K.M.",middleName:null,surname:"Stavropoulos",slug:"katherine-k.m.-stavropoulos",fullName:"Katherine K.M. Stavropoulos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRdFuQAK/Profile_Picture_2022-05-24T09:03:48.jpg",biography:"Katherine Stavropoulos received her BA in Psychology from Trinity College, in Connecticut, USA. Dr. Stavropoulos received her Ph.D. in Experimental Psychology from the University of California, San Diego. She completed her postdoctoral work at the Yale Child Study Center with Dr. James McPartland. Dr. Stavropoulos’ doctoral dissertation explored neural correlates of reward anticipation to social versus nonsocial stimuli in children with and without autism spectrum disorders (ASD). She has been a faculty member at the University of California, Riverside in the School of Education since 2016. Her research focuses on translational studies to explore the reward system in ASD, as well as how anxiety contributes to social challenges in ASD. She also investigates how behavioral interventions affect neural activity, behavior, and school performance in children with ASD. She is also involved in the diagnosis of children with ASD and is a licensed clinical psychologist in California. She is the Assistant Director of the SEARCH Center at UCR and is a Faculty member in the Graduate Program in Neuroscience.",institutionString:null,institution:{name:"University of California, Riverside",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:2,paginationItems:[{id:"89",title:"Education",coverUrl:"https://cdn.intechopen.com/series_topics/covers/89.jpg",isOpenForSubmission:!1,editor:{id:"260066",title:"Associate Prof.",name:"Michail",middleName:null,surname:"Kalogiannakis",slug:"michail-kalogiannakis",fullName:"Michail Kalogiannakis",profilePictureURL:"https://mts.intechopen.com/storage/users/260066/images/system/260066.jpg",biography:"Michail Kalogiannakis is an Associate Professor of the Department of Preschool Education, University of Crete, and an Associate Tutor at School of Humanities at the Hellenic Open University. He graduated from the Physics Department of the University of Crete and continued his post-graduate studies at the University Paris 7-Denis Diderot (D.E.A. in Didactic of Physics), University Paris 5-René Descartes-Sorbonne (D.E.A. in Science Education) and received his Ph.D. degree at the University Paris 5-René Descartes-Sorbonne (PhD in Science Education). His research interests include science education in early childhood, science teaching and learning, e-learning, the use of ICT in science education, games simulations, and mobile learning. 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The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}},{id:"338856",title:"Mrs.",name:"Nur Alvira",middleName:null,surname:"Pascawati",slug:"nur-alvira-pascawati",fullName:"Nur Alvira Pascawati",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universitas Respati Yogyakarta",country:{name:"Indonesia"}}},{id:"441116",title:"Dr.",name:"Jovanka M.",middleName:null,surname:"Voyich",slug:"jovanka-m.-voyich",fullName:"Jovanka M. Voyich",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Montana State University",country:{name:"United States of America"}}},{id:"330412",title:"Dr.",name:"Muhammad",middleName:null,surname:"Farhab",slug:"muhammad-farhab",fullName:"Muhammad Farhab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"349495",title:"Dr.",name:"Muhammad",middleName:null,surname:"Ijaz",slug:"muhammad-ijaz",fullName:"Muhammad Ijaz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}}]}},subseries:{item:{id:"38",type:"subseries",title:"Pollution",keywords:"Human activity, Pollutants, Reduced risks, Population growth, Waste disposal, Remediation, Clean environment",scope:"\r\n\tPollution is caused by a wide variety of human activities and occurs in diverse forms, for example biological, chemical, et cetera. In recent years, significant efforts have been made to ensure that the environment is clean, that rigorous rules are implemented, and old laws are updated to reduce the risks towards humans and ecosystems. However, rapid industrialization and the need for more cultivable sources or habitable lands, for an increasing population, as well as fewer alternatives for waste disposal, make the pollution control tasks more challenging. Therefore, this topic will focus on assessing and managing environmental pollution. It will cover various subjects, including risk assessment due to the pollution of ecosystems, transport and fate of pollutants, restoration or remediation of polluted matrices, and efforts towards sustainable solutions to minimize environmental pollution.
",coverUrl:"https://cdn.intechopen.com/series_topics/covers/38.jpg",hasOnlineFirst:!1,hasPublishedBooks:!0,annualVolume:11966,editor:{id:"110740",title:"Dr.",name:"Ismail M.M.",middleName:null,surname:"Rahman",slug:"ismail-m.m.-rahman",fullName:"Ismail M.M. Rahman",profilePictureURL:"https://mts.intechopen.com/storage/users/110740/images/2319_n.jpg",biography:"Ismail Md. Mofizur Rahman (Ismail M. M. Rahman) assumed his current responsibilities as an Associate Professor at the Institute of Environmental Radioactivity, Fukushima University, Japan, in Oct 2015. He also has an honorary appointment to serve as a Collaborative Professor at Kanazawa University, Japan, from Mar 2015 to the present. \nFormerly, Dr. Rahman was a faculty member of the University of Chittagong, Bangladesh, affiliated with the Department of Chemistry (Oct 2002 to Mar 2012) and the Department of Applied Chemistry and Chemical Engineering (Mar 2012 to Sep 2015). Dr. Rahman was also adjunctly attached with Kanazawa University, Japan (Visiting Research Professor, Dec 2014 to Mar 2015; JSPS Postdoctoral Research Fellow, Apr 2012 to Mar 2014), and Tokyo Institute of Technology, Japan (TokyoTech-UNESCO Research Fellow, Oct 2004–Sep 2005). \nHe received his Ph.D. degree in Environmental Analytical Chemistry from Kanazawa University, Japan (2011). He also achieved a Diploma in Environment from the Tokyo Institute of Technology, Japan (2005). Besides, he has an M.Sc. degree in Applied Chemistry and a B.Sc. degree in Chemistry, all from the University of Chittagong, Bangladesh. \nDr. Rahman’s research interest includes the study of the fate and behavior of environmental pollutants in the biosphere; design of low energy and low burden environmental improvement (remediation) technology; implementation of sustainable waste management practices for treatment, handling, reuse, and ultimate residual disposition of solid wastes; nature and type of interactions in organic liquid mixtures for process engineering design applications.",institutionString:null,institution:{name:"Fukushima University",institutionURL:null,country:{name:"Japan"}}},editorTwo:{id:"201020",title:"Dr.",name:"Zinnat Ara",middleName:null,surname:"Begum",slug:"zinnat-ara-begum",fullName:"Zinnat Ara Begum",profilePictureURL:"https://mts.intechopen.com/storage/users/201020/images/system/201020.jpeg",biography:"Zinnat A. Begum received her Ph.D. in Environmental Analytical Chemistry from Kanazawa University in 2012. She achieved her Master of Science (M.Sc.) degree with a major in Applied Chemistry and a Bachelor of Science (B.Sc.) in Chemistry, all from the University of Chittagong, Bangladesh. Her work affiliations include Fukushima University, Japan (Visiting Research Fellow, Institute of Environmental Radioactivity: Mar 2016 to present), Southern University Bangladesh (Assistant Professor, Department of Civil Engineering: Jan 2015 to present), and Kanazawa University, Japan (Postdoctoral Fellow, Institute of Science and Engineering: Oct 2012 to Mar 2014; Research fellow, Venture Business Laboratory, Advanced Science and Social Co-Creation Promotion Organization: Apr 2018 to Mar 2021). The research focus of Dr. Zinnat includes the effect of the relative stability of metal-chelator complexes in the environmental remediation process designs and the development of eco-friendly soil washing techniques using biodegradable chelators.",institutionString:null,institution:{name:"Fukushima University",institutionURL:null,country:{name:"Japan"}}},editorThree:null,series:{id:"25",title:"Environmental Sciences",doi:"10.5772/intechopen.100362",issn:"2754-6713"},editorialBoard:[{id:"252368",title:"Dr.",name:"Meng-Chuan",middleName:null,surname:"Ong",slug:"meng-chuan-ong",fullName:"Meng-Chuan Ong",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRVotQAG/Profile_Picture_2022-05-20T12:04:28.jpg",institutionString:null,institution:{name:"Universiti Malaysia Terengganu",institutionURL:null,country:{name:"Malaysia"}}},{id:"63465",title:"Prof.",name:"Mohamed Nageeb",middleName:null,surname:"Rashed",slug:"mohamed-nageeb-rashed",fullName:"Mohamed Nageeb Rashed",profilePictureURL:"https://mts.intechopen.com/storage/users/63465/images/system/63465.gif",institutionString:null,institution:{name:"Aswan University",institutionURL:null,country:{name:"Egypt"}}},{id:"187907",title:"Dr.",name:"Olga",middleName:null,surname:"Anne",slug:"olga-anne",fullName:"Olga Anne",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSBE5QAO/Profile_Picture_2022-04-07T09:42:13.png",institutionString:null,institution:{name:"Klaipeda State University of Applied Sciences",institutionURL:null,country:{name:"Lithuania"}}}]},onlineFirstChapters:{paginationCount:6,paginationItems:[{id:"82135",title:"Carotenoids in Cassava (Manihot esculenta Crantz)",doi:"10.5772/intechopen.105210",signatures:"Lovina I. Udoh, Josephine U. Agogbua, Eberechi R. Keyagha and Itorobong I. Nkanga",slug:"carotenoids-in-cassava-manihot-esculenta-crantz",totalDownloads:8,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Carotenoids - New Perspectives and Application",coverURL:"https://cdn.intechopen.com/books/images_new/10836.jpg",subseries:{id:"13",title:"Plant Physiology"}}},{id:"81576",title:"Carotenoids in Thermal Adaptation of Plants and Animals",doi:"10.5772/intechopen.104537",signatures:"Ivan M. Petyaev",slug:"carotenoids-in-thermal-adaptation-of-plants-and-animals",totalDownloads:25,totalCrossrefCites:0,totalDimensionsCites:0,authors:[{name:"Ivan",surname:"Petyaev"}],book:{title:"Carotenoids - New Perspectives and Application",coverURL:"https://cdn.intechopen.com/books/images_new/10836.jpg",subseries:{id:"13",title:"Plant Physiology"}}},{id:"81358",title:"New Insights on Carotenoid Production by Gordonia alkanivorans Strain 1B",doi:"10.5772/intechopen.103919",signatures:"Tiago P. Silva, Susana M. Paixão, Ana S. Fernandes, José C. 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